Utilization Management Guidelines for Children's State Plan and Demonstration Services for Medicaid Managed Care Plans

October 2017i

  • Guidelines also available in Portable Document Format
Service Prior Authorization Concurrent Authorization Additional Guidance
Outpatient Clinic: Services including initial assessment; psychosocial assessment; and individual, family/collateral, group psychotherapy, and Licensed Behavioral Practitioner (LBHP). No Yes MMCOs/HARPs must pay for at least 30 visits per calendar year without requiring authorization. MMCOs/HARPs must ensure that concurrent review activities do not violate parity law. Note: the 30–visit count should not include: a) FFS visits or visits paid by another MMCO/HARP; or b) psychiatric assessment and medication management visits. Multiple services received on the same day shall count as a single visit (and must be delivered consistent with OMH clinic restructuring regulations).
Mental Health Clinic Services: Psychiatric Assessment; Medication Treatment No No MH clinic visits exclusively for Medication Management or Psychiatric Assessment will not count towards the 30 visits per calendar year.
Psychological or neuropsychological testing Yes N/A  
Mental Health Partial Hospitalization Yes Yes  
Mental Health Continuing Day Treatment (CDT) Yes Yes  
Personalized Recovery Oriented Services (PROS) Pre–Admission Status No No Begins with initial visit and ends when Initial Service Recommendation (ISR) is submitted to Plan. Providers bill the monthly Pre–Admission rate but add–ons are not allowed. Pre– Admission is open–ended with no time limit
PROS Admission: Individualized Recovery Planning Yes No Admission begins when Individual Service Recommendation (ISR) is approved by Plan. Initial Individualized Recovery Plan (IRP) must be developed within 60 days of the admission date. Upon admission, providers may offer additional services and bill add–on rates accordingly for:
  • Clinical Treatment;
  • Intensive Rehabilitation (IR); or
  • Ongoing Rehabilitation and Supports (ORS).
Prior authorization will ensure that individuals are not receiving duplicate services from other clinical or BH HCBS providers.
PROS Active Rehabilitation Yes Yes  
Assertive Community Treatment (ACT) Yes Yes Plans will collaborate with SPOA agencies around determinations of eligibility and appropriateness for ACT following NYS guidelines. New ACT referrals must be made through local Single Point Of Access (SPOA) agencies.
Plans will collaborate with SPOA to facilitate referrals. In NYC, the referring provider contacts MMCO/HARP to request ACT referral. Provider and MMCO/HARP care manager review whether the member meets ACT level of care admission criteria. The MMCO/HARP notifies the referring provider a level of service determination (LOSD) to the referring provider that a level of service determination for ACT admission has been made. T he provider sends the referral and LOSD to SPOA.
In ROS, the referring provider makes a SPOA referral and contacts MMCO/HARP to request an ACT level of service determination. The referring provider and MMCO/HARP care manager review whether the member meets ACT level of care admission criteria. Simultaneously, SPOA reviews the referral and assesses for capacity/availability of ACT slot. The MMCO/HARP notifies the referring provider and LGU/SPOA that a level of service determination for ACT admission has been made.
OASAS outpatient rehabilitation programs No Yes  
OASAS outpatient and opioid treatment program (OTP) services No Yes  
Outpatient and Residential Addiction services No Yes  
Residential Supports and Services No Yes  
Other Licensed Practitioner (OLP) No Yes MMCOs may not require prior authorization for the initial provider assessment. As indicated in the SPA all treatment plans* must be prior authorized by DOH or its designee, in this case that designee is MMCO. Therefore, the MMCO will review the treatment plan, inclusive of the provider assessment, to evaluate medical necessity for authorization prior to receipt of further services. The initial authorization must be inclusive of at least 30 service visits. The MMCO will review services at reasonable intervals thereafter (as determined by the MMCO and consistent with the child´s treatment plan and/or Health Home plan of care). The MMCO must ensure that prior and concurrent review activities do not violate parity law.
Note: the 30–visit count should not include: a) FFS visits or visits paid by another MMCO; or b) psychiatric assessment and medication management visits. Multiple services received on the same day shall count as a single visit (and must be delivered consistent with OMH clinic restructuring regulations).

