Health Care Department Operations Manual

Chapter 1 – Health Care Governance and Administration

Article 2 – Health Care Program Governance

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1.2.21 Statewide Medical Authorization Review Team

Policy
- California Correctional Health Care Services (CCHCS) shall maintain a Statewide Medical Authorization Review Team (SMART) to ensure patients have timely access to medically necessary, safe, and cost-effective specialty services.
Procedure
- Statewide Medical Authorization Review Team
  - The SMART shall conduct the third level of review in the specialty services pre-authorization process for services that require headquarters (HQ) level approval.
  - The Chief Medical Executive (CME), or designee, is responsible for ensuring that requests for specialty services that require HQ level approval are submitted to the SMART along with all necessary clinical documentation
  - Membership
    - The SMART Chairperson and voting members shall be appointed by the DD, Medical Services.
    - The SMART membership shall consist of:
      - Regional Deputy Medical Executives.
      - At least two HQ Physician Managers.
      - At least two institution Physician Managers.
  - Meetings
    - The SMART shall meet as often as is necessary to conduct its business within established timeframes, but not less frequently than monthly.
    - A quorum is necessary to conduct business of the SMART and exists when a minimum of 50 percent of the voting members are in attendance. A quorum must be present to take action on any agenda item.
      - The SMART Chairperson, or designee, may serve as a voting member if needed to meet quorum.
    - In the event of a tie, the Chairperson shall vote in order to break the stalemate.
  - Committee Proceedings Documentation
    - At minimum, the record shall describe all committee actions and recommendations.
    - Records of committee proceedings shall be kept at a secure, accessible medical program site for a period of three years.
    - The proceedings and records of the SMART shall be confidential and protected from discovery to the extent permitted by law including, but not limited to, California Evidence, Code Section 1157.
- SMART Conflict of Interest
  A committee member shall not participate in deliberations or voting if they were the designated provider or approver of the second level review or has provided longitudinal care within the past 12 months. Such members may present information and respond to questions but may not vote.
- SMART Scope of Review
  - The procedures set forth in the Health Care Department Operations Manual (HCDOM), Section 3.1.11, Outpatient Specialty Services, shall be followed for the first and second level review of Requests for Services (RFS).
  - If the criteria for medical necessity is met, a physician manager shall refer the following services to the SMART:
    - Solid Organ Transplant.
    - Bariatric Surgery Evaluation.
    - Total Joint Replacement.
    - Spine Surgery.
    - Tubal Ligation.
    - Hysterectomy, except for requests related to gender affirming surgery.
    - Salpingectomy, except for requests related to gender affirming surgery.
    - Oophorectomy, except for requests related to gender affirming surgery.
    - Automatic Implantable Cardioverter Defibrillator.
    - Bone Growth Stimulator.
    - Cochlear Implants.
    - Device, Hardware, Appliance, or Controller Requiring Network Connectivity to Function (Wired, Wireless, Cellular, Bluetooth, or any other method).
    - Wearable Cardioverter Defibrillator.
    - Orchiectomy, except for requests related to gender affirming surgery.
    - An exclusion pursuant to Title 15, Section 3999.200(b).
- Submission of Documents
  - The Primary Care Provider shall complete and sign the SMART Requisition Form.
  - The Utilization Management Registered Nurse (UM RN) or a Primary Care Team member shall collect the following supporting documents:
    - Completed SMART requisition form.
    - Printed copy of the RFS.
    - Provider progress notes.
    - Relevant consultation notes.
    - Labs and diagnostic reports.
    - Additional supporting documentation (e.g., information chrono, nurse’s notes).
  - The UM RN shall notify SMART of a referral by emailing the documents to CDCRCCHCSSMART@cdcr.ca.gov within two business days of receiving the completed SMART requisition form.
- Headquarters Level of Review
  - Designated health care staff shall:
    - Review the submitted packet for completeness and request any missing documents from the UM RN.
    - Log and schedule the case for the SMART review once verified as complete.
  - Upon submission, referrals shall be reviewed as follows:
    - High Priority – within seven calendar days.
    - Routine Priority – within 30 calendar days.
  - SMART Decisions
    - The SMART Chairperson shall record the decision in the Electronic Health Record System (EHRS).
    - Designated health care staff shall prepare and submit a memorandum to the institution CME stating the outcome of the SMART review.
      - If approved, the referral order shall be electronically routed to the appropriate EHRS scheduling queue.
      - If denied, the patient shall be notified in accordance with HCDOM, Section 3.1.11, Outpatient Specialty Services, Section (c)(2)(F).
References
- California Evidence Code, Division 9, Chapter 3, Section 1157
- Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.16, Gender Affirming Surgery Review Committee
- Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.11, Outpatient Specialty Services
- Utilization Management Nursing Reference Manual
- Changes in Specialty Referral and Authorization Process Memorandum dated April 10, 2025
- CCHCS/DHCS Care Guide: Transgender
Policy Control
Executive Sponsor: Deputy Director, Medical Services
Effective: 08/24/2026