(a) For a beneficiary of a Medi-Cal managed care plan who meets the criteria for an expedited resolution of an appeal as set forth in subdivision (c) of Section 14197.3 or Section 438.410 of Title 42 of the Code of Federal Regulations, the department shall take final administrative action as expeditiously as the individual’s health condition requires, but no later than three working days after the department receives, from the Medi-Cal managed care plan, the case file and information for any appeal of an adverse benefit determination that, as indicated by the Medi-Cal managed care plan or determined by the administrative law judge, meets either of the following criteria:
(1) Meets the criteria for expedited resolution as set forth in Section 438.410(a) of Title 42 of the Code of Federal Regulations, but was not resolved within the timeframe for expedited resolution.
(2) Was resolved within the timeframe for expedited resolution, but reached a decision wholly or partially adverse to the beneficiary.
(b) Upon notice from the department that a Medi-Cal managed care plan’s beneficiary has requested a state fair hearing, the Medi-Cal managed care plan shall provide to the department a copy of the following information within three business days of the Medi-Cal managed care plan’s receipt of the department’s notice of a request by a beneficiary for a state fair hearing:
(1) The case file.
(2) Information for any appeal of an adverse benefit determination that, as indicated by the Medi-Cal managed care plan, meets either of the criteria described in paragraph (1) or (2) of subdivision (a).
(c) (1) The department shall take final administrative action on a fair hearing request within the time limits set forth in this section except under either of the following unusual circumstances:
(A) The department cannot reach a decision because the beneficiary requests a delay or fails to take a required action.
(B) There is an administrative or other emergency beyond the department’s control.
(2) The department shall document the reasons for any delay in the beneficiary’s record.
(Amended by Stats. 2018, Ch. 92, Sec. 230. (SB 1289) Effective January 1, 2019.)
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