Violation Category: Residential Treatment
Short Description: Plaintiff suffered from addiction and on August 30, 2013, he was admitted to Malvern Institute, an inpatient, non-hospital addiction treatment facility, for detoxification. Plaintiff transferred to Malvern’s residential treatment program on September 5, 2013. His treatment in the residential treatment program was not authorized, and thus not paid for, by his health insurance carrier. Before his transfer from the detoxification program to the residential treatment program, Plaintiff’s providers requested preauthorization from Independence Blue Cross’s (IBC) mental healthcare subcontractor, Magellan Behavioral Health (Magellan). Magellan denied the request. Plaintiff <span class="SS_CRBHighlight" data-id="I3BDYJGBF2X0008GT0S002MJ"><span class="SS_RFCPassage_Deactivated" data-func="LN.Advance.ContentView.getCitationMap" data-docid="5F46-S791-F04F-4013-00000-00" data-rfcid="I5F9P8K22HM6B60040000400">appealed to IBC and OPM simultaneously. OPM issued a final denial for treatment coverage, stating: </span></span>(1) the plan does not cover services billed by residential treatment facilities, and (2) Malvern is not a preferred provider.
Appeal/Disposition: Upon consideration of Plaintiff’s Complaint, Defendant’s Motion for a Protective Order Staying Discovery and to Quash Subpoena, Plaintiff’s responses thereto, and Defendant’s Motion to Dismiss or, in the Alternative, for Summary Judgment Plaintiff’s response, Defendant’s reply, and Plaintiff’s sur-reply, Court denied Defendant’s Motion to Dismiss and granted Defendant’s Motion for Protective Order Staying Discovery to the extent that the Clerk of Court is directed to remand this matter to OPM to evaluate Smith’s claim for benefits in light of his contention that the Independence Blue Cross plan violates the law and to compile an administrative record related to its contract with Independence Blue Cross, including an explanation of its reasons for approving a plan that excludes residential treatment facilities.