* Treatment plan in this context indicates the needed clinical or functional information the MMCO needs from the treating provider in order to evaluate medical necessity for each service in the applicable MMCO benefit package.
Crisis Intervention No No None
Community Psychiatric Supports and Treatment (CPST) Yes Yes MMCOs may not require prior authorization for the initial provider assessment. As indicated in the SPA all treatment plans* must be prior authorized by DOH or its designee, in this case that designee is MMCO. Therefore, the MMCO will review the treatment plan, inclusive of the provider assessment, to evaluate medical necessity for authorization prior to receipt of further services. The initial authorization must be inclusive of at least 30 service visits. The MMCO will review services at reasonable intervals thereafter (as determined by the MMCO and consistent with the child´s treatment plan and/or Health Home plan of care). The MMCO must ensure that prior and concurrent review activities do not violate parity law. Note: the 30–visit count should not include: a) FFS visits or visits paid by another MMCO; or b) psychiatric assessment and medication management visits. Multiple services received on the same day shall count as a single visit (and must be delivered consistent with OMH clinic restructuring regulations).

* Treatment plan in this context indicates the needed clinical or functional information the MMCO needs from the treating provider in order to evaluate medical necessity for each service in the applicable MMCO benefit package.
Psychosocial Rehabilitation (PSR) Yes Yes MMCOs may not require prior authorization for the initial provider assessment. As indicated in the SPA all treatment plans* must be prior authorized by DOH or its designee, in this case that designee is MMCO. Therefore, the MMCO will review the treatment plan, inclusive of the provider assessment, to evaluate medical necessity for authorization prior to receipt of further services. The initial authorization must be inclusive of at least 30 service visits. The MMCO will review services at reasonable intervals thereafter (as determined by the MMCO and consistent with the child´s treatment plan and/or Health Home plan of care). The MMCO must ensure that prior and concurrent review activities do not violate parity law. Note: the 30–visit count should not include: a) FFS visits or visits paid by another MMCO; or b) psychiatric assessment and medication management visits. Multiple services received on the same day shall count as a single visit (and must be delivered consistent with OMH clinic restructuring regulations).

* Treatment plan in this context indicates the needed clinical or functional information the MMCO needs from the treating provider in order to evaluate medical necessity for each service in the applicable MMCO benefit package.
Family Peer Supports and Services (FPSS) Yes Yes MMCOs may not require prior authorization for the initial provider assessment. As indicated in the SPA all treatment plans* must be prior authorized by DOH or its designee, in this case that designee is MMCO. Therefore, the MMCO will review the treatment plan, inclusive of the provider assessment, to evaluate medical necessity for authorization prior to receipt of further services. The initial authorization must be inclusive of at least 30 service visits. The MMCO will review services at reasonable intervals thereafter (as determined by the MMCO and consistent with the child´s treatment plan and/or Health Home plan of care). The MMCO must ensure that prior and concurrent review activities do not violate parity law. Note: the 30–visit count should not include: a) FFS visits or visits paid by another MMCO; or b) psychiatric assessment and medication management visits. Multiple services received on the same day shall count as a single visit (and must be delivered consistent with OMH clinic restructuring regulations).

* Treatment plan in this context indicates the needed clinical or functional information the MMCO needs from the treating provider in order to evaluate medical necessity for each service in the applicable MMCO benefit package.
Youth Peer Support and Training (YPST) Yes Yes MMCOs may not require prior authorization for the initial provider assessment. As indicated in the SPA all treatment plans* must be prior authorized by DOH or its designee, in this case that designee is MMCO. Therefore, the MMCO will review the treatment plan, inclusive of the provider assessment, to evaluate medical necessity for authorization prior to receipt of further services. The initial authorization must be inclusive of at least 30 service visits. The MMCO will review services at reasonable intervals thereafter (as determined by the MMCO and consistent with the child´s treatment plan and/or Health Home plan of care). The MMCO must ensure that prior and concurrent review activities do not violate parity law. Note: the 30–visit count should not include: a) FFS visits or visits paid by another MMCO; or b) psychiatric assessment and medication management visits. Multiple services received on the same day shall count as a single visit (and must be delivered consistent with OMH clinic restructuring regulations).

* Treatment plan in this context indicates the needed clinical or functional information the MMCO needs from the treating provider in order to evaluate medical necessity for each service in the applicable MMCO benefit package.

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i. Additional policy guidance regarding utilization review requirements is forthcoming.  i