Section 1300.74.721 - Mental Health and Substance Use Disorder Utilization Review Requirements(a) A health plan subject to Health and Safety Code section 1374.721 is responsible for ensuring compliance with that section regardless of contracting and/or delegation arrangements. The health plan shall ensure that any specialized health plan, including a mental health plan, or other delegated entity conducting mental health and substance use disorder (MH/SUD) medical necessity and utilization review on its behalf uses only the nonprofit criteria listed in Rule 1300.74.721(c), unless the circumstances set forth in Health and Safety Code section 1374.721(c)(1) and/or (2) apply.(b) Utilization review as used in this Rule has the same meaning as that term is defined in Health and Safety Code section 1374.721(f)(3) and includes the following procedures or practices: (1) Issuing or making available practice criteria or guidelines intended to help guide or assist providers in determining, diagnosing, or treating MH/SUD; or(2) Guiding authorization, modification, or denial of a service if the plan engages in additional or heightened quality monitoring, re-training, re-educating, or adverse action(s) based on the provider's MH/SUD coverage or utilization review determinations.(c) Clinical criteria developed by the following nonprofit professional associations, or a successor organization thereto, shall be used to make utilization review determinations that are within the scope of the criteria:(1) American Academy of Child and Adolescent Psychiatry.(2) American Academy of Family Physicians.(3) American Academy of Neurology.(4) American Academy of Pediatrics.(5) American Academy of Sleep Medicine.(6) American Association for Community Psychiatry.(7) American College of Physicians.(8) American Medical Association.(9) American Psychiatric Association.(10) American Psychological Association.(11) American Society of Addiction Medicine.(12) Canadian Network for Mood and Anxiety Treatments.(13) Council of Autism Service Providers.(14) World Professional Association for Transgender Health.(d) A health plan shall not apply utilization review criteria other than those set forth in subdivision (c) of this Rule unless the circumstances in Health and Safety Code section 1374.721(c)(1) or (c)(2) apply. A health plan shall not conduct repeated utilization review of a case at intervals more frequent than those prescribed or recommended by the relevant nonprofit professional association criteria or guidelines.(e) A health plan shall file as a Notice of Material Modification pursuant to Rule 1300.52.4 all health plan proposals to adopt nonprofit professional association criteria and guidelines for use in utilization review, including any contracts between the health plan and a nonprofit professional association. This Notice of Material Modification shall include information about the adopted nonprofit professional associations described in (c)(1)-(c)(14) of this Rule, information about criteria or guidelines adopted from other nonprofit professional associations, information explaining why any nonprofit professional associations listed in subdivision (c) of this Rule do not cover the applicable conditions, and what the health plan proposes as MH/SUD criteria.(f) A health plan shall file with the Department as an Amendment pursuant to Rule 1300.52.4 any revised policies and procedures reflecting adoption of nonprofit professional association criteria and guidelines and listing all nonprofit professional association criteria used other than those listed in subdivision (c) of this Rule, above. (1) These policies and procedures shall include the following:(A) A list of the MH/SUD services provided by the health plan that meet the criteria under subdivision (d) of this Rule.(B) A description of the process the health plan used to determine the MH/SUD services listed above meet the criteria of subdivision (d) of this Rule.(C) A description of the health plan's process for determining that the criteria and guidelines proposed by the health plan pursuant to subdivision (d) of this Rule are consistent with generally accepted standards of MH/SUD care. The health plan shall include any valid, evidence-based periodically updated sources, setting forth generally accepted standards of MH/SUD care the health plan relied on when developing or licensing/purchasing criteria and guidelines, including peer-reviewed scientific studies and medical literature, clinical practice guidelines and recommendations of nonprofit professional associations, specialty societies, federal government agencies, and drug labeling approved by the United States Food and Drug Administration.(g) If a health plan uses a contracted entity or delegate to conduct utilization review on its behalf, the health plan shall file with the Department as a Notice of Material Modification pursuant to Rule 1300.52.4 a filing entitled "Delegated Compliance with Health and Safety Code sections 1374.72, 1374.721, and 1374.722," containing the following information:(1) The name of the entity or delegate company;(2) A complete list of all the nonprofit professional association criteria the company will use when conducting MH/SUD utilization review;(3) The policies and procedures the entity or delegate will utilize to conduct MH/SUD utilization review;(4) A copy of the health plan's contract(s) with the delegate or entity, which sets forth the requirement for compliance with this Rule and Health and Safety Code sections 1374.72, 1374.721, and 1374.722, including exclusive use of the relevant nonprofit professional association criteria, and all provisions of that criteria to conduct utilization review; and,(5) The policies and procedures the health plan will utilize to conduct oversight of the delegate or contracted entity to ensure compliance with the Knox-Keene Act and title 28, including this Rule and Rules 1300.74.72 and 1300.74.72.01.