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 for the adult system 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 Adult 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

Will Medicaid Managed Care Plans (MMCP) need to approve Treatment Plans for Children and Family Treatment and Support Services?

MMCPs do need to approve scope, frequency and duration, but the goal is not to have plans ‘over manage’.  MMCPs are approving services based on their review of the documentation submitted by the provider to substantiate medical necessity. This may include the treatment plan.  

Source: CFTSS June 2018

Who needs to authorize a child's CFTSS treatment plan, DOH or the Medicaid Managed Care Plans?

Medicaid Managed Care Plans (MMCP) will be authorizing services for children enrolled in managed care. Each MMCP will develop a process by which providers will obtain authorization in line with the State issued utilization management guidelines. Specific MMCP processes for authorization can be found here. 

Source: July 2018 CFTSS Billing In-Person Training

Do you need authorization for offsite CFTSS, separately from service authorization?

Please discuss with your Managed Care Plan to determine their rules.

Source: July 2018 CFTSS Billing In-Person Training

Please explain the statement, "multiple CFTSS services on same day are to be considered 1 visit.” Is this only for the purpose of counting the 30 visits (as authorized after concurrent review) or is this also for billing i.e. will only one service be paid for per day?

This refers to the counting of 30 visits as authorized after concurrent review. This is not related to billing. Providers may bill for more than one CFTSS in one day, within the daily unit limits outlined in the billing manual.

Source: UM for CFTSS: OLP, PSR, CPST 9.18.18

Is the 30 visit authorization per CFTSS service or is 30 visits inclusive of any services being authorized?

Concurrent review authorizations must be for  at least 30 visits for each individual service that the child is receiving. If the child is receiving OLP, CPST, and PSR they get at least 30 visits for each.

Source: UM for CFTSS: OLP, PSR, CPST 9.18.18

Is a behavioral health diagnosis required for concurrent review of OLP, PSR and CPST?

OLP and CPST do not require a diagnosis to begin the service, however it is likely that a diagnosis and/or documentation of medical necessity would be determined before the point at which concurrent review is needed. PSR, on the other hand, does require a diagnosis for receipt of the service.

Source: UM for CFTSS: OLP, PSR, CPST 9.18.18

Since medication management is not a service under OLP, CPST or PSR, is the 30 visit count inclusive of the child’s clinic visits or doctor visits?

Doctor and clinic visits do not count towards the 30 visits that are authorized as part of concurrent review for OLP, CPST, or PSR.

Source: UM for CFTSS: OLP, PSR, CPST 9.18.18

For the 3 visits that are allowed before concurrent review needs to be authorized for CFTSS is that equal to 3 one-hour services or 3 fifteen-minute billing units?

A visit is one interaction with child and family. It could be 15 minutes or 1 hour.

Source: UM for CFTSS: OLP, PSR, CPST 9.18.18

Are you anticipating issues with MMCPs denying coverage if notification of the first 3 visits of OLP, PSR or CPST is not received either on a timely basis or at all?

Providers should refer to MMCP specific guidance on notification requirements prior to service delivery at. 

Source: UM for CFTSS: OLP, PSR, CPST 9.18.18

Since prior authorization is not needed, who is checking that medical necessity is met in order to approve the 30 visits for CFTSS?

Prior authorization is not needed; as a result, the first 3 visits can occur without authorization. After that, concurrent review may be required, based on MMCP specific requirements, so that the MMCP can authorize additional visits. As part of concurrent review, medical necessity must be supported. Please refer to the MMCP specific guidance.

Source: UM for CFTSS: OLP, PSR, CPST 9.18.18

Is the 90 days of service, before authorization is needed for CFTSS, guaranteed for every child who is recommended for a service or only those that are beginning services on day one of the service becoming available (1-1-19)?

For OLP, CPST, and PSR, the State has extended the UM prohibition from 90 days to 180 days. This time period is from January 1, 2019 through June 30, 2019. This is a fixed timeframe, regardless of when the child begins receiving services. The purpose of this is to prevent disruptions in care while MMCPs and providers gain experience with services.

