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

Date Issued

Tuesday, December 20, 2022

Submitting OIG

Department of Health & Human Services OIG

Other Participating OIGs

Department of Health & Human Services OIG

Agencies Reviewed/Investigated

Department of Health & Human Services

Components

Centers for Medicare and Medicaid Services

Report Number

A-03-20-00201

Report Type

Audit

Location

PA,
United States

Number of Recommendations

Questioned Costs

Funds for Better Use

External Entity

Keystone First

Open Recommendations

This report has 4 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
23-A-03-021.01	No	$0	$0
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	No	$0	$0
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	No	$0	$0
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	No	$0	$0
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.