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Wraparound-impartial review I  

Opportunity for parents to supplement record for impartial review 

Whenever an MA managed care plan decides it is not going to authorize the amount or level of epsdt services (such as wraparound or summer therapeutic programs) prescribed for a child, the managed care plan must send in the documentation concerning the request and the reasons for the denial to DPW for review by a psychiatrist. This is called "impartial review". The MA managed care plan cannot put the denial into effect until after the DPW psychiatrist reviews the material sent by the managed care plan and then only if the DPW psychiatrist agrees with the managed care plan. Some parents have expressed concern that the managed care plans may not always submit all the documentation to MA especially information provided by the parent. This concern is bolstered by the fact that there is no good way for the parent to find out what the managed care plan sent to DPW unless and until the request is denied and the parent files an appeal. In response to those concerns, Mike Adams, Chief of OMHSAS Division of Grievance and Appeals, has agreed to forward any documentation faxed to him from a parent or prescriber to the DPW psychiatrist doing the impartial review in order to ensure the reviewing psychiatrist has all the pertinent documentation. Unfortunately, he can only do this for impartial reviews done for managed care plans outside of HealthChoices (Phila., Bucks, Chester, Delaware and Montgomery Cos.). For families outside of southeast PA whose managed care plan is sending their decision to reduce or terminate services to DPW for impartial review, they can fax the pertinent documentation they wish to have considered to Mike Adams at 717-772-7827.

David Gates
PA Health Law Project

Prepared by the Pennsylvania Health Law Project

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