Concurrent Review Memo for Crisis Residence Facilities

TO: CRISIS RESIDENCE FACILITIES

Effective May 3, 2024, per the NYS 2023-2024 Budget – Subpart B, modification for previously existing coverage requirement for members related to hospitals have been amended to include Crisis Residence facilities. Crisis residence facility licensed or operated by OMH cannot be subject to preauthorization.

For members who are under the age 18 –

• During the first 14 days of admission, concurrent utilization review should not occur if the facility:
  • Notifies MetroPlusHealth of both the admission and the initial treatment plan within 2 business days of the admission,
  • Performs daily clinical review of the member, and
  • Participates in periodic consultation with MetroPlusHealth to ensure that the facility is using the OMH approved evidence-based and peer reviewed clinical review criteria used by MetroPlusHealth. This is to ensure that the inpatient care is medically necessary and appropriate for the age of the member.

For members who are over the age of 18/older –

• During the first 30 days of inpatient or residential admission, concurrent utilization review should not occur if the facility:
  • Notifies MetroPlusHealth of both the admission and the initial treatment plan within 2 business days of the admission,
  • Performs daily clinical review of the member, and
  • Participates in periodic consultation with MetroPlusHealth to ensure that the facility is using the OMH approved evidence-based and peer reviewed clinical review criteria used by MetroPlusHealth. This is to ensure that the inpatient or residential care admission is medically necessary and appropriate for the age of the member.

Concurrent reviews may be conducted during the first 30 days if the member –

• Meets clinical criteria designated by OMH or
• If the member is admitted to a hospital or facility which has been designated by the OMH for concurrent review, in consultation with the department of health (DOH) and the Department of Financial Services (DFS).

All inpatient care in a hospital and coverage for sub-acute care in a crisis residence facility licensed or operated by OMH may be reviewed retrospectively.

If care is denied retrospectively, the member should not have any financial obligation to the facility for treatment other than any copayment, coinsurance, or deductible.

If you have any questions regarding this memo, please contact MetroPlusHealth at: [email protected].

Thank you.

MetroPlusHealth

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