Clinical Practice Utilization Management Guidelines

The Behavioral Health Utilization/Care Management Clinical staff uses Medical Necessity Criteria sets for New York State Child Health Plus, Commercial, Essential Plan, and Medicaid Manage Care members. The clinical staff verifies eligibility, coverage type, and available benefits in order to identify the correct Medical Necessity Criteria to use. MetroPlusHealth adheres to the New York State guidance that outlines the notification of admission process to be followed by plans and their providers. When appropriate, MetroPlusHealth Medical Necessity Criteria sets for New York State Child Health Plus, Commercial, Essential Plan, and Medicaid Manage Care members are:

• MetroPlusHealth is using InterQual Concurrent criteria in addition to following the guiding principles which are incorporated in NY OMH Secondary Assessment for Dimensions 4-6, Pediatric or NY OMH Secondary Assessment for Dimensions 4-6, Adults for Mental Health clinical reviews. https://omh.ny.gov/omhweb/bho/omh_mnc_guiding_principles.pdf
• OMH Criteria is applied to the following treatment services and levels of care for Medicaid Managed Care members:
  • Assertive Community Treatment (ACT) or here
  • Personalized Recovery Oriented Services (PROS)
  • Continuing Day Treatment (CDT)Adult Home and Community Based Services
  • Children’s Home and Community Based Services
  • Children and Family Treatment and Support Services (CFTSS)
  • Intermediate Care Unit
• New York State Office of Mental Health (OMH) Criteria
  • https://omh.ny.gov/omhweb/act/program_guidelines.html
  • https://omh.ny.gov/omhweb/bho/docs/pros-utilization-management.pdf
  • hcbs-utilization-man-guide.pdf
  • article-28-intermediate-care-units.pdf
  • https://health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/hcbs_manual.pdf
  • https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/billing_manual.pdf
  • https://www.ctacny.org/uploads/files/Billing%20Tech%20Specs%20for%20CFTSS%20and%20HCBS%20Children%20and%20Families_v1-6.pdf
  • OMH COVID-19 Guidance – CDT Program and Billing 04-13-20
• New York State Office of Addiction Services and Supports Level of Care for Alcohol and Drug Treatment Referral (LOCADTR). LOCADTR Criteria is applied to all substance use treatment services and levels of care for Child Health Plus, Commercial, Essential Plan, HIV SNP, HARP, and Medicaid Managed Care members receiving treatment from providers located in New York State. MetroPlusHealth covers in-network medically necessary services for the treatment of SUD: https://oasas.ny.gov/locadtr.