Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 1 – Complete Care Model

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3.1.11 Outpatient Specialty Services

  • Procedure Overview

    • This procedure describes the structures, processes and resources that California Correctional Health Care Services (CCHCS) and California Department of Corrections and Rehabilitation (CDCR) staff shall utilize to ensure patients have timely access to safe and cost-effective specialty services that are medically necessary in order to establish diagnoses, make recommendations for diagnostic work-up, provide therapy, and establish treatment plans that include frequency of follow-up appointments with the specialist or the Primary Care Provider (PCP).

  • Responsibility

    • Statewide

      • CCHCS and CDCR departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place and appropriate tools, training, technical assistance, and levels of resources are available to ensure patients have timely access to safe and cost-effective specialty services that are medically necessary.

    • Regional

      • Regional Health Care Executives are responsible for implementation of this procedure at the subset of institutions within an assigned region.

    • Institutional

      • The Chief Executive Officer (CEO) has overall responsibility for implementation and ongoing oversight of the system at the institution. The CEO and all members of the institution leadership team are responsible for establishing an organizational culture that promotes interdisciplinary teamwork and continuous process improvement. The CEO delegates decision-making authority to the Chief Medical Executive (CME) and Chief Nurse Executive (CNE) for daily operations of specialty services to ensure that resources are deployed to support the system including, but not limited to, the following:

        • Ensuring access to equipment, supplies, health information systems, Patient Registries, Patient Summaries, and evidence-based guidelines.

        • Adequately preparing new Care Team members to assume team roles and responsibilities, including onboarding.

        • Providing Care Team members with adequate resources, staffing, physical plant, information technology, and equipment and supplies to accomplish daily tasks.

        • Requiring that Care Team members review pertinent patient information related to access to specialty services.

        • Requiring that each Care Team conduct Population Management Working Sessions, pursuant to the Health Care Department Operations Manual (HCDOM), Section 3.1.6, Population and Care Management Services, utilizing tools such as Dashboards, Patient Registries, and Patient Summaries to address concerns related to potential gaps in specialty services.

        • Providing ongoing training and assessing competence of Care Team members.

        • Reviewing and comparing institution Care Team performance including the overall quality of services, health outcomes, assignment of consistent and adequate resources; utilization of Dashboards, Patient Registries, Patient Summaries, and decision support tools; and addressing issues as necessary.

        • Updating procedures, roles and responsibilities, and training as new tools and technology become available.

        • Collaborating with the Warden to ensure that custody staff are available to provide timely, safe, and efficient escort and transportation of patients to specialty appointments.

        • Requiring institution leadership to establish a consistent and dedicated back-up system to ensure that specialty services’ scheduling is managed when staff are on leave or otherwise unable to meet daily demands to avoid specialty care delays.

      • The CME is responsible for the overall medical management of patients and ensures resources are available to meet the needs of the population.

      • The CNE is responsible for:

        • Ensuring that the institution has a designated Supervising Registered Nurse (SRN) to monitor specialty scheduling processes on a daily basis and identify and address or elevate barriers to access. 

        • Managing and overseeing daily operations of the specialty scheduling system to include telemedicine and onsite and offsite scheduling processes.

        • Coordinating the delivery of health care services which includes familiarizing team members with the use of contracted services via access to and navigation of the provider directory.

        • Ensuring the most effective delivery of health care services to reduce cost and patient refusals by minimizing the need for long distance travel through effective use of the provider directory, local specialists, telemedicine services, and elevating scheduling and access to care issues to Direct Care Contracts’ Specialty Network Administration Program, and Headquarters (HQ) Utilization Management (UM) as necessary.

      • The Chief Physician and Surgeon (CP&S), SRN, and appropriate specialty services staff shall meet on an ongoing and weekly basis to ensure that patients with specialty referrals have timely access to these services.

      • The Institution Utilization Management Committee shall meet pursuant to the HCDOM, Section 1.2.15, Utilization Management Program, to review trends in specialty services including, but not limited to, timeliness of services and unexplained or significant outlier patterns of specialty services in order to reduce avoidable and unnecessary utilization and costs.

