A Medi-Cal managed care plan shall meet all of the following requirements:
(a) Use all current and applicable CCS program guidelines, including CCS program regulations, CCS numbered letters, and CCS program information notices in developing criteria for use by the plan’s chief medical officer or the equivalent and other care management staff.
(b) In cases in which applicable CCS clinical guidelines do not exist, use evidence-based guidelines or treatment protocols that are medically appropriate given the child’s CCS-eligible condition.
(c) Utilize only CCS providers to treat CCS conditions in any circumstance in which the child’s CCS-eligible condition requires treatment from the provider types in paragraph (1), (2), or (3) of subdivision (a) of Section 14094.4, except a plan may use an out-of-state provider if an in-state CCS provider does not possess the clinical expertise to appropriately treat the CCS condition of the child or youth.
(d) Utilize a provider dispute resolution process that meets the standards established under Section 1371.38 of the Health and Safety Code.
(Added by Stats. 2016, Ch. 625, Sec. 7. (SB 586) Effective January 1, 2017.)
Last modified: October 25, 2018