Review of Denials

Date: 01/18/17

Any time we make a decision to deny, reduce, suspend or stop coverage of certain services, California Health & Wellness will send you and your patient written notification. The denial notice includes information on the availability of a medical director to discuss the decision.

Peer-To-Peer Reviews

If a request for medical services is denied due to a lack of medical necessity, a provider can request a peer-to-peer review with our medical director on the member’s behalf. The medical director may be contacted by calling California Health & Wellness at 877-658-0305. A case manager may also coordinate communication between the medical director and the requesting practitioner as needed.

Filing Appeals

The denial notice will also inform you and our member about how to file an appeal. In urgent cases, an expedited appeal is available and can be submitted verbally or in writing.

Please remember to always include sufficient clinical information when submitting prior authorization requests to allow for California Health & Wellness to make timely medical necessity decisions based on complete information.