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.
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.
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.
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.
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.
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.
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.
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.