Series: Medicaid Managed Care Organizations' Denials

LHCC complied with Federal and State requirements when it denied 64 of the 76 sampled behavioral health service requests that required a prior authorization. However, the remaining 12 denied service requests did not meet the administrative or procedural requirements. Specifically, LHCC did not:

• Provide written notices of adverse determinations (11 prior authorization denials)
• Provide written notice of adverse determination within the specified timeframe (1 prior authorization denial)

Based on the sample results, we estimated that 3,209 prior authorization denials for behavioral health service requests during our audit period (15.8 percent) did not comply with Federal and State requirements.

Of the 100 denied service requests we sampled, 21 did not comply with all Federal and State requirements for denying medical services and items, prescription drugs, and dental procedures that required a prior authorization. Of these 21 denied service requests that did not comply, 6 did not comply with more than one requirement. Specifically, Health Share:

• Denial decisions were not made by individuals with appropriate expertise in addressing the enrollees’ medical or oral health needs (13 denied service requests)
• Denial notices did not include required contact information or were not provided in the enrollee’s non-English language (7 denied service requests)
• Did not provide denial notices timely (6 denied service requests)
• Did not consult with providers before making a denial decision (4 denied service requests)
• Did not notify the provider of the denial decision (1 denied service request)

Based on our sample results, we estimated that 5,677 denied service requests that required a prior authorization (21 percent of the denied service requests covered by our audit) did not comply with all Federal and State requirements during calendar year 2023.