  • Procedure

    • General Requirements

      • An eConsult shall be initiated for appropriate specialties and conditions prior to generating a Request for Service (RFS).

      • Specialty services requests shall only be placed by PCPs or dentists who practice within CDCR. The ordering PCP shall complete the request in Cerner and shall indicate the timeframe in which the service is necessary (e.g., routine, medium, or high priority health care requests). Routine priority health care requests shall be the default priority for any health care request. Specialty service requests by a dentist shall follow Electronic Dental Record System Workflow #1-7.1 and Electronic Health Record System (EHRS) Workflow 100-71.

      • The PCP shall inform the patient of the plan for specialty referral including a general timeframe of expected service.

        • If a specialty service is scheduled outside of compliance timeframes, the Primary Care Team (PCT) shall evaluate and inform the patient that the requested service has been scheduled.

        • The information provided to the patient shall be documented in the health record.

        • The specific date, time, and location of the offsite appointment shall not be shared with the patient.

      • Patients with pending high priority specialty services shall be placed on a medical hold to prevent transfer and discontinuity of care pursuant to the HCDOM, Section 1.2.14, Medical Classification System.

      • If a patient is approved for a medium priority or routine priority specialty service and is subsequently transferred to another institution before the service occurs, the receiving institution shall continue with the original RFS and place an order maintaining the original compliance date unless the PCP at the receiving institution examines the patient and determines that it is no longer medically necessary or can be rescheduled to a later date. The PCP shall document their findings in the health record at the time the specialty service is cancelled or rescheduled.

      • The PCP or dentist shall continue to monitor the patient as clinically indicated, until the initial specialty service has occurred. The PCP or dentist shall document the patient encounters in the health record.

    • Pre-authorization Process

      • Emergent health care requests are exempt from the pre-authorization process. 

      • The PCP shall submit the RFS order for electronic routing to the UM nurse. The UM nurse shall complete the first level review to determine if the RFS order meets evidence-based clinical decision support criteria. 

      • Upon completion of the UM nurse review, the RFS order shall be electronically routed to the CME or CP&S for second level review.

      • At their discretion, the CME or CP&S may obtain input from other medical providers at the regularly scheduled provider meetings in order to determine medical necessity. The decision-making authority to approve or deny the RFS order at the second level remains with the CME or CP&S.

        • Requests for high or medium priority specialty services shall be processed in a manner that allows for both the first and second level of review to be completed within five calendar days from the date of the RFS order.

        • Requests for routine priority specialty services shall be processed in a manner that allows for both the first and second level of review to be completed within seven calendar days from the date of the RFS order.

      • The Statewide Medical Authorization Review Team (SMART) is the third level of review and shall review those services which are determined to require HQ approval within 30 calendar days of receipt of a routine priority health care RFS, 15 calendar days of receipt of a medium priority health care RFS, and seven calendar days of receipt of a high priority health care RFS. 

        • Notwithstanding the above, requests for gender affirming surgery (GAS) or revisions to GAS shall be processed in their entirety pursuant to the HCDOM, Section 1.2.16, Gender Affirming Surgery Review Committee. All GAS requests require an HQ level of review.

      • If the RFS order is denied, the reason for the denial shall be documented in the health record, and the PCP shall be notified via the health record. The PCP shall review the decision, and, if determined appropriate, resubmit the RFS with additional information, documenting any such action in the health record. The PCP shall discuss the decision and if necessary provide the patient with alternate treatment strategies during the next encounter which shall be within 30 calendar days of the denial of the specialty service. 

      • If the RFS order is approved, it shall be valid for 12 months even if the patient declines an appointment. Ongoing treatments such as for cancer, pacemaker or Automated Implantable Cardioverter Defibrillator interrogation, and hemodialysis require only an initial RFS and do not expire after 12 months.

