Effective July 1/2017

California’s Department of Health Care Services (DHCS) has issued a new All Plan Letter, APL 17-006.

Here is what you, as a provider, need to know about APL 17-006.

1. New federal regulations require beneficiaries to file an Appeal within sixty (60) calendar days from the date of the Notice of Action (NOA) letter.

2. Beneficiaries must also exhaust HPSJ’s Appeal process prior to requesting a State Hearing.

3. In accordance with existing regulations, Appeals may be filed by a beneficiary, a provider acting on behalf of the beneficiary, or an authorized representative either orally or in writing. Appeals filed by the provider on behalf of the beneficiary require written consent from the beneficiary. In addition, an oral Appeal (excluding expedited Appeals) shall be followed by a written, signed Appeal.

4. Federal regulations revise the timeframe for resolving Appeals from forty-five (45) to thirty (30) calendar days. HPSJ may extend the timeframe for Appeals resolution by 14 calendar days in accordance with federal regulations if either of the following two conditions apply.

• The beneficiary requests the extension.
• The Managed Care Plan demonstrates, to the satisfaction of DHCS upon request, that there is a need for additional information and how the delay is in the beneficiary’s best interest.

5. Overturned Decisions: HPSJ shall authorize or provide the disputed services promptly and as expeditiously as the beneficiary’s health condition requires, but no later than 72 hours from the date it receives notice reversing the determination.

Should you have any further questions, please contact our Customer Services Department at (209) 942-6320.