Medicaid Managed Care Behavioral Health Service Denials in Philadelphia by Community Behavioral Health

CBH did not comply with address-change notification procedures and sent denial notices to incorrect addresses (17 denied service requests).

CBH did not provide timely notification that a request was denied (1 denied service request).

CBH did not inform enrollees of their right to access all relevant documents free of charge (all 100 denied service requests).

CBH issued denial notices that did not clearly explain the adverse benefit determinations (14 denied service requests).

CBH did not document the extra steps it took to request that the enrollee’s representative contact the provider before CBH denied services for enrollees under 21 (34 denied service requests).

Update CBH policies and procedures to reconcile address discrepancies between addresses of record and addresses given to treatment providers and implement a process to determine residency changes and notify the County Assistance Office accordingly.

Implement a process for identifying service requests that are considered approved because a decision notification was not sent within the 21-day window.

Coordinate with the State agency to implement a revised initial denial notice informing enrollees of their right to access all documents, records, and other information relevant to the adverse benefit determination, free of charge, as required by 42 CFR 438.404(b)(2).

Revise the denial notice language to clarify when services are denied as requested but alternative services not requiring prior authorization are recommended, as opposed to an outright denial with no alternatives.

Update CBH policies to require staff to document steps taken to contact the enrollee’s representative to request that the representative ask the provider to communicate with CBH, and efforts to reach the provider before denial notices for enrollees under 21.

State agency: Revise the HealthChoices denial notice template to include a statement that the enrollee has the right to receive, upon request and at no charge, all documents and records relevant to the adverse determination.