      • The UM nurse or other designated specialty clinic staff shall determine if the services can be provided via telemedicine, onsite, or require an offsite appointment and schedule as appropriate. If a change in location is necessary at any point after the initial determination is made, a new RFS is not required unless the RFS has expired.

      • If after the patient has been scheduled for the specialty appointment and there is a need to schedule the patient with a different specialty provider, a new RFS is not required unless it has expired or the new specialty provider requests a new RFS.

      • If at any point the priority of the specialty services changes (e.g., from medium to high priority), a new RFS shall be submitted by the PCP.

      • Requests for specialty services from a dentist shall be approved by a Supervising Dentist (SD) or Regional Dental Director (RDD).

    • Patient Declined Appointments

      • The procedures set forth in HCDOM, Section 3.1.5, Scheduling and Access to Care, shall be followed for patients who decline to comply with specialty appointment ducats.

      • The declined appointment shall not be automatically rescheduled. Licensed health care staff shall:

        • Provide education to the patient using effective communication to ensure the patient is fully informed that they are declining a medically necessary service if the patient communicates their intention to decline.

        • Obtain a signed CDCR 7225, Refusal of Examination and/or Treatment, through an informed refusal process and subsequently cancel the order in the EHRS.

          • If the patient refuses to sign the CDCR 7225, two licensed health care staff shall sign.  In restricted housing units and specialized health care housing, the CDCR 7225 may be signed by two staff members, one of whom shall be a licensed health care staff.

        • Document the reason for declining the appointment in the EHRS and that effective communication was reached.

        • Message the Specialty RN upon conclusion of the encounter, confirming a signed CDCR 7225 was completed and is in the EHRS, so the Specialty RN can proceed with cancellation.

          • The Specialty RN shall message the licensed health care staff to ensure the patient is ducated to the clinic in order to obtain an informed refusal pursuant to the HCDOM, Section 3.1.5(c)(3)(C)3 if they are unable to confirm there is a signed CDCR 7225 in the EHRS for the respective specialty services appointment.

          • The licensed health care staff shall message the Specialty RN upon conclusion of the encounter, confirming a signed CDCR 7225 has been completed and is in the EHRS so that the Specialty RN can proceed with cancellation.

      • If the patient changes their mind regarding a specialty appointment refusal and wishes to see the specialist, the following actions shall be taken:

        • The PCP shall determine if the specialty service is still clinically indicated and, if so, message the Specialty RN.

          • If the initial RFS has expired, the Specialty RN shall request that the PCP place a new RFS order.

          • For initial specialty consults, the Specialty RN shall place a “referral to” order.

          • For follow-up specialty services, the PCP shall place a follow-up specialty order.

          • If the specialty service is no longer clinically indicated, the PCP shall discuss the treatment plan with the patient and document in the EHRS.

        • If the patient communicates their intention to be rescheduled for the specialty appointment via the CDCR 7362, Health Care Services Request Form, process or during a nursing encounter, the licensed health care staff shall message the PCP to determine if a primary care appointment is needed prior to proceeding with a new specialty service appointment.

          • If the PCP determines a primary care appointment is necessary, the patient shall be scheduled as appropriate.

          • If the PCP determines that the specialty service is still clinically indicated, they shall message the Specialty RN.

          • If the initial RFS has expired, the Specialty RN shall request that the PCP place a new RFS order.

          • For initial specialty consults, the Specialty RN shall place a “referral to” order.

          • For follow-up specialty services, the PCP shall place a follow-up order.

    • Specialty Appointments Occurring Outside the Institution

      • The designated health care staff shall complete the clinical portion of the CDC 7252, Request for Authorization of Temporary Removal for Medical Treatment, for health care services that are provided offsite.

      • The designated health care staff shall include relevant information for transportation staff regarding infectious precautions and disabilities requiring accommodation as well as any medical transportation needs in the “Remarks” section of the CDC 7252. 

