State of california

Additional Provisions.

1. 
   Books and Records.
   

The Contractor shall maintain such books and records as are necessary to disclose how the Contractor discharged its obligations under this contract. These books and records shall identify the quantity of covered services provided under this contract, the quality of those services, the manner and amount of payment made for those services, the beneficiaries who received covered services, the manner in which the Contractor administered the provision of specialty mental health services and the cost thereof.

2. 
   Transfer of Care.
   

Prior to the termination or expiration of this contract, and upon request by the Department, the Contractor shall assist the State in the orderly transfer of mental health care for beneficiaries in «County» County. In doing this, the Contractor shall make available to the Department copies of medical records, patient files, and any other pertinent information, including information maintained by any subcontractor that is necessary for efficient case management of beneficiaries, as determined by the Department. Costs of reproduction shall be borne by the Department. In no circumstances shall a beneficiary be billed for this service.

3. 
   Department Policy Letters.
   

The Contractor shall comply with policy letters issued by the Department to all Mental Health Plans as defined in Title 9, CCR, Section 1810.226. Policy letters shall provide specific details of procedures established by the Department for performance of contract terms when procedures not covered in this agreement are determined to be necessary for performance under this agreement, but are not intended to change the basis and general terms of the contract.

4. 
   Delegation.
   

Unless specifically prohibited by this contract or by federal or state law, Contractor may delegate duties and obligations of Contractor under this contract to subcontracting entities if Contractor determines that the subcontracting entities selected are able to perform the delegated duties in an adequate manner in compliance with the requirements of this contract. In addition, Contractor may accept the certification of a provider by another Mental Health Plan, or by the Department, in order to meet the Contractor’s obligations under Exhibit A1, Section 4. However, regardless of any such delegation to a subcontracting entity or acceptance of a certification by another MHP, Contractor shall remain ultimately responsible for adequate performance of all duties and obligations under this contract.

15. Beneficiary Problem Resolution Processes.

1. 
   General Provisions.
   

1. 
   Pursuant to Title 42, CFR, Section 438.228 and Title 9, CCR, Section 1850.205, the Contractor shall develop problem resolution processes that enable beneficiary to request and receive review of a problem or concern he or she has about any issue related to the Contractor's performance of its duties under this Chapter, including the delivery of specialty mental health services.
   

2. 
   The Contractor’s beneficiary problem resolution processes shall include:
   

1. 
   A grievance process;
   

2. 
   An appeal process; and,
   

3. 
   An expedited appeal process.
   

3. 
   For the grievance, appeal, and expedited appeal processes, described in Title 42, CFR, Subpart F, and Title 9, CCR, Sections 1850.206, 1850.207 and 1850.208 respectively, the Contractor shall comply with all of the following requirements:
   

1. 
   Assure that each beneficiary has adequate information about the Contractor's problem resolution processes by taking at least the following actions:
   

1. 
   Including information describing the grievance, appeal, and expedited appeal processes in the Contractor's beneficiary booklet and providing the beneficiary booklet to beneficiaries as described in Section 7 of this contract.
   

2. 
   Posting notices explaining grievance, appeal, and expedited appeal process procedures in locations at all Contractor provider sites. Notices shall be sufficient to ensure that the information is readily available to both beneficiaries and provider staff. The posted notice shall also explain the availability of fair hearings after the exhaustion of an appeal or expedited appeal process, including information that a fair hearing may be requested whether or not the beneficiary has received a notice of action pursuant to Title 9, CCR, Section 1850.210. For the purposes of this Section, a Contractor provider site means any office or facility owned or operated by the Contractor or a provider contracting with the Contractor at which beneficiaries may obtain specialty mental health services.
   

3. 
   Pursuant to Title 9 CCR Section 1850.205(c)(1)(C), making available forms that may be used to file grievances, appeals, and expedited appeals and self-addressed envelopes that beneficiaries can access at all Contractor provider sites without having to make a verbal or written request to anyone.
   

4. 
   Pursuant to 42, CFR, Section 438.406(a), giving beneficiaries any reasonable assistance in completing the forms and other procedural steps not limited to providing interpreter services and toll-free numbers with TTY/TDD and interpreter capability.
   

2. 
   The Contractor shall acknowledge receipt of each grievance appeal, and request for expedited appeal to the beneficiary in writing.
   

