Superior Systems Waiver

The federal Centers for Medicare & Medicaid Services has approved the Superior Systems Waiver (SSW) renewal application, effective for a five-year period, October 1, 2019 through September 30, 2024. The approved waiver is located in the section below.

The SSW describes the utilization review process for acute inpatient hospitals that serve fee-for-service Medi-Cal patients. It specifies how the non-designated public hospitals and private hospitals will use their own utilization management systems using nationally recognized, evidence-based medical criteria in lieu of a treatment authorization requests (TAR) for most services.

In this approach, DHCS conducts post-payment clinical and administrative monitoring and oversight. This utilization management method is being used by most of California’s designated public hospitals, which DHCS has already transitioned from the TAR process.

DHCS initiated this in a pilot project fashion, beginning with a small group of 11 hospitals in February of 2016. This measured implementation plan will help DHCS ensure that appropriate processes and system changes are in place so that hospital claims can be paid in a timely manner.

Please direct your comments, questions, and suggestions regarding the SSW renewal to the following Clinical Assurance Division (CAD) email address: SSWRenewal@dhcs.ca.gov.