Attention Rest of State Adult BH Providers: Authorization and UM Guidance
The transition to Medicaid managed care for rest of state adult BH providers has occurred, and we would like to highlight the two distinct authorization/UM practices as a reminder.
Please carefully review the below guidance for new and existing clients after go live.
UM criteria for existing clients: 90 day transition language prohibits plans from applying utilization review criteria for a period of 90 days from the effective date of the Behavioral Health benefit inclusion in either NYC or the rest of state, respectively. Accordingly, plans must accept existing plans of care.
Transitioning Active Client/Member: A course of ambulatory behavioral health treatment, other than ambulatory detoxification and withdrawal services, which began prior to the Effective Date of the Behavioral Health Benefit Inclusion in each geographic service area in which services had been provided at least twice during the six months preceding the Behavioral Health Benefit Inclusion Date by the same provider to an Enrollee for the treatment of the same or related a behavioral health condition.
For all clients who don’t meet the definition of existing clients and for UM practices after the first 90 days, please consult the presentation.
We strongly recommend that you work closely with your MCO partners on this process. Please refer to MCTAC’s Managed Care Matrix tool for contact information.