2. 
   A beneficiary may authorize another person to act on the beneficiary's behalf. The beneficiary may select a provider as his or her representative in the appeal or expedited appeal process, if the provider consents.
   

2. 
   A beneficiary's legal representative may use the grievance, appeal, or expedited appeal processes on the beneficiary's behalf.
   

2. 
   At the beneficiary’s request, the Contractor shall identify staff or another individual to be responsible for assisting a beneficiary with these processes, including providing assistance in writing the grievance, appeal, or expedited appeal. If the individual identified by the Contractor is the person providing specialty mental health services to the beneficiary requesting assistance, the Contractor shall identify another individual to assist that beneficiary.
   

2. 
   A beneficiary shall not be subject to discrimination or any other penalty for filing a grievance, appeal, or expedited appeal.
   

2. 
   Procedures for these beneficiary problem resolution processes shall maintain the confidentiality of each beneficiary’s information.
   

2. 
   A procedure shall be included by which issues identified as a result of the grievance, appeal or expedited appeal processes are transmitted to the Contractor's Quality Improvement Committee, the Contractor's administration or another appropriate body within the Contractor’s operations. These issues shall be considered in the Contractor's Quality Improvement Program, as required by Title 9, CCR, Section 1810.440(a)(5).
   

2. 
   Individuals involved in any previous review or decision-making on the issue(s) presented in a problem resolution process shall not participate in making the decision on the grievance, appeal, or expedited appeal.
   

2. 
   The individual making the decision on the grievance, appeal, or expedited appeal shall have the appropriate clinical expertise, as determined by the Contractor, required to treat the beneficiary's condition, if the grievance concerns the denial of a request for an expedited appeal or if the grievance, appeal, or expedited appeal addresses any clinical issue, including a lack of medical necessity per 42 CFR 438.406(a)(3)(ii).
   

4. 
   Pursuant to record keeping and review requirements in Title 42, CFR, 438.416, and to facilitate monitoring consistent with Title 9, CCR, Sections 1810.440(a)(5), 1850.205,1850.206, 1850.207, and 1850.208, the Contractor shall:
   

1. 
   Maintain a grievance and appeal log and record grievances, appeals, and expedited appeals in the log within one working day of the date of receipt of the grievance or appeal. The log entry shall include, but not be limited to, the name of the beneficiary, the date of receipt of the grievance, appeal, or expedited appeal, and the nature of the problem;
   

2. 
   Record in the grievance and appeal log or another central location determined by the Contractor, the final dispositions of grievances, appeals, and expedited appeals, including the date the decision is sent to the beneficiary. If there has not been final disposition of the grievance, appeal, or expedited appeal, the reason(s) shall be included in the log;
   

3. 
   Provide a staff person or other individual with responsibility to provide information requested by the beneficiary or the beneficiary’s representative regarding the status of the beneficiary's grievance, appeal, or expedited appeal;
   

4. 
   Acknowledge the receipt of each grievance, appeal, and expedited appeal to the beneficiary in writing;.
   

5. 
   Identify in its grievance, appeal, and expedited appeal documentation, the roles and responsibilities of the Contractor, the provider, and the beneficiary;
   

6. 
   Notify the beneficiary, in writing, of the final disposition of the problem resolution process. The notification shall include the reasons for the disposition; and
   

7. 
   Notify, in writing, any provider identified by the beneficiary or involved in the grievance, appeal, or expedited appeal of the final disposition of the beneficiary's grievance, appeal, or expedited appeal.
   

5. 
   No provision of a Contractor's beneficiary problem resolution processes shall be construed to replace or conflict with the duties of county patients' rights advocates as described in Welfare and Institutions Code Section 5520.
   

2. 
   Grievance Process.
   

1. 
   Allow beneficiaries to present their grievance orally, or in writing;
   

2. 
   Provide for a decision on the grievance and notify the affected parties within 60 calendar days of receipt of the grievance. This timeframe may be extended by up to 14 calendar days if the beneficiary requests an extension, or if the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframe, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in Title 9, CCR, Section 1810.230.5.
   

3. 
   Provide for notification of the beneficiary or the appropriate representative in writing of the grievance decision and documentation of the notification or efforts to notify the beneficiary, if he or she could not be contacted.
   