      • The designated health care staff shall sign the completed CDC 7252 and forward it to the designated custody staff. Custody staff shall prepare the “Custodial status” of the CDC 7252 and shall ensure all necessary signatures are obtained.

      • Custody staff shall contact the institutional transportation team that provides transportation for the patient to the scheduled appointment.

      • The CME or CP&S shall prioritize the scheduled appointments when transportation needs exceed custody availability. Appointments shall be rescheduled and should not exceed the initial timeframe based on clinical needs.

      • The designated health care staff shall place a copy of the RFS order and any other pertinent clinical information in an envelope and provide it to custody staff for delivery to the specialty provider. Pertinent clinical information includes, but is not limited to:

        • For initial encounters:

          • CDC 7243, Health Care Services Physician Request for Services.

          • Health care provider’s progress notes.

          • Relevant laboratory studies, imaging studies, and diagnostic results.

          • Current medication profile and allergies.

          • Any additional pertinent information.

          • Effective communication accommodations shall be provided in accordance with the Armstrong Remedial Plan and related Court Orders.

        • For follow-up encounters:

          • Any subsequent consults, test results, diagnostic results, workups, and physician’s orders or recommendations requested as a result of previous encounter(s).

          • The status of the patient’s effective communication accommodations information shall be reviewed, and effective communication shall be provided in accordance with the Armstrong Remedial Plan and related court orders.

      • Custody staff shall obtain the clinical documentation including, but not limited to, the specialty consultation report, prescriptions, clinical notes, discharge summaries, and brief operative notes, from the specialty provider and return the clinical documentation to the Triage and Treatment Area (TTA) upon return of the patient to the institution. 

      • All patients who receive specialty services outside the institution shall be processed in the TTA (Standby Emergency Medical Services at California Health Care Facility) upon return to the institution.

      • The TTA RN shall assess the patient, review the findings and recommendations made by the specialist, and document their findings in the health record.

        • The TTA RN shall notify the PCP or on-call provider of any immediate medication or follow-up requirements. If the specialty appointment included treatment of fractures to the maxilla, mandible, dental related infection, or resulted in maxillo-mandibular fixation, the TTA RN shall also notify the SD or dentist on-call. If the specialty appointment included pathology specimen collection, the procedures listed in the HCDOM, Section 3.1.14, Laboratory Services, Appendix 3, Offsite Pathology Orders, shall be followed.

        • The TTA RN shall enter and implement all telephone orders given by the PCP or on-call provider including but not limited to, housing, Durable Medical Equipment (DME), treatments, and scheduling. For a follow-up appointment with the PCT, the provider shall remain on the line until the order has been read back and verified.

        • The TTA RN shall submit the clinical documentation to Health Information Management (HIM) staff for scanning into the health record.

      • If a patient returns without the clinical documentation, the TTA RN shall call the specialty provider to obtain a copy of the clinical documentation.

        • The telephone contact shall be documented by the TTA RN in the health record.

        • If the specialty provider is unavailable, the TTA RN shall contact the PCP or on-call provider for direction.

        • If unable to obtain the clinical documentation, the TTA RN shall inform HIM staff to obtain it.

      • Clinical documentation is required to be submitted by the specialty provider within 48 hours of the encounter with the exception of studies that require longer than 48 hours to complete. Exceptions include, but are not limited to, cultures, biopsies, pathology, cytology, cardiac lab studies, sleep lab studies, pulmonary studies, neurologic studies, and other specialized labs.

    • Specialty Clinic Appointments Occurring Within the Institution

      • If trained and provisioned access, the onsite specialty provider shall document their recommendations and findings in the health record or provide written documentation to the designated nursing staff on the day of the encounter.

      • If the onsite specialty provider is not trained and provisioned access to the health record, pertinent clinical information shall be provided including, but not limited to:

        • For initial encounters:

          • CDC 7243.

          • Health care provider’s progress notes.

          • Relevant laboratory studies, imaging studies, and diagnostic results.

          • Current medication profile and allergies.

          • Any additional pertinent information.