Source: UM for CFTSS: OLP, PSR, CPST 9.18.18

For children currently enrolled in transitioning Waiver services, is there a different authorization period? Is it still the case, that children will be authorized for 6 months after go live for any service they are currently receiving?

The 6 month provision is for the MMCP authorizing existing Plans of Care for children in HCBS and begins when HCBS become part of the managed care benefit package, currently targeted for Oct 1, 2019.

Source: UM for CFTSS: OLP, PSR, CPST 9.18.18

Will there be a standard form for the child's Treatment plan? For the assessments to determine medical necessity for each service?

There will not be a standard template for the treatment plan. A sample form for recommending services/ documenting medical necessity can be found here: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/example_lpha_recommendation_memo.pdf

No specific assessment tool needs to be completed for a child to access CFTSS; all that is needed is for the child to meet medical necessity criteria for the service.

Care Managers can refer directly to a CFTSS provider who is designated for OLP, for the non-physician licensed behavioral health practitioner to determine medical necessity for any CFTSS.

In addition, any licensed practitioner treating the child (such as their doctor) can make a recommendation to CFTSS by completing a written recommendation to document medical necessity based on clinical judgement.

Source: UM for CFTSS: OLP, PSR, CPST 9.18.18

Is there a standard form for notifying MMCP of CFTSS to be provided to children? Should providers anticipate some acknowledgement by the MMCPs that they received the notification? If no form, what does this notification look like?

There is no standard form for notifying plans prior to service delivery. Notification method/process depends on the MMCP. 

MCTAC has created a grid with more details about plan notification and authorization processes. This can be viewed https://ctacny.org/sites/default/files/UM%20Authorization%20Grid%203%20CFTSS%20jan%2015.pdf

Source: CFTSS: OLP, PSR, CPST Billing and UM Office Hour 11.15.18

Please clarify how long transitioning waiver children are authorized for CFTSS. Are they authorized to receive the cross-walked services for one year from initial CANS?

CFTSS are Medicaid State Plan services. Any child on Medicaid can receive these services as long as they continue to meet medical necessity. Waiver eligibility is not required for access to CFTSS.

Source: CFTSS: OLP, PSR, CPST Billing and UM Office Hour 11.15.18

Will Waiver HCBS Providers who bill Managed Care for cross-walked CFTSS be required to submit Plans of Care to MMCP's?

Plans of Care for Waiver children will need to be submitted to MMCPs beginning 30 days before HCBS become part of the managed care benefit package, currently targeted for July 1, 2019. Plans of Care include a list of all services the child is receiving, including CFTSS. 

Plans of Care are separate than the required Treatment Plans for CFTSS. Treatment Plans for CFTSS are not required to be submitted to MMCPs, however, the information necessary to demonstrate medical necessity criteria may need to be submitted to the MMCP for concurrent authorization. 

Please refer to MMCP specific authorization requirements at: https://ctacny.org/sites/default/files/UM%20Authorization%20Grid%203%20CFTSS%20jan%2015.pdf

Source: CFTSS: OLP, PSR, CPST Billing and UM Office Hour 11.15.18

Does medical necessity need to be signed by a provider with an NPI and a MMIS number? If one number was included but not the other, is that medical necessity form no longer valid?

No, medical necessity can be signed by any LPHA listed in the Children and Family Treatment and Support Services (CFTSS) Provider Manual as long as it is within their scope of practice. If the LPHA does not have an NPI and/or MMIS number, that practitioner may use the NPI and/or MMIS number of their employing agency. There are some LPHAs who can make recommendations/determine medical necessity who may not be eligible to enroll in Medicaid as an individual practitioner. Therefore, those practitioners may not need to obtain an NPI. In these cases, the NPI number of the agency can be used in the Referring Provider field of the claim form.

Source: State January Roundtable 2019

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