3. 
   Appeal Process.
   

1. 
   Consistent Title 42, CFR, Section 438.408 and Title 9, CCR, Section 1850.205 and 1850.207, the appeal process shall, at a minimum:
   

1. 
   Allow a beneficiary to file an appeal orally or in writing;
   

2. 
   Pursuant to Title 42, CFR, 438.402(b)(3), require a beneficiary who makes an oral appeal, that is not an expedited appeal, to subsequently submit the appeal in writing. The date the Contractor receives the oral appeal shall be considered the filing date for the purpose of applying the appeal timeframes;
   

3. 
   Pursuant to Title 42, CFR, 438.408(a-c), provide for a decision on the appeal and notify the affected parties within 45 calendar days of receipt of the appeal. This timeframe may be extended by up to 14 calendar days, if the beneficiary requests an extension or the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframes, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in Title 9, CCR, Section 1810.230.5;
   

4. 
   Pursuant to Title 42, CFR, Section 438.408(e), inform the beneficiary of his or her right to request a fair hearing after the appeal process of the Contractor has been exhausted;
   

5. 
   Allow the beneficiary to have a reasonable opportunity to present evidence and arguments of fact or law, in person and/or in writing, in accordance with the beneficiary’s election ;
   

6. 
   Allow the beneficiary and/or his or her representative to examine the beneficiary's case file, including medical records, and any other documents or records considered before and during the appeal process, provided that there is no disclosure of the protected health information of any individual other than the beneficiary;
   

7. 
   Allow the beneficiary and/or his or her representative, or the legal representative of a deceased beneficiary's estate, to be included as parties to the appeal.
   

2. 
   Pursuant to Title 42, CFR, 438.408(d-e), the Contractor shall notify the beneficiary, and/or his or her representative, of the resolution of the appeal in writing. The notice shall contain:
   

1. 
   The results of the appeal resolution process;
   

2. 
   The date that the appeal decision was made;
   

3. 
   If the appeal is not resolved wholly in favor of the beneficiary, the notice shall also contain information regarding the beneficiary's right to a fair hearing and the procedure for filing for a fair hearing, if the beneficiary has not already requested a fair hearing on the issue involved in the appeal.
   

4. 
   If the appeal is not resolved wholly in favor of the beneficiary, the notice shall include information on the beneficiary’s right to continue to receive benefits while the fair hearing is pending and how to request the continuation of benefits. Such notice shall state that the beneficiary could be held liable for the cost of services received, if his or her appeal is not granted as a result of the fair hearing.
   

3. 
   If the decision of the appeal resolution process reverses a decision to deny, limit or delay services, the Contractor shall promptly provide or arrange and pay for the services at issue in the appeal.
   

4. 
   Expedited Appeal Process.
   

1. 
   Be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that taking the time for a standard appeal resolution could seriously jeopardize the beneficiary's life, health or ability to attain, maintain, or regain maximum function.
   

2. 
   Pursuant to Title 42, CFR, Section 438.402(b)(3), the Contractor must allow the beneficiary to file the request for an expedited appeal orally without requiring that the request be followed by a written appeal.
   

3. 
   Ensure that punitive action is not taken against a beneficiary or a provider because they request an expedited appeal or support a beneficiary's request for an expedited appeal.
   

4. 
   Pursuant to Title 42, CFR, Section 438.408(a-c), the Contractor must resolve an expedited appeal and notify the affected parties in writing, no later than three working days after the Contractor receives the appeal. This timeframe may be extended by up to 14 calendar days if the beneficiary requests an extension, or the Contractor determines that there is need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframes, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in Title 9, CCR, Section 1810.230.5.
   

5. 
   Pursuant to Title 42, CFR, Section 438.408(d)(2), the Contractor must provide a beneficiary with a written notice of the expedited appeal disposition and make reasonable efforts to provide oral notice to the beneficiary and/or his or her representative. The written notice shall meet the requirements of Section 1850.207(h).
   

6. 
   Pursuant to Title 42, CFR, Section 438.410(c), if the Contractor denies a request for expedited appeal resolution, the Contractor shall:
   

1. 
   Transfer the expedited appeal request to the timeframe for appeal resolution as required by Title 9, CCR, Section 1850.207(c).
   

2. 
   Make reasonable efforts to give the beneficiary and his or her representative prompt oral notice of the denial of the request for an expedited appeal and provide written notice within two calendar days of the date of the denial. The written notice of the denial of the request for an expedited appeal is not a Notice of Action as defined in Title 9, CCR, Section 1810.230.5.
   