          • Effective communication accommodations shall be provided in accordance with the Armstrong Remedial Plan and related Court Orders.

        • For follow-up encounters:

          • Any subsequent consults, test results, diagnostic results, workups, and physician’s orders or recommendations requested as a result of previous encounter(s).

          • The status of the patient’s effective communication accommodations information shall be reviewed, and effective communication shall be provided in accordance with the Armstrong Remedial Plan and related court orders.

      • The designated nursing staff shall:

        • Review the findings and recommendations made by the specialty provider.

        • Notify the PCP or on-call provider of any immediate medication or follow-up requirements.

        • Implement all telephone orders given by the PCP or on-call provider including, but not limited to, housing, DME, treatments, and scheduling. For a follow-up appointment with the PCT, the provider shall remain on the line until the order has been read back and verified.

        • Forward all written documentation to HIM staff for scanning into the EHRS.

        • Forward documentation directly entered into the EHRS to the PCP for review.

    • Contracted Specialty Clinic Appointments Occurring via Telemedicine

      • Use of Clinical Presenters

        • Consistent with HCDOM, Section 3.4.1, Telemedicine Specialty Services and Primary Care, the Clinical Presenter or Telemedicine Coordinator presents the patient from the originating site to the hub site telemedicine services provider and is responsible for clinical support at the institution’s site during the telemedicine encounter.

        • The presenter shall be an RN trained to support the telemedicine clinic, who is available at the originating site to present the patient, manage the telemedicine peripheral examination instruments and assist in performing any hands-on exams to complete the encounter successfully.

      • Clinical Presenter Chart Review Prior to Clinic (Pre-Clinic)

        • It is the responsibility of the originating institution’s Telemedicine Coordinator to review the health record prior to the telemedicine encounter to ensure that all required testing and diagnostics have been conducted and that the results and reports have been uploaded to the web-based medical documents transfer system.

        • The clinical information required for the telemedicine encounter shall be uploaded to the Health Insurance Portability and Accountability Act (HIPAA)-compliant, web-based medical documents transfer system a minimum of three business days prior to the encounter. Any applicable, additional clinical information obtained between the date sent and the encounter shall be sent to the hub site provider or designee immediately. Patients without the required work-up may not be seen until the necessary pre-work-up has been completed.

          • For initial encounters, medical information shall be obtained per the telemedicine encounter checklist including, but not limited to:

            • CDC 7243.

            • Health care provider’s progress notes.

            • Relevant laboratory studies, imaging studies, and diagnostic results.

            • Current medication profile and allergies.

            • Any additional pertinent information.

            • Effective communication accommodations shall be provided in accordance with the Armstrong Remedial Plan and related Court Orders.

          • For follow-up encounters, medical information shall be obtained per the telemedicine encounter checklist, including:

            • Any subsequent consults, test results, diagnostic results, workups, and physician’s orders or recommendations requested as a result of previous encounter(s).

            • The status of the patient’s effective communication accommodations information shall be reviewed, and effective communication shall be provided in accordance with the Armstrong Remedial Plan and related court orders.

      • Use of the Health Record

        • The originating institution shall have the health record available at the time of the patient’s telemedicine encounter. The Clinical Presenter at the originating institution shall review the health record prior to the encounter and when necessary, or at the hub provider’s request, shall provide additional information from the health record.

      • Clinic Service Follow-up (Post-Clinic)

        • After all telemedicine encounters the Clinical Presenter shall complete the CDCR-approved effective communication documentation and shall document in the progress notes the hub provider’s name, specialty, date of the encounter, and note that the session was conducted via telemedicine.

        • The contracted, non-CCHCS hub provider shall dictate and sign a final consultation and recommendation and submit the documentation to the institution’s Telemedicine Coordinator at the originating site via the HIPAA-compliant, web-based medical documents transfer system within three business days from the encounter. These are considered to be the original records and are routed per the institution’s process for placement into the health record.

