Working in partnership with CHA, the California Department of Managed Health Care (DMHC) and the Department of Health Care Services (DHCS) have developed a process for hospital case managers and others to report concerns about health plan communication and prior authorization practices.
The goal of this reporting form is to provide DMHC and DHCS with information to better understand statewide issues of concern and to inform future DMHC and DHCS policy and oversight. Examples of reportable problems include a lack of timely response from plan personnel, delays in authorization for services, or the lack of beneficiary access to post-hospital care.
The form can be used to report a pattern or practice of concern (e.g., the plan does not respond to requests for prior authorization on weekends), or specific examples (e.g., no network skilled-nursing facility is willing/able to accept a patient). This reporting process will also provide a process for submitting similar information for Medicare Advantage (MA) plans. CHA will collect MA data and submit it to the Centers for Medicare & Medicaid Services, the entity with responsibility for oversight of MA plans.
The newly developed form and related materials are available below:
- Instructions for Managed Care Reporting Decision Tree and Reporting Form
- Managed Care Plan Reporting Form
- (Updated) Decision Tree (this version now includes the link to the list of plan contacts in the “escalate” step of the tree)
- Plan-by-County Contact Sheet (this is a standalone link to the list, which is also linked in the decision tree)
- MA Plan Online Reporting