5. 
   Beneficiary Problem Resolution Processes Established by Providers.
   

1. 
   The Contractor delegates the responsibility for the beneficiary problem resolution process to the provider in writing, specifically outlining the provider's responsibility under the delegation;
   

2. 
   The provider's beneficiary problem resolution process fully complies with this Section of the contract, the relevant provisions of Title 42, CFR, Subpart F, Title 9, CCR, Sections 1850.205 and 1850.209, and depending on processes delegated, Title 9, CCR, Sections 1850.206, 1850.207, and/or 1850.208; and
   

3. 
   No beneficiary is prevented from accessing the grievance, appeal or expedited appeal processes solely on the grounds that the grievance, appeal or expedited appeal was incorrectly filed with either the Contractor or the provider.
   

6. 
   Fair Hearing.
   

1. 
   If a beneficiary requests a State Fair Hearing, the Department (not the Contractor) shall grant the request. The right to a State Fair Hearing, how to obtain a hearing, and representation rules at a hearing must be explained to the beneficiary and provider by Contractor in its notice of decision or notice of action. Beneficiaries and providers shall also be informed of the following:
   

1. 
   A beneficiary may request a State Fair Hearing.
   

2. 
   The provider may request a State Fair Hearing only if the Department permits the provider to act as the beneficiary's authorized representative.
   

3. 
   The Department must permit the beneficiary to request a State Fair Hearing within a reasonable time period specified by the Department, not in excess of 90 days from whichever of the following dates applies:
   

1. 
   From the date indicated on the Contractor’s notice of action, if the Department does not require exhaustion of the Contractor-level appeal procedures and the beneficiary appeals directly to the Department for a fair hearing.
   

2. 
   From the date indicated on the Contractor’s notice of resolution, if the Department requires exhaustion of Contractor-level appeals.
   

2. 
   The Department must reach its decisions within the specified timeframes:
   

1. 
   Standard resolution: within 90 days of the date the beneficiary filed the appeal with the Contractor, if the beneficiary filed initially with the Contractor (excluding the days the beneficiary took to subsequently file for a State Fair Hearing), or the date the beneficiary filed for direct access to a State Fair Hearing.
   
2. 
   Expedited resolution (if the appeal was heard first through the Contractor appeal process): within 3 working days from agency receipt of a hearing request for a denial of a service that:
   

1. 
   Meets the criteria for an expedited appeal process but was not resolved using the Contractor’s expedited appeal timeframes, or
   

2. 
   Was resolved wholly or partially adversely to the beneficiary using the Contractor’s expedited appeal timeframes.
   

3. 
   Pursuant to Title 42, CFR, Section 438.408(f)(2), the parties to the State Fair Hearing include the Contractor as well as the beneficiary and his or her representative or the representative of a deceased beneficiary's estate.
   

7. 
   Expedited Fair Hearing.
   

8. 
   Continuation of Services Pending Fair Hearing Decision.
   

1. 
   A beneficiary receiving specialty mental health services pursuant to this Chapter shall have a right to file for continuation of specialty mental health services pending the outcome of a fair hearing pursuant to Title 22, Section 51014.2, and Title 9, CCR, Section 1850.215.
   

2. 
   The Contractor shall continue to provide specialty mental health services pending the outcome of a fair hearing in accordance with Title 22, Section 51014.2. If the Contractor allows providers to deliver specialty mental health services for a set number of visits or a set duration of time without prior authorization, the Contractor shall continue to provide specialty mental health services pending the outcome of a fair hearing when the Contractor denies a payment authorization request from a provider requesting continuation of services beyond the number or duration permitted without prior authorization and the beneficiary files a timely request for fair hearing.
   

3. 
   Before requesting a state fair hearing, the beneficiary must exhaust the Contractor's problem resolution processes as described in Title 9, CCR, Section 1850.205.
   

9. 
   Provision of Notice of Action.
   

(a) A denial, modification, reduction or termination of a provider's request for MHP payment authorization of a specialty mental health service covered by the MHP.

(b) A determination by the MHP or its providers that the medical necessity criteria in Section 1830.205(b)(1), (b)(2), (b)(3)(C), or 1830.210(a) have not been met and the beneficiary is not entitled to any specialty mental health services from the MHP.

(c) A failure by the MHP to provide a specialty mental health service covered by the MHP within the timeframe for delivery of the service established by the MHP; or

(d) A failure by the MHP to act within the timeframes for resolution of grievances, appeals, or the expedited appeals.

