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

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 for adult clients?

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

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

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 well-being. 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