RCPA - Rehabilitation and Community Providers Association


DPW Holds Training for MCOs on Denials
May 11, 2002

Previous reports from the Department of Public Welfare (DPW) indicated that there were a low number of denials reported in the HealthChoices program. PCPA members had reported a very different experience and the Association has been working with DPW to highlight the problem of the under reporting of denials. DPW has followed up on the concerns reported and has held special training sessions for counties and managed care organizations (MCOs) clarifying the definition of denials and reviewing the elements that must be included in a denial notice. They have also introduced a new quality improvement process to be used to monitor compliance.

Members are encouraged to contact the Association if denials continue to be experienced and not reported. Please keep in mind that denial is defined as follows:

Denial of Services - A determination made by a behavioral health managed care organization (BH-MCO) in response to a provider's request for approval to provide in-plan services of a specific duration and scope which:

  • disapproves the request completely; or
  • approves provision of the requested service(s), but for a lesser scope or duration than requested by the provider; (an approval of a requested service which includes a requirement for a concurrent review by the BH-MCO during the authorized period does not constitute a denial); or
  • disapproves provision of the requested service(s), but approves provision of an alternate service(s).

OMHSAS officials have emphasized that situations where a BH-MCO is unwilling to provide what is prescribed or wants to try a different set of services should be reported as denials. Also, instances where a provider feels the MCO is putting pressure on them directly or indirectly to change the prescribed services (which are in the clinical best interest of the client) should be reported as denials. The absence of a report of the denial eliminates the clients' opportunity to file a grievance. A report should occur so that it can go through the denial process.

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