Frequently Asked Questions

NYS Policy Top Question
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How will managed care plans work with legal mandates (parole supervision, etc.)?

New York State expects managed care plans and providers to continue to follow any legal/court mandated aspects of treatment.

Source: UM: NYC 10.5.15

How does confidentiality factor in, when you have calls from Medicaid and managed care organizations needing client information?

The NYS website offers formal guidance and providers should refer to their own policies and standards around HIPAA: https://www.omh.ny.gov/omhweb/hipaa/phi_protection.html

Source: UM: NYC 10.5.15

If a provider does not have a contract (or is in the middle of contracting) with a managed care plan, how does that provider pay the plan for individual clients?

The provider will have to communicate with the managed care plan to determine how to handle this client. Usually a single case agreement will be reached. 

Source: UM:NYC 10.5.15

Will the specifics of outlier management be shared?

A specific list of outliers will likely not be generated because context is key to determining an outlier. For more guidance around outlier management consult the October 2015 OMH and OASAS UM Implementation presentations, available via the links below. 

Source: UM:NYC 10.5.15

Do clients that are not covered by an agency's contracted managed care plans have to be referred out?

For current patients, no; this falls under the two year window for continuity of care. For new patients, yes; they have to stay within network unless single case agreements are arranged with the managed care plan.

Please consult the following presentation about transitioning existing clients on day one of managed care, available here

Source: UM:NYC 10.5.15

Are providers required to provide care before authorization from the managed care plan?

Typically no, a provider is not required to provide care before the managed care plan gives authorization. Exceptions include if there is a crisis situation or an organization's own policies and procedures require them to provide care.

Source: UM:NYC 10.6.15

Is prior-authorization required?

This varies by program and service type. Please refer to MCTAC's guidance on utilization management on our website's resources page, found here

Source: RCM/UM/Outcomes Event: Buffalo 5.1.15

When is the LOCADTR supposed to be done and how many times? How does this impact authorization? Who is qualified to use this tool? How does this tool interact with court mandates?

The LOCADTR should be completed upon admission (within 24 hours for all levels except outpatient; with outpatient the LOCADTR should be completed within 3 visits) or when a change in level of care is considered. For example a LOCADTR would be used for step down, relapse, and life transition. Plans may request a completed LOCADTR only if they believe the level of care is not appropriate. The LOCADTR should be completed by a clinical staff person. Medical staff are, when there is a potential for serious or life threatening withdrawal, required to complete the crisis decision tree. Clinical detoxification recommendations should always be made by appropriate medical staff. Court mandates must be adhered to. As providers work to form a suitable treatment plan they should indicate in their records adherence to a legal mandate.    

For more guidance consult the LOCADTR guidance document, found here

Source: RCM/UM/Outcomes Event: Buffalo 5.1.15

Regarding UM, who organizationally is best situated to handle/manage?

There isn't one path fits all -- depends on an organization's size, how many clients, and how many contracts with MCOs. A recommended approach is to balance centralized vs individual. Consider how well equipped a central staff, social worker or nurse is able to speak to a case just by looking at a chart? On the other side, training 20 people to do UM reduces the amount of time they can spend on other things. Also raises question of supervision. 

Source: Children's System Transformation, Albany, 4.1.16

Can you clarify what documentation the foster care providers can request from clinics?

Voluntary Foster Care Agencies should have full access to documentation that the provider has related to the child. The OCFS rule of thumb is that for children in foster care receiving services in the community (outside of the foster care agency) the foster care providers should have full access to information.  Voluntary foster care agencies under contract with the Local Departments of Social Services (LDSS) -- have legal responsibility just as a parent would have responsibility for a child. 

Source: Transforming the Children's Medicaid System Webinar Part 1, 1.27.16

Under a value based system, how will authorization work for individuals who struggle with severe mental illness and are doing well but do not demonstrate progress as it is traditionally known?

Symptom reduction may not always be the primary goal. The State will look at functional assessment and how the service that is being provided is creating a functional improvement to the client and their wellbeing. Managed care organizations will also pay attention, specifically, to how services keep individuals out of the hospital.

Source: RCM/UM/Outcomes Event: NYC 4.17.15