21-128 How to File Appeals and Grievances for Pharmacy Issues
Date: 11/16/21
Filing process changes due to Medi-Cal Rx transition
Effective January 1, 2022, Medi-Cal outpatient pharmacy benefits will be administered through the Department of Health Care Services (DHCS) fee-for-service delivery system called Medi-Cal Rx. Medi-Cal pharmacy benefits and services will also transition to Medi-Cal Rx. Appeals and grievances for these benefits and services provided on or after January 1, 2022, will therefore not be California Health & Wellness Plan’s (CHWP’s) responsibility as of that date.
How to file Medi-Cal Rx member appeals
Appeals involving disagreement with benefit-related decisions, such as coverage disputes, disagreeing with and seeking reversal of a request for prior authorization (PA) involving medical necessity, etc., that are associated with a Notice of Action issued for an outpatient pharmacy service provided on or after January 1, 2022, will be adjudicated through the State Fair Hearing (SFH) process. These appeals should go to the California Department of Social Services (CDSS) via the following contacts and not to CHWP:
- By mail:
California Department of Social Services State Hearings Division
P.O. Box 944243, Mail Station 21-37
Sacramento, California 94244-2430
- By fax: 833-281-0905
- Online: California Department of Social Services website
- By phone: 800-743-8525 (voice) and 800-952-8349 (TTY)
Medi-Cal beneficiaries are no longer required to exhaust any internal and/or administrative DHCS processes prior to requesting a SFH through CDSS. Additionally, under Medi-Cal Rx, Medi-Cal enrollees no longer have the right to apply for an Independent Medical Review for pharmacy services carved out to Medi-Cal Rx. If CHWP receives an appeal related to these services, it will redirect it to CDSS SFH in a timely manner and in the manner outlined by DHCS.
How to file member complaints and grievances
On or after January 1, 2022, a CHWP Medi-Cal member may file Medi-Cal Rx complaints and grievances at any time to the Medi-Cal Rx Customer Service Center (CSC), who will administer all aspects of the complaints and grievances processes and related procedures for Medi-Cal pharmacy benefits. Complaints or grievances may be filed with the Medi-Cal Rx CSC by telephone at 800-977-2273 or via fax to 800-869-4325. If CHWP receives a Medi-Cal Rx grievance or complaint, it will redirect those issues to the Medi-Cal Rx CSC.
Provider PA appeals on a member’s behalf
Providers, on behalf of a Medi-Cal beneficiary, may appeal Medi-Cal Rx PA denials, delays and modifications issued on or after January 1, 2022. Providers may submit appeals of PA adjudication results through the Medi-Cal Rx website or by mail clearly identified as appeals, to:
Medi-Cal CSC, Provider Claims Appeals Unit
P.O. Box 610
Rancho Cordova, CA, 95741-0610
Medi-Cal Rx will acknowledge each submitted PA appeal within three days of receipt and make a decision within 60 days of receipt. Medi-Cal Rx will send a letter of explanation in response to each PA appeal. Providers who are dissatisfied with the decision may submit subsequent appeals. Medi-Cal providers may seek a judicial review of the appeal decision, as authorized under state law. For more information about the Medi-Cal Rx provider PA appeal process, please visit the Medi-Cal Rx website.
Provider claim appeals
Provider claim appeals to resolve claim payment problems (e.g., resubmission, non-payment, underpayment, overpayment, etc.) for services provided on or after January 1, 2022, may be filed to Medi-Cal CSC. Providers must complete the Medi-Cal Rx provider appeal form and submit the completed form to:
Medi-Cal CSC, Provider Claims Appeals Unit
P.O. Box 610
Rancho Cordova, CA, 95741-0610
Once the Medi-Cal Rx provider appeal form is submitted, Medi-Cal Rx will acknowledge each appeal within 15 days of receipt and make a decision within 45 days of receipt.
Resources
For more information, refer to the resource table below.
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Additional information
Relevant sections of the provider operations manuals will be revised to reflect the information contained in this update as applicable. The provider operations manual is available in the Provider Resources section of the provider website.
Providers are encouraged to access CHWP’s provider portal online for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.