CHA News Article

DHCS Seeks Comments on New Utilization Review Process

The California Department of Health Care Services (DHCS) has posted the draft Superior Systems Waiver (SSW) renewal application online for review and comment. The SSW describes the utilization review process for acute inpatient hospitals that serve fee-for-service Medi-Cal patients. Specifically, under the new waiver, private and non-designated public hospitals would transition to a utilization review system that no longer requires treatment authorization requests for the majority of acute inpatient stays. Instead, hospitals would use evidence-based medical criteria, such as Milliman or InterQual, to complete the utilization review. To ensure hospitals are appropriately using standardized medical review criteria, DHCS would review a statistically valid sample of cases approximately six months after claim submission.

The current SSW expires Sept. 30, and DHCS will submit the final renewal application to the federal Centers for Medicare & Medicaid Services no later than June 30. Comments on the draft may be submitted to DHCS no later than June 1 at CHA requests that members who have comments also submit them to Amber Ott at