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22 CCR 42321
22 CCR 42321
§ 42321. Continuation.
(a)
If the CCS client's request for appeal or CCS Fair Hearing includes a request for continuation or resumption of services previously authorized by the CCS agency, during the time the appeal is under active consideration, the medical decision regarding the need for continuation of medically necessary services shall occur as follows: Within five days of the receipt of the request for evaluation, the CCS agency shall provide the client, parent(s), and/or legal guardian with the names of three such physicians. Within five days of the receipt of the names of the three physicians the client, parent(s) and/or legal guardian shall choose one physician whom the CCS agency shall authorize to perform the evaluation. Within five days of notification to CCS of the choice of physician the CCS agency shall contact the physician to set up an appointment for an evaluation. The evaluation shall be at a time mutually acceptable to the client and the physician. Medically necessary benefits shall continue until the evaluation has been completed and the physician's recommendation received by CCS.
(1)
If the appeal or Fair Hearing request concerns continuing financial or residential eligibility, the client's request for continuation of previously authorized medical services shall be decided by the prescribing physician.
(2)
If the appeal or Fair Hearing request concerns medical eligibility or the need for the continuation of previously authorized medical services, the CCS agency director shall authorize that the client be evaluated by an expert physician whose specialty encompasses the client's medical condition and/or service at issue and who is not a CCS employee or under consultant contract with CCS.
(b)
Benefits and services shall be continued or resumed pursuant to section 42321, pending the outcome of the administrative appeal, from the date of the first letter of appeal, if any of the following exists:
(1)
The expert physician finds upon evaluation that a termination or change of the client's current medical services will result in:
(A)
potential injury or loss of life to the client; or
(B)
measurable, significant loss of physical functioning; or
(C)
significant risk of deterioration of the client's condition if the medically necessary benefits are discontinued.
(2)
No other reasonable alternative exists for the provision of such services.
(3)
The service or benefit being appealed is an approved CCS program benefit.
(c)
Failure of the client, parent(s) or representative to agree to an evaluation or failure to keep the appointment shall result in denial of continuation of services.
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