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Keystone First Should Improve Its Procedures for Reviewing Service Requests That Require Prior Authorization

Submitting OIG:

Department of Health & Human Services OIG

Date Issued:

Tuesday, December 20, 2022

Agency Reviewed / Investigated:

Department of Health & Human Services

Submitting OIG-Specific Report Number:

A-03-20-00201

Component, if applicable:

Centers for Medicare & Medicaid Services

Centers for Medicare and Medicaid Services

External entity, if applicable:

Keystone First

Location(s):

PA,

United States

Type of Report:

Audit

Questioned Costs:

$0

Funds for Better Use:

$0

Number of Recommendations:

4

View Document:

Attachment	Size
32000201.pdf	1.38 MB

Related Open Recommendations

Recommendation Number	Recommendation Status	Significant Recommendation	Additional Details
23-A-03-021.01	Open	No
We recommend that Keystone First HealthChoices coordinate with the Pennsylvania Department of Human Services, Office of Medical Assistance Program, to update Keystone First's administrative process to require that medical directors assess whether overnight care requests meet the medical necessity requirement based on the documentation Keystone First has received even if some documentation, such as the caregiver's work verification documentation, is missing.
23-A-03-021.02	Open	No
Review all pediatric skilled nursing service requests for which overnight care was completely denied and determine whether the overnight care requests meet the medical necessity requirement regardless of whether the caregiver provided work or school verification documentation.
23-A-03-021.03	Open	No
Implement a revised initial denial notice to explain that a beneficiary has the right to request a State fair hearing after exhausting the MCO's appeals process.
23-A-03-021.04	Open	No
We recommend that the Pennsylvania Department of Human Services, Office of Medical Assistance Program, revise the initial denial notice template referenced under Exhibit N in the HealthChoices Agreement to include information regarding the beneficiary's right to request a State fair hearing after exhausting the MCO's appeals process.