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Recent Case Wins by MHAIP
MHAIP Leverages NY State Regulator - Wins Overturn and Secures Claims Reimbursements
MHAIP has recently seen yet another case where a health plan was not paying claims for a period of residential treatment that had already been authorized. This was a New York State regulated plan for a teen female diagnosed with OCD, ADHD, agoraphobia and GAD. It was only after we filed an external review request with the regulator that the health plan issued payment. This despite the fact we had clearly lodged provider disputes through the appropriate channels, and there was no reason given for nonpayment. This resulted in recovery of more than $80,000 for the initial 82 days.
Overturn on External Review for Medical Necessity and Network Exception Denials
A 17-year-old from New Hampshire admitted to a residential program in New Hampshire, and care was authorized for 45 days. Though the plan had no facilities that could treat a teen with OCD, our request for a Network Exception was denied upon admission. United Behavioral Health (UBH) wrongly told the member that they were required to use their out-of-network benefits, despite evidence to the contrary. The member went on a home visit, which is a key part of the therapeutic process in residential therapy, and UBH denied care from the date of return. Our appeals to the plan were denied. We filed a request for External Review with the Massachusetts regulator, and both the network exception and the denial post home visit were overturned, securing 74 additional days (total 119 days covered) at the in-network benefit level.
9 Months of PHP Level of Care Won on Appeal
MHAIP successful appealed the denial of PHP level of care for a teen boy with autism spectrum disorder, major depressive disorder, obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD) with the California Department of Managed Healthcare and won 9 months of coverage at Heritage Residential Treatment Center.
Highlights of Pre-Authorization/UR Services
AD, a 16-year-old from California with MDD, GAD and Anorexia NOS received 64 days and ongoing from AETNA at a treatment center in New Hampshire.
EC, a 15-year-old from New Jersey with Specific Phobia, Separation Anxiety D/O and GAD, received 86 days covered by United at a treatment center in New Hampshire.
EM, a 19-year-old from Virginia with Autism and Persistent Depressive Disorder, received 99 days covered by United at a treatment center in New Hampshire.
JE, a 15-year-old from PA with MDD, OCD, Autism Spectrum Disorder and GAD, received a network exception and 38 days and ongoing covered by Independence at a treatment center in New Hampshire.
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