(h) Utilization review determinations concerning service intensity, level of care placement, continued stay, and transfer or discharge that are within the scope of the following instruments shall be considered compliant with Health and Safety Code section 1374.721:(1) For a primary substance use disorder diagnosis in adolescents and adults, The ASAM Criteria by the American Society of Addiction Medicine.(2) For a primary mental health diagnosis in adults nineteen (19) years of age and older, Level of Care Utilization System (LOCUS) by the American Association for Community Psychiatry.(3) For a primary mental health diagnosis in children six (6) to eighteen (18) years of age, Child and Adolescent Level of Care/Service Intensity Utilization System (merged CALOCUS-CASII) by the American Association for Community Psychiatry and the American Academy of Child and Adolescent Psychiatry.(4) For a primary mental health diagnosis in children five (5) years of age and younger, Early Child Service Intensity Instrument (ECSII) by the American Academy of Child and Adolescent Psychiatry.(i) When an enrollee has met criteria for a level of care as determined by a ASAM Criteria, LOCUS, CALOCUS-CASII, and/or ECSII assessment, but either clinical services or supports (e.g., nonclinical interventions such as peer support) consistent with that level are not available, the health plan shall authorize the next higher level of care. When there is ambiguity on a dimension of an assessment regarding the correct score in that dimension, the reviewer shall assign the higher score, as directed by the nonprofit professional criteria.(j) Health plans shall incorporate the criteria and guidelines pursuant to subdivision (h) of this Rule into the health plan's utilization review in a manner that demonstrates the health plan has adopted and implemented the criteria. Compliance shall be substantiated by health plan filings submitted in compliance with subdivision (f) of this Rule, which shall include the specific procedures by which the health plan uses the criteria and guidelines in subdivision (h) of this Rule to identify the appropriate level of care. For the purpose of this subdivision (j) of this Rule, incorporating the criteria and guidelines pursuant to subdivision (h) of this Rule into the health plan's utilization review in a manner that demonstrates the health plan has adopted and implemented the criteria shall mean:(1) Using the instrument, tool, algorithm, cloud-based platform, or system interface established by the relevant nonprofit professional association listed in subdivision (h) of this Rule or its contracted entity; or(2) Using a system or tool that has in effect a current certification of approval from the relevant nonprofit professional association.(k) An enrollee, an enrollee's authorized representative, or an enrollee's provider may submit a request for MH/SUD services, orally or in writing, to the health plan or the health plan's contracted entity or delegate, as applicable, that is responsible for conducting utilization review as defined in Health and Safety Code section 1374.721(f)(3).(l) If a health plan, its contracted entity, or delegate delays, denies, or modifies MH/SUD services following utilization review when such services were requested by an enrollee, the enrollee's authorized representative, or the enrollee's provider, the health plan shall issue a written communication to the enrollee or the enrollee's authorized representative and any requesting provider(s) outlining the basis for the delay, denial, or modification. The required written communication to the enrollee, the enrollee's authorized representative, or the requesting provider(s) shall be sent within five (5) calendar days of the decision for non-urgent care and within 72 hours for urgent care. Specifically, the written notification shall include the following information:(1) The enrollee's MH/SUD condition(s) for which the health plan or contracted entity conducted utilization management review;(2) The clinical specialty at issue;(3) A list of all criteria or guidelines (e.g., CALOCUS-CASII for Mental Health Disorders in Patients Under the Age of Eighteen) used, including any nonprofit professional association criteria, criteria outside the scope of the nonprofit professional association criteria or criteria that relate to advancements in technology or types of care not covered in the most recent versions of the nonprofit professional association criteria;(4) A summary of the reasons for deviating from the criteria listed in this Rule, if applicable; and,(5) A summary of the health plan's clinical reason(s) for its decision, including providing full details of the plan or contracted entity's application of and/or scoring using the criteria listed in this Rule.