Alert: Consumers Face Barriers Challenging Service Denials by Keystone First and AmeriHealth Caritas

Over the past few months, PHLP has documented numerous instances in which participants in Keystone First’s and AmeriHealth Caritas’ Medicaid managed care plans, including Community HealthChoices, have encountered interference with their rights when appealing service denial or service reductions.   

The deficiencies that participants have faced include Keystone’s and AmeriHealth Caritas’ include:  

  • failure to keep services that are being denied in place when someone appeals in time to be able to continue the services;  
  • failure to provide timely written notice of the date of a Grievance review;  
  • failure to include participants or their representatives in the Grievance review; 
  • failure to provide to participants all documents relevant to their Grievance so that they can understand the denial and prepare for their appeal;  
  • failure to send Grievance decisions timely;  
  • failure to implement grievance decisions; and,  
  • barriers to appealing Grievance decision.

PHLP has made the state aware of the deficiencies in Keystone’s and AmeriHealth Caritas’ appeals processes, and the state is closely monitoring the situation.  If you or someone you know confront problems with these or any other MCOs’ appeals processes, reach out to PHLP’s Helpline at 1-800-274-3258.   

For information on how to appeal service denials and appeal rights, see our article here.