Community Behavioral Health Did Not Comply With Requirements When Denying Prior Authorization Requests

Why OIG Did This Audit

• OIG has identified longstanding challenges, including insufficient oversight and limited access to specialists, that may reduce the quality of behavioral health care services provided to Medicaid enrollees.
• We audited Community Behavioral Health (CBH), a Pennsylvania behavioral health Medicaid managed care organization (BH-MCO), because it had the highest number of denied service requests of any BH-MCO in Pennsylvania.
• This audit is part of a series of reports examining Medicaid MCO denials; this is the first to review behavioral health service denials.

What OIG Found

None of the 100 denied service requests we sampled met all requirements for denying behavioral health service requests that required prior authorization. The findings raise concerns about CBH’s ability to protect enrollee rights under the Medicaid program.

• CBH may have delayed or denied medically necessary services or appeals.
• CBH sent denial notices to incorrect addresses.
• CBH issued unclear denial notices.
• Pennsylvania’s denial notice templates provided to CBH and other BH-MCOs did not inform Medicaid enrollees of their right to request copies of all documents and records relevant to the denial at no charge to the enrollee.

What OIG Recommends

We made five recommendations for CBH to improve how it communicates service denials—especially for children. We also made one recommendation for Pennsylvania to improve its denial notice templates. The full recommendations are in the report.

CBH did not indicate concurrence or nonoccurrence with our recommendations but stated that it concurred with two of our findings and detailed steps it has taken and plans to take in response to our recommendations. Pennsylvania concurred with the recommendation addressed to it.

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