Louisiana Healthcare Connections Generally Complied With Federal and State Process Requirements When Denying Prior Authorization Requests

Why OIG Did This Audit

• OIG has identified longstanding challenges, including limited oversight and access to specialists, thatmay reduce the quality of behavioral health care services provided to Medicaid enrollees.
• We audited Louisiana Healthcare Connections (LHCC), a Louisiana Medicaid managed care organization(MCO), because it had the highest number of denied service requests of any MCO in Louisiana.
• This audit, part of a series of reports examining Medicaid MCO service denials, assessed whether LHCCcomplied with Federal and State requirements when it denied requested behavioral health servicesthat required a prior authorization.

Results of Audit

LHCC complied with Federal and State requirements when it denied 64 of the 76 sampled behavioral health service requests that required a prior authorization. However, the remaining 12 denied service requests did not meet the administrative or procedural requirements. Specifically, LHCC did not:

• Provide written notices of adverse determinations (11 prior authorization denials)
• Provide written notice of adverse determination within the specified timeframe (1 prior authorization denial)

Based on the sample results, we estimated that 3,209 prior authorization denials for behavioral health service requests during our audit period (15.8 percent) did not comply with Federal and State requirements.

What OIG Recommends

This report does not contain recommendations.