Process for reviewing requests received by Healthcare services.
CHG confirms you are a member.
CHG reviews the request to see if it needs an approval. Items listed below don’t need an approval.
Services labelled as “sensitive” and/or “freedom of choice” by the Medi-Cal program. These services include:
Sexually transmitted disease (STD)
Routine OB/GYN services and basic prenatal care through network providers
Out-of-Area renal dialysis services
What CHG will do:
CHG will review the urgency of the request. CHG reviews urgent requests within 72 hours. It reviews routine ones within 5 working days for Medi-Cal members & 14 calendar days for CMC members.
A referral specialist will first review the request. If the referral specialist is able to make a decision with the notes sent, they will process the request. If not, they will send the request to a nurse for review.
A nurse will review the request and medical notes sent by your doctor to make a decision. If the nurse sees that the notes do not have the information that justifies the request, they will send your request to our doctor for review.
A referral specialist may process requests that are not complete.
CHG uses the following member information to reach a decision:
Your health condition (Diagnosis)
Treatment tried, failed, or not recommended (contraindicated)
Other health conditions you may have
Progress of treatment
Your emotional and social situation
Your home environment, when appropriate
How urgent the condition is
CHG also uses its provider network and practice standards to reach a decision.
For members enrolled in CHG’s Medi-Cal plan, CHG applies established Medi-Cal guidelines before any others.
CHG applies current California Children Services (CCS) referral guidelines when appropriate for requests for services for children and young adults under 21 years of age enrolled in Medi-Cal.
If the member has primary Medicare coverage, CHG applies appropriate Medicare guidelines.
If the request is for behavioral health services, CHG applies MCG (Milliman Care Guidelines). Where –MCG criteria does not exist, CHG will apply guidelines it develops.
After applying the criteria that is specific to your plan, CHG applies MCG criteria.
CHG applies its disease management protocols before benefit coverage or MCG criteria, when available.
If there aren’t any applicable, plan-specific, MCG criteria, CHG may use the following to decide if something is medically necessary:
Criteria developed and agreed upon by peers (doctors who practice in the same field)
Standard quality markers (such as those developed by the National Committee for Quality Assurance (NCQA) or the Health Plan and Employer Data and Information Set (HEDIS))
American Medical Association (AMA) specialty guidelines and state or county medical association guidelines
Length of Stay (LOS) by Diagnosis and Operation, United States (developed by HCIA, Inc.)
Governmental agencies, such as Centers for Disease Control, Food and Drug Administration, Agency for Healthcare Research and Quality, National Institutes of Health
Local or regional agencies (such as state and county health departments)
Non-profit health care organizations (such as the American Heart Association, American Diabetes Association, American Lung Association)
Peer-reviewed periodicals and journals
Consultation with doctors who are in practice and who teach at universities, work at research foundations and/or are members of recognized specialty societies.
Standards of Practice for Case Management of the Case Management Society of America (CMSA).
CHG reviews requests for non-formulary medicines or formulary medicines that need prior authorization as mentioned above.
Once CHG has made a decision, it will notify your doctor immediately through the provider portal. CHG will notify members by mail or phone call.