Pursuant to Title 42, CFR, Section 438.404(a), the notice of action shall be in writing and shall meet the language and format requirements of Title 42, CFR, Section 438.10(c) and (d). The notice of action shall contain the items specified in Title 42, CFR, Section 438.404(a) and (b) and Title 9, CCR, Sections 1850.210.

1. 
   The Contractor shall provide a beneficiary with a Notice of Action when the Contractor denies or modifies a Contractor payment authorization request from a provider for a specialty mental health service to the beneficiary.
   

2. 
   When the denial or modification involves a request from a provider for continued Contractor payment authorization of a specialty mental health service or when the Contractor reduces or terminates a previously approved Contractor payment authorization, notice shall be provided in accordance with Title 22, CCR, Section 51014.1.
   

3. 
   A Notice of Action is not required when a denial is a non-binding verbal description to a provider of the specialty mental health services that may be approved by the Contractor.
   

4. 
   A Notice of Action is not required when the Contractor modifies the duration of any approved specialty mental health services as long as the Contractor provides an opportunity for the provider to request Contractor payment authorization of additional specialty mental health services before the end of the approved duration of services.
   

5. 
   Except as provided in subsection 6 below, a Notice of Action is not required when the denial or modification is a denial or modification of a request for Contractor payment authorization for a specialty mental health service that has already been provided to the beneficiary.
   

6. 
   A Notice of Action is required when the Contractor denies or modifies a payment authorization request from a provider for a specialty mental health service that has already been provided to the beneficiary when the denial or modification is a result of post-service, prepayment determination by the Contractor that the service was not medically necessary or otherwise was not a service covered by the Contractor.
   

7. 
   The Contractor shall deny the Contractor payment authorization request and provide the beneficiary with a Notice of Action when the Contractor does not have sufficient information to approve or modify, or deny on the merits, a Contractor payment authorization request from a provider within the timeframes required by Title 9, CCR, Sections 1820.220 or 1830.215.
   

8. 
   The Contractor shall provide the beneficiary with a Notice of Action if the Contractor fails to notify the affected parties of a grievance decision within 60 calendar days, of an appeal decision within 45 days, or of an expedited appeal decision within three working days. If the timeframe for a grievance, appeal or expedited appeal decision is extended pursuant to Title 9, CCR, Sections 1850.206, 1850.207 or 1850.208 and the Contractor failed to notify the affected parties of its decision within the extension period, the Contractor shall provide the beneficiary with a Notice of Action.
   

9. 
   The Contractor shall provide a beneficiary with a Notice of Action if the Contractor fails to provide a specialty mental health service covered by the Contractor within the timeframe for delivery of the service established by the Contractor.
   

10. 
    The Contractor shall comply with the requirements of Title 42, CFR, Section 438.404(b), and Title 9, CCR, Section 1850.210, regarding the content of Notices of Action and with the following timeframes for mailing of Notices of Action:
    

1. 
   The written Notice of Action issued pursuant to (1) or (6) above shall be deposited with the United States Postal Service in time for pick-up no later than the third working day after the action. A Notice of Action issued pursuant to (2) above shall be provided in accordance with the applicable timelines set forth in Title 22, Section 51014.1 and Title 42, CFR, 431.220(E).
   

2. 
   The written Notice of Action issued pursuant to (7) or (8) above shall be deposited with the United States Postal Service in time for pick-up on the date that the applicable timeframe expires.
   
3. 
   The written Notice of Action issued pursuant to subsection (9) above shall be deposited with the United States Postal Service in time for pick up on the date that the timeframe for delivery of the service established by the Contractor expires.
   

11. 
    When a Notice of Action would not be required as described in (3)-(5) above, the Contractor shall provide a beneficiary with a Notice of Action when the Contractor or its providers determine that the medical necessity criteria in Title 9, CCR, Section 1830.205(b)(1),(b)(2),(b)(3)(C), or 1830.210(a) have not been met and that the beneficiary is, therefore, not entitled to any specialty mental health services from the Contractor. A Notice of Action is not required when a provider, including the Contractor acting as a provider, determines that a beneficiary does not qualify for a specific service covered by the Contractor, including but not limited to: crisis intervention, crisis stabilization, crisis residential treatment services, psychiatric inpatient hospital services, or any specialty mental health service to treat a beneficiary's urgent condition, provided that the determination does not apply to any other specialty mental health service covered by the Contractor. The Notice of Action shall, at the election of the Contractor, be hand-delivered to the beneficiary on the date of the action or mailed to the beneficiary in accordance with Title 9, CCR, Section 1850.210(f)(1), and shall specify the information contained in Title 9, CCR, Section 1850.212(b).
    

