EXAMPLE Medical Necessity Form - LPHA Recommendation for CFTSS
- Memo is also available in Portable Document Format (PDF)
To: New York State Children's Service Providers
Re: Accessing the new Children and Family Treatment and Support Services - An Example of a Medical Necessity/LPHA Recommendation Form (*Not a required form)
Date: December 5, 2019
Starting in January 2019, New York State (NYS) has launched new health and behavioral health services under Medicaid, called Children and Family Treatment and Support Services (CFTSS). The services include:
- Other Licensed Practitioner (OLP) - provides individual, group, or family therapy in the home or in the community for a child/youth who has or may be at risk of a mental health or substance use diagnosis.
- Community Psychiatric Supports and Treatment (CPST) - maintains children/youth in their home and community, by helping to improve communication and interactions with family, friends and others for a child/youth who has or may be at risk of a mental health or substance use diagnosis.
- Psychosocial Rehabilitation (PSR) - helps the child/youth relearn skills to help support the child/youth in their home, school and community. The child/youth must have a mental health or substance use diagnosis to receive this service.
- Family Peer Support Services (FPSS) - an individual with their own lived experience, supports families and caregivers to help address the physical*, mental health or substance use needs of their child/youth.
- Youth Peer Support and Training (YPST) (CFTSS Beginning January 1, 2020) - an individual with their own lived experience, supporting young people to be informed and proactive in the planning and delivery of their services to help address the physical*, mental health or substance use needs.
*For children with physical health conditions only, the State will be issuing additional guidance on the application of this service for medical needs.
In order to access the new CFTSS, anyone can make a referral for a child/youth who is demonstrating a need to a NYS designated provider of the service(s) ("Find a Designated Provider"), and the provider will determine if the child/youth is eligible.
In addition, a Licensed Practitioner of the Healing Arts (LPHA) can make a determination of medical necessity (Medical Necessity Criteria) and make a recommendation in writing for one or more of the services to a designated CFTSS provider. A LPHA can include an individual currently licensed as one of the following practitioners: Registered Professional Nurse, Nurse Practitioner, Psychiatrist, Licensed Psychologist, Licensed Psychoanalyst, Licensed Master Social Worker, Licensed Clinical Social Worker, Licensed Marriage & Family Therapist, Licensed Mental Health Counselor, Licensed Creative Arts Therapist, or Physician.
To make a recommendation, when an LPHA identifies a particular need in a child/youth based on ongoing treatment and/or a completed assessment, the LPHA would document the medical necessity for the service and submit the recommendation in writing to the NYS designated provider. The attached form is an example of how an LPHA may document medical necessity and recommend one or more of the CFTSS.
PLEASE NOTE: The form is not required to be used for a recommendation for CFTSS, but only demonstrates an example of how medical necessity can be determined and documented. This form is intended to serve as an example of the elements necessary for making a recommendation but is not a required form by the State. It is an optional form, to be used at the discretion of the recommending LPHA and/or designated CFTSS provider.
EXAMPLE
Medical Necessity Form - LPHA Recommendation for Children & Family Treatment & Support Services
(NOT A REQUIRED FORM. This form is NOT required to be used, but a sample template to capture the information necessary to demonstrate medical necessity.)
Instructions: This form can only be completed and signed by a Licensed Practitioner of the Healing Arts (Individual currently licensed as a Registered Professional Nurse, Nurse Practitioner, Psychiatrist, Licensed Psychologist, Licensed Psychoanalyst, Licensed Master Social Worker, Licensed Clinical Social Worker, Licensed Marriage & Family Therapist, Licensed Mental Health Counselor, or Licensed Creative Arts Therapist, or Physician).
Recommendation for Rehabilitative Service(s):
| Participant Name: | Date of Birth: |
| Parent/Caregiver: | Relationship: |
| Address: | Phone: |
| County of Residence: | Medicaid CIN #: |
Behavioral Health Information: (*A MH/SUD diagnosis is required for a recommendation of PSR, FPSS, YPST) Check all that apply:
| List | Diagnosis Category | Specific Diagnosis or Symptoms of Mental Illness (MH)/Substance Use (SUD) |
Dx Code |
|---|---|---|---|
| Primary | |||
| Secondary | |||
| Other |
Areas of Functioning: (As a result of the symptoms or diagnosis of MH/SUD, the child/youth has functional impairment that interferes with or limits functioning in at least one of the following areas and is likely to benefit from and respond to the service(s) recommended to prevent the onset or worsening of symptoms.) Check all that apply:
| Check | Domain | Description of Impairment |
|---|---|---|
| Self-Direction/Control | ||
| Self-Care | ||
| Family Life | ||
| Social Relationships | ||
| Symptom Management |
Recommended Children and Family Treatment and Support Service(s): Check all that apply:
| Check | Rehabilitative Service | Description of Needed Intervention (if known/applicable) |
|---|---|---|
| Other Licensed Practitioner (OLP) | ||
| Community Psychiatric Supports and Treatment (Intensive counseling) | ||
| * Psychosocial Rehabilitation (PSR) (Skill development and building) | ||
| *Family Peer Support Services (FPSS) | ||
| *Youth Peer Support & Training (YPST) |
Reason for recommendation:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
**By signing below, I am recommending the above-named individual for Children and Family Treatment and Support Service(s)
________________________ ________________________ ________________________ ________________________
**LPHA Signature Printed Name NPI# Date
