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:

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

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

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 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

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

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:

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

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

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

What are the guidelines for authorization of Children's HCBS?

Authorization for continued services will entail a conversation between the MMCP and the HCBS provider, primarily. However, the Health Home Care Manager would notify the MMCP of the services. Continued authorization is between the HCBS provider and the MMCP.  

Guidelines regarding authorization for units/days of service for HCBS service type can be located in Appendix C of the Children’s Home and Community Based Services Provider Manual.

Source: State Children's Waiver HCBS Workflow FAQ 2019

Can the Medicaid Managed Care Plan deny claims during the children's HCBS transition time period for instances in which the member has exceeded the benefit limit? Would this be permissible if plans denied these types of claims for a medical necessary review?

During the first 90 days, there is to be no utilization review conducted on Children’s HCBS (except for a new request for AT/E-Mods/V-Mods) and transitioning children are provided 180 days continuity of care. The plan should not pend or deny claims for medical necessity review during this period. If it appears the member is exceeding a benefit limit, the MCO should discuss the current HCBS Service Plan with the provider to understand the current goals, and the possibility of other covered services that might benefit the child.

Source: State Released MMCP FAQ Sept 27, 2019

How are Medicaid Managed Care Plans (MMCPs) notified of the first appointment date with each Children's HCBS provider?

As outlined in the policy, the first appointment is established with the HCBS provider. The HCBS provider reports the date of the first appointment to the MMCP through the means established between the two entities – can be by phone, secure email, or other. 

Source: State Children's Waiver HCBS Workflow FAQ 2019

Are Children's HCBS services placed on hold until all necessary approvals are received from the Medicaid Managed Care Plans (MMCPs)? What is the process to handle delays in MMCP approvals?

Services should not be delayed for child/youth in need of and eligible for HCBS. Providers are encouraged to request continued coverage of HCBS at least 14 days in advance of the current authorization’s expiration to avoid delays.

During the first 180 days HCBS services will be covered without MMCP utilization management (clinical review).

An enrollee has the right to request an appeal from the plan regarding a delay in approval, denial or reduction in services. With written consent, the provider may appeal on behalf of the enrollee. The enrollee also has fair hearing rights, once the plan’s appeal process is exhausted. The provider or the enrollee may also file a complaint at any time with the Department of Health at

Source: State Children's Waiver HCBS Workflow FAQ 2019

If the Children's HCBS provider has their own referral form can that be used instead of the State’s form?

No, the Referral for Home and Community Based Services (HCBS) to HCBS Provider form must be used. The form as a fillable PDF can be located here.

Source: State Children's Waiver HCBS Workflow FAQ 2019

Does an Article 29-I Facility need authorization from MMCP to provide Core Limited Health Related Services?

No,  Medicaid Managed Care Plan (MMCP) authorization is not required to provide Core Limited Health Related Services.

Source: 2.10.21 Article 29-I Billing Office Hour