    • Follow-up with the Primary Care Team after Specialty Services

      • The PCP or dentist shall endorse the specialty consultation report within five calendar days of receipt and document in the health record that the review has been completed and whether the PCP or dentist agrees or disagrees with the specialist’s recommended actions. If there is disagreement with the recommended actions, the PCP or dentist shall document the reason for disagreement. If the PCP or dentist agrees with the specialist’s recommendation, the appropriate order(s) shall be placed.

      • Following a high priority specialty services appointment, the patient is required to be seen by the PCP or dentist within five calendar days.

      • Following a medium or routine priority specialty services appointment, the PCP shall review the clinical documentation and determine whether a primary care follow-up appointment is needed. If a PCP follow-up appointment is not needed, the PCP shall send a letter to the patient within five calendar days of receipt of the specialty report notifying them of relevant diagnostic study results, recommended specialty treatments that will be ordered, and the timeframe in which these treatments will be ordered.

      • After an initial appointment with a specialist, subsequent appointments with that specialist or recurrent treatments do not require a follow-up appointment with the PCP nor written patient notification unless there are significant changes in the treatment plan as determined by the PCP or there are other reasons the PCP determines follow-up or notification is necessary.

      • At the follow-up appointment, the PCP or dentist shall discuss the specialty provider’s findings and recommendations with the patient, as clinically appropriate, and document the discussion in the health record.

        • Ongoing treatments such as dialysis, chemotherapy, radiation therapy, pacemaker interrogations, and related follow-ups require only an initial approval to initiate the series of treatments and consultations.

        • If the specialty provider recommends a new procedure, surgery, or specialist consultation, and the PCP or dentist agrees with the specialty provider’s recommendations, a new RFS shall be submitted. 

        • Follow-up with the specialty provider after a procedure or surgery does not require another RFS order if completed within the global surgery schedule timeframes.

        • All other specialty follow-up services occurring 12 months after the date of the original RFS order require a new RFS order.

      • Specialty providers may not directly order follow-up consultations, diagnostic studies or treatments. The specialty provider shall make recommendations and the PCP or dentist shall review these recommendations to determine the need based on clinical guidelines, if applicable, and medical necessity.

        • If there are questions regarding medical necessity, the PCP shall discuss the case with the CME or designee including possible referral to the SMART.

        • If it is determined that the follow-up consultations, diagnostic studies or treatments recommended by the specialty provider do not meet clinical guidelines and are not medically necessary, the PCP shall document the reason in the health record.

        • If applicable, an eConsult shall be utilized.

        • Recommendations regarding dental treatments shall be approved by the SD or RDD.

    • Statewide Medical Authorization Review Team

      • The SMART is the third level of review and shall review cases appealed by the PCP or that meet criteria for a higher level of review to determine if the specialty service is medically necessary.

        • Membership

          • The SMART Chairperson shall be designated by the Deputy Director, Medical Services.

          • The SMART membership shall consist of Regional Deputy Medical Executives, at least two other headquarters-based physician managers, and two physician managers from the field.

        • 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 met when a minimum of 50 percent of the members are in attendance. A quorum must be present to take action on any agenda item.

        • Committee Proceedings Documentation

          • Records of committee proceedings shall be kept at a secure, accessible medical program site for a period of three years. At minimum, the record shall describe all committee actions and recommendations.

          • The proceedings and records of the SMART shall be confidential and protected from discovery to the extent permitted by law.

          • Patients shall be provided a letter stating the outcome of the SMART review.

  • References

    • California Civil Code, Division 1, Part 2.6, Section 56, et seq.

    • California Evidence Code, Division 9, Chapter 3, Section 1157

    • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.14, Medication Classification System

    • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.15, Utilization Management Program

    • 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 3.1.6, Population and Care Management Services

    • California Department of Corrections and Rehabilitation, Department Operations Manual, Section 62070.9.3

    • Centers for Medicare and Medicaid Services Global Surgery Booklet

  • Revision History

    • Effective: 04/2019
      Revised: 02/18/2026