12. 
    For the purpose of this Section, each reference to a Medi-Cal managed care plan in Title 22, Section 51014.1, shall mean the Contractor.
    

13. 
    For the purposes of this Section, “medical service”, as used in Title 22, Section 51014.1, shall mean specialty mental health services that are subject to prior authorization by a Contractor pursuant to Title 9, CCR, Sections 1820.100 and 1830.100.
    

14. 
    The Contractor shall retain copies of all Notices of Action issued to beneficiaries under this Section in a centralized file accessible to the Department and DHCS.
    

10. 
    Contents of a Notice of Action.
    

1. 
   The Notice of Action issued pursuant to Section I of this contract and Title 42, CFR, Section 438.404(b) and Title 9, CCR, Sections 1850.210(a)-(e) and 1850.212, shall contain the following information:
   

1. 
   The action taken by the Contractor;
   

2. 
   The reason for the action taken;
   

3. 
   Citations to the regulations or Contractor payment authorization procedures supporting the action;
   

4. 
   The beneficiary's right to file an appeal or expedited appeal with the Contractor; and,
   

5. 
   The circumstances under which an expedited resolution is available, and how to request it; and,
   

6. 
   Information about the beneficiary's right to request a fair hearing or an expedited fair hearing, including:
   

1. 
   The method by which a hearing may be obtained;
   

2. 
   A statement that the beneficiary may be either self-represented, or represented by an authorized third party such as legal counsel, a relative, friend or any other person;
   

3. 
   An explanation of the circumstances under which a specialty mental health service will be continued if a fair hearing is requested; and,
   

4. 
   The time limits for requesting a fair hearing or an expedited fair hearing.
   

2) A Notice of Action issued pursuant to Title 9, CCR, Sections 1850.210(g) and 1850.212(b), relating to denials for lack of medical necessity, shall specify the following:

1. 
   The reason that the medical necessity criteria were not met, including a citation to the applicable regulation;
   

2. 
   The beneficiary's options for obtaining care from sources other than the Contractor, if applicable;
   

3. 
   The beneficiary's right to request a second opinion on the determination;
   

4. 
   The beneficiary's right to file an appeal or expedited appeal with the Contractor; and,
   

5. 
   The beneficiary's right to request a fair hearing or an expedited fair hearing, including:
   

1. 
   The method by which a hearing may be obtained;
   
2. 
   The time period in which the request for a fair hearing or expedited fair hearing must be filed;
   
3. 
   That the beneficiary may be either self–represented, or represented by an authorized third party such as legal counsel, a relative, friend or any other person;
   

K. Pursuant to Title 42, CFR, Section 438.404(c), the Contractor shall give notice at least 10 days before the effective date of action when the action is a termination, suspension, or reduction of previously authorized Medi-Cal-covered services, except:

1. 
   The period of advanced notice is shortened to 5 days if probable beneficiary fraud has been verified;
   

2. 
   The action shall be effective on the date of the Notice under the following circumstances:
   

1. 
   The death of a beneficiary;
   

2. 
   Receipt of a signed written beneficiary statement requesting service termination or giving information requiring termination or reduction of services (provided the beneficiary understands that this will be the result of supplying that information);
   

3. 
   The beneficiary's admission to an institution where he or she is ineligible for further services;
   

4. 
   The beneficiary's whereabouts are unknown and mail directed to him or her has no forwarding address;
   

5. 
   Notice that the beneficiary has been accepted for Medicaid services by another local jurisdiction;
   

6. 
   A change in the beneficiary's physician’s prescription for the level of medical care;
   

7. 
   Endangerment of the safety or health of individuals in the facility; improvement in the resident’s health sufficient to allow a more immediate transfer or discharge; urgent medical needs that require a resident’s immediate transfer or discharge; or notice that a resident has not resided in the nursing facility for 30 days (but only in adverse actions based on NF transfers).
   

3. 
   Pursuant to Title 42, CFR, Section 438.404(c)(2), timeframes for notice of action of denial of payment. If payment is denied, the Contractor shall give notice to the beneficiary on the date of the action.