Frequently Asked Questions

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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

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