10951.5. (Amended by Stats. 2018, Ch. 92, Sec. 230.)

(a) For a beneficiary of a Medi-Cal managed care plan who meets the criteria for an expedited resolution of an appeal as set forth in subdivision (c) of Section 14197.3 or Section 438.410 of Title 42 of the Code of Federal Regulations, the department shall take final administrative action as expeditiously as the individual’s health condition requires, but no later than three working days after the department receives, from the Medi-Cal managed care plan, the case file and information for any appeal of an adverse benefit determination that, as indicated by the Medi-Cal managed care plan or determined by the administrative law judge, meets either of the following criteria:

(1) Meets the criteria for expedited resolution as set forth in Section 438.410(a) of Title 42 of the Code of Federal Regulations, but was not resolved within the timeframe for expedited resolution.

(2) Was resolved within the timeframe for expedited resolution, but reached a decision wholly or partially adverse to the beneficiary.