PROVIDER PROBLEM RESOLUTION AND APPEALS

All SFMHP Providers have access to problem resolution and appeals procedures. These are described below.

Provider Problem Resolution Process

Organizational providers who have been assigned a program monitor may contact them at San Francisco Community Behavioral Health Services (CBHS) either through the information desk at (415) 255-3400 or directly with any concerns or problems. Their role is to resolve these issues as quickly as possible.

All other organizational providers and practitioner (both individual and group) providers with concerns or problems may call the Provider Systems Office at (415) 255-3773. Staff of this office will attempt to identify and resolve provider concerns and problems quickly and easily.

If the problem or concern involves a claim, providers may call the numbers above, or a copy of the attached Claims Review Request (CRR): (copies available from the Provider Systems Office) may be sent to the Provider Systems Office by fax at (415) 252-3032. A response will be sent to the provider within 10 calendar days of the receipt of a Claims Review Request.

The Provider Systems Office will keep a log of provider concerns and problems and their resolution for purposes of quality improvement. The log will be part of the quality improvement committee protocols.

At any time before, during or after calling a program monitor or the Provider System Office regarding the problem, a provider may use the appeal process described below.

Provider Appeal Process

Any provider (organizational, group or individual) who wishes to formally appeal a decision of the San Francisco Mental Health Plan (SFMHP) regarding a denied or modified treatment authorization request, or a dispute concerning the processing or payment of a provider's claim, may appeal that decision formally in writing.

Provider May File a Written Appeal Within 90 Days

A provider may appeal a denied or modified request for treatment authorization or a decision regarding the processing or payment of a claim within 90 calendar days of the provider’s receipt of the decision. The appeal must be in writing and include supporting documentation. Supporting documentation shall include, but not is not limited to:

• A copy of the original decision received from the SFMHP.
• Any documentation supporting allegations related to timeliness, if at issue, including copies of fax records, phone records or memos.
• Clinical records supporting the existence of medical necessity, if at issue.
• A summary of reasons why the SFMHP should have approved treatment authorization or a more intensive level of treatment.
• A contact person(s) name, address and phone number.

Submit the appeal to:

Appeals Provider Systems Office
1380 Howard Street, 2nd Floor
San Francisco, CA 94103-2614.

Exception: Providers who receive their payments through the State's fiscal intermediary, currently Electronic Data Systems (EDS), file appeals concerning claims payment or processing directly to the fiscal intermediary.

SFMHP Shall Respond to the Appeal No Later than 60 Days

The provider will receive a written response to their appeal no later than 60 calendar days from the time it is received in the Provider Systems Office.

Appeals regarding treatment authorization will be reviewed by senior clinical staff from the SFMHP excluding the person who made the decision under dispute. Appeals related to inpatient services will be reviewed by senior clinical staff from the inpatient authorization section. Appeals regarding claims decisions will be reviewed by the Claims Unit Supervisor or Manager. Denials that are upheld in the appeal process will be submitted to the SFMHP Director or designee(s) before a written response is made to the appellant.

The written response from the SFMHP staff person reviewing the appeal shall include a statement of the reasons for the decision that addresses each issue raised by the provider, and any action required by the provider to implement the decision.

A copy of the decision will be forwarded to the appropriate SFMHP authorizer if the decision involves a modification to an existing authorization.

The Provider May be Required to Submit a Revised Authorization Request Within 30 Calendar Days

If the appeal is approved and the response so indicates, the provider may be asked to submit a revised authorization request to the SFMHP within 30 calendar days of receipt of the approval.

Submit the revised request within 30 calendar days to:

Appeals
Provider Systems Office
1380 Howard Street, 2nd Floor
San Francisco, CA 94103-2614.

The Provider Systems Office will forward it to the Billing Office for payment or to the Inpatient Authorization Unit for processing revised authorizations for inpatient services through the State fiscal intermediary.

Hospital Providers May Appeal SFMHP Denial of an Appeal for Payment Authorization of Emergency Services to the State Department of Mental Health.

State regulations define an emergency psychiatric condition as one which requires voluntary or involuntary hospitalization and meets the criteria for medical necessity for psychiatric inpatient hospital services.

Within 30 days after receiving denial of an appeal for payment authorization of emergency services, a provider may file an appeal with the State Department of Mental Health. This process is described in Chapter 11, Title 9, Division 1, California Code of Regulations, section 1850.305 Provider Problem Resolution and Appeal Processes and in the SFMHP Inpatient Psychiatric Utilization Review/Payment Authorization Plan.

Questions about the processes described above should be directed to the Provider Systems Office at (415) 255-3723.