(m) At any time upon request by the Department, a health plan shall demonstrate that the plan and, if applicable, any specialized health plan, mental health plan, or delegate or entity that performs utilization review, is making MH/SUD determinations pursuant to Health and Safety Code sections 1374.72, 1374.721, 1374.722, and this Rule.(n) A health plan shall preserve the books and records required under this Rule for a period of not less than five (5) years, the last two (2) years of which shall be in an easily accessible location at the headquarters office of the health plan and as required under Rule 1300.85.1.(o) To ensure proper application and implementation of criteria described in Health and Safety Code section 1374.721(a), and submitted to and approved by the Department consistent with this Rule, the health plan shall adopt an education program consistent with Health and Safety Code section 1374.721(e), which meets the following requirements:(1) The health plan shall sponsor a formal education program by a nonprofit clinical specialty association to educate all health plan staff and any staff of contracted or affiliated third parties that conduct utilization review under Health and Safety Code sections 1374.72, 1374.721, and 1374.722, within six (6) months of adoption of this Rule and at least every three (3) years thereafter. Sponsoring includes arranging and paying for such formal education program, whether or not the health plan contracts with third parties or affiliates, or non-profit organizations to provide the education program.(2) A health plan shall ensure all utilization review staff, including supervisors, are trained in the use and application of the most recent edition, instrument, or tool of the sources set forth pursuant to the guidelines in Health and Safety Code section 1374.721 and this Rule before they perform any utilization review using the identified and adopted nonprofit professional association criteria.(3) Pursuant to Health and Safety Code section 1374.721(e)(2), a health plan shall make any utilization review determination criteria and any education program materials available upon request to other stakeholders, including:(A) Subscribers, enrollees, or the enrollee's legally authorized representatives; and(B) Providers offering services to the health plan's enrollees pursuant to Rule 1300.74.72(b).(p) A health plan shall notify the enrollee or the enrollee's authorized representative, and the enrollee's requesting provider(s) that all utilization review determination criteria and any education program materials identified in paragraph (o) of this Rule shall be made available upon request at no cost. This notice shall be published on the health plan's website, contained in the health plan's Evidence of Coverage documents, and included in the written communication required by Health and Safety Code section 1367.01(h)(4) sent to an enrollee, the enrollee's authorized representative, or the enrollee's requesting provider when delaying, denying, or modifying a requested MH/SUD service.(q) Method of Delivery. Upon request, health plans shall provide the utilization review determination and training materials in one or more of the following ways:(1) In paper form, free of charge, and delivered to the individual's mailing address.(2) Electronically by email. The health plan shall notify the enrollee a paper copy is available free of charge and inform the enrollee how to contact the health plan for a paper copy or with questions.(3) If provided on the health plan's website, the health plan shall: (A) Ensure the utilization review training materials allow for electronic retention, such as saving and printing;(B) Ensure the utilization review training materials are accessible, in accordance with section 508 of the federal Rehabilitation Act of 1973, as amended; and California Government Code sections 7405 and 11135, to individuals living with disabilities; and(C) Notify the enrollee, enrollee's authorized representative, or provider that a paper copy is available free of charge and inform the enrollee how to contact the health plan for a paper copy or with any questions.(4) Timeframe for Delivery. Such utilization review determination and training materials shall be sent to the requesting party within thirty (30) calendar days of the request.(r) Nothing in this Rule discharges a health plan from complying with federal laws regarding mental health and substance use disorder parity, including, 29 CFR § 2590.712 and 45 CFR § 146.136.(s) Enforcement. Failure by a health plan to comply with the requirements of this Rule constitutes a basis for disciplinary action against the health plan. The Director shall have the civil, criminal, and administrative remedies available under the Knox-Keene Act.Cal. Code Regs. Tit. 28, § 1300.74.721
Note: Authority cited: Section 1344, Health and Safety Code. Reference: Sections 1345, 1346, 1367.005, 1367.01, 1374.72, 1374.721, 1374.722 and 1386, Health and Safety Code.
1. New section filed 1-12-2024; operative 4/1/2024 (Register 2024, No. 2).
2. Change without regulatory effect amending subsection (c)(13) filed 5-17-2024 pursuant to section 100, title 1, California Code of Regulations (Register 2024, No. 20).