OIG: None of 100 Philadelphia CBH Denials Met the Rules. IBHS and ABA Were 36%.

The audit of Community Behavioral Health's 2023 denials found every children's denial skipped a required consultation step, and every notice omitted a right that Pennsylvania's own templates left out.

HHS-OIG audited Community Behavioral Health, Philadelphia's behavioral health Medicaid plan, and reported in June that “none of the 100 denied service requests we sampled met all requirements.” CBH denied 1,102 of 96,130 prior authorization requests in 2023. The category covering IBHS and ABA (assessment, initial treatment, behavior consultation) accounted for 395 denials, 36%, the most of any category.

The turn: part of the problem is statewide

Every one of the 100 notices failed to tell families they could get all documents relevant to the denial free of charge. OIG traced that to Pennsylvania's denial notice templates, provided “to CBH and other BH-MCOs.” Pennsylvania agreed to fix them. Notices from other HealthChoices behavioral health plans may have had the same gap.

For children, the HealthChoices agreement requires more before a denial. The plan must ask the enrollee, parent or representative to have the provider contact the plan, and must document that it asked. “In all 34 denied service requests in our sample associated with enrollees under 21 years of age, CBH did not provide any documentation” that it had done so.

The ABA case OIG singled out

  • A 2-year-old with autism. The request was for ABA consultation up to 6 hours a month and technician services up to 30 hours a month, for a year.
  • CBH denied it for lack of information, saying the order lacked a signature, an NPI and a PROMISe ID. OIG found the order was signed and had an NPI. Only the PROMISe ID was missing.
  • The denial came 14 days after a standard request letter, with no documented further contact. CBH approved the same services 27 days later.

Families grieved 63 of the 1,102 denials, and CBH overturned 13.

The limits

The data covers 2023. CBH didn't say whether it concurred with OIG's recommendations, though it agreed with two findings and described changes. The IBHS category isn't ABA alone, and the sample of 100 spans all service types.

What you must know or do

  • PA staff at Pennsylvania practices: add the prescriber's PROMISe ID to your written order template, next to the signature and NPI.
  • For any “lack of information” denial of a client under 21, ask the family whether the plan asked them to have you call. Then help them request the full case file, which is free. It shows whether the plan documented that step.
  • Help families grieve denials that cite information you can show was in the request. OIG's example is the pattern.