Report 2009-112 Recommendation 3 Responses

Report 2009-112: Department of Health Care Services: It Needs to Streamline Medi-Cal Treatment Authorizations and Respond to Authorization Requests Within Legal Time Limits (Release Date: May 2010)

Recommendation #3 To: Health Care Services, Department of

To ensure that Medi-Cal recipients are receiving timely medical services from providers, Health Care Services should start tracking prior-authorization medical TARs separately and should ensure that such TARs are processed within an average of five working days. Although state law and regulations specifically require prior authorization for certain medical services, Health Care Services generally does not require prior authorizations in practice. Consequently, Health Care Services should seek legislation to update existing laws and amend its regulations to render them consistent with its TAR practices.

Annual Follow-Up Agency Response From May 2016

A process was developed, and has been implemented, to track and adjudicate prior authorization TARs received in paper form. The ability to implement such a process for TARs received electronically is part of a replacement TAR processing system currently under development by Xerox State Healthcare, LLC. Changes to the existing system would be costly and time-intensive and not a prudent use of limited resources. Due to current uncertainties and the likelihood of significant change to the TAR process with the implementation of the Affordable Care Act, Health Care Services is not seeking legislation to update existing laws and/or regulations to make them consistent with the TAR process.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement


Annual Follow-Up Agency Response From December 2015

A process was developed, and has been implemented, to track and adjudicate prior authorization TARs received in paper form. The ability to implement such a process for TARs received electronically is part of a replacement TAR processing system currently under development by Xerox State Healthcare, LLC. Changes to the existing system would be costly and time-intensive and not a prudent use of limited resources. Due to current uncertainties and the likelihood of significant change to the TAR process with the implementation of the Affordable Care Act, Health Care Services is not seeking legislation to update existing laws and/or regulations to make them consistent with the TAR process.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement


Annual Follow-Up Agency Response From October 2013

A process was developed, and has been implemented, to track and adjudicate prior authorization TARs received in paper form. The ability to implement such a process for TARs received electronically is part of a replacement TAR processing system currently under development by Xerox State Healthcare, LLC. Changes to the existing system would be costly and time-intensive and not a prudent use of limited resources. Due to current uncertainties and the likelihood of significant change to the TAR process with the implementation of the Affordable Care Act, Health Care Services is not seeking legislation to update existing laws and/or regulations to make them consistent with the TAR process.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement


Annual Follow-Up Agency Response From October 2012

As indicated in previous status reports, Health Care Services has implemented a process to separately track paper prior-authorization medical TARs. Health Care Services will separately track electronic prior-authorization medical TARs when Xerox, the new CA-MMIS contractor, develops and implements the new TAR submission and adjudication system. The current system does not have the ability to track prior-authorization TARs, and it would be costly and time intensive to make the modifications that would enable it to do so.

As noted in previous status reports, Health Care Services is not currently seeking legislation to update existing laws and regulations to make them consistent with the TAR process. The reason is that the continuing implementation of the Affordable Care Act will lead to considerable changes in the Medi-Cal program and California's entire health care system in the coming months and years, and this will likely lead to significant, as yet unknown, changes to the TAR process. Given current uncertainties and the likelihood of significant change, it would not be advisable to make this kind of modification of existing TAR related laws or regulations at this time.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement


All Recommendations in 2009-112

Agency responses received after June 2013 are posted verbatim.


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