Evidence record
New York Did Not Ensure That A Managed Care Organization Complied With Requirements For Denying Prior Authorization Requests
- Jurisdiction
- New York
- Publication date
- September 2023
- Source record
- Original document linked
Findings
1
Recommendations
3
Overall conclusion
The audit concluded that the New York State Department of Health’s oversight was ineffective in ensuring that CPHL complied with requirements for denying prior authorization requests, resulting in delays and potential adverse impacts on Medicaid enrollees' health and safety.
Scope
The audit covered denials of prior authorization requests for CPHL long-term care services and dental services during the period from April 2018 through March 2020. It included a review of 70 sampled denials that were overturned or withdrawn during internal appeals, external appeals, or fair hearing processes, and assessed CPHL's compliance with federal and state regulations regarding prior authorization denials.
Findings (1)
Each finding has a stable link.
- F-032
New York’s oversight of CPHL did not ensure compliance with requirements for denying prior authorization requests. Specifically, the monitoring procedures did not include obtaining and reviewing information related to initial denials and internal appeals before external appeals or fair hearings. For 35 of 70 sampled denials, CPHL justified denials with incorrect information in denial notices, leading to delays in access to services, with a median delay of 75 days and up to 282 days in one case.
Recommendations (3)
- R-035
Use the findings to determine CPHL's compliance and consider corrective actions or sanctions.
Related finding F-032 - R-036
Review and revise CPHL’s appeal process to ensure compliance with denial requirements.
Related finding F-032 - R-037
Implement procedures to obtain and review information related to MCOs’ initial denials and internal appeals.
Related finding F-032