Community Behavioral Health, a Medicaid behavioral health managed care plan in Philadelphia, didn’t meet federal and state requirements around prior authorization denials, according to a June audit report from HHS’ Office of Inspector General.
CBH received about $1.28 billion in Medicaid payments in 2023 and served roughly 100,600 people. The OIG said it selected CBH for review because it had the highest number of denied service requests of any behavioral managed care organization in the state. The agency sampled 100 of the 1,102 prior auth denials CBH issued in 2023 and found none of them complied with all applicable requirements.
Five flagged categories of noncompliance:
- Seventeen of 100 prior auth denial notices were sent to incorrect addresses, including six for enrollees experiencing homelessness. The OIG said CBH may have received capitation payments for the potentially ineligible enrollee for more than four years.
- One denial should have been automatically approved because CBH sent the notice 31 days after receiving the request, past the 21-day window in its contract.
- All 100 notices failed to inform enrollees of their right to obtain records relevant to the denial free of charge, which the OIG attributed to a deficiency in the state-provided template.
- 14 notices used a “denied completely” template while also recommending alternative services, which the OIG said could confuse enrollees about what was available.
- All 34 sampled cases involving enrollees under 21 lacked documentation that CBH asked the enrollee’s representative to have the provider contact the plan before the denial.
CBH concurred with two of the audit’s findings (addresses and the one late notice) but disputed the other three.
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