Prior Authorization — Co-Occurring Enhanced RRS

Co-Occurring Enhanced RRS: Prior authorization required. Admission must be supported by an ASAM-based assessment (six ASAM dimensions) and documentation of co-occurring DSM-5-TR/ICD diagnoses. Prior utilization history (recent inpatient psych hospitalization, ≥2 ED/MCI evaluations, or unsuccessful engagement in community services within past 3 months) must be documented. Members discharged from inpatient psych or post-withdrawal induction on MAT may be admitted when stabilized and documentation and coordination with inpatient providers is provided. Exclusion triggers: medically monitored withdrawal or hospital-level needs, inability to be safely treated in community, lack of a co-occurring MH diagnosis, or ability to be treated in a Co-Occurring Capable RRS. Step-up rule: member should step up from Co-Occurring Capable RRS only after less-intensive RRS has been tried and found insufficient; document prior attempts and rationale.

• Required: ASAM six-dimension assessment; DSM-5-TR/ICD diagnoses; recent service utilization history (see above).
• Prior authorization applies to admissions and continued stay determinations.

IHT Service Delivery & Team Requirements

In-Home Therapy (IHT) delivery requires a multidisciplinary team (licensed clinician plus paraprofessionals as needed), 24/7 urgent response capability, flexible, needs‑matched session duration, and services delivered in natural environments (home, school, community). Treatment planning is team-based with family involvement; identification of natural supports and care coordination is required. Exclusion triggers include residence in a hospital or residential setting not ready for family/home discharge, concurrent FIT enrollment, services fully meeting needs, unsafe environment for provider, independent living not returning to family, or medical conditions preventing benefit.

• Team composition: qualified practitioner(s) and paraprofessional(s); licensed clinician develops and supervises treatment plan.
• Operational expectations: 24/7 urgent response, flexible session lengths, sessions where youth naturally located.
• Document: treatment plan, consent, MA CANS where indicated, active coordination with PCP and other providers.

Assessment & Treatment Plan Required for Admission

A comprehensive assessment and an individualized treatment plan are required at admission for applicable levels of care. Assessments must include DSM-5-TR/ICD diagnoses, relevant standardized tools (MA CANS when applicable), ASAM dimensions for SUD levels, functional/behavioral assessments (FBA/FA) when addressing behaviors, observations, and utilization history. Treatment plans must be multidisciplinary, measurable, time-framed, list services/roles, safety/risk management, discharge planning, and family/caregiver involvement.

• Assessment elements: DSM-5-TR/ICD diagnosis, MA CANS (where required), ASAM dimensions for SUD, prior treatment/utilization history, FBA when indicated.
• Treatment plan elements: measurable goals/objectives, frequency/intensity rationale, coordination plan, discharge planning, consent documentation.

Emergency Services — No Prior Authorization; Evaluation & Notification

Emergency services (AMCI/YMCI and ED evaluations) do not require prior authorization. Providers must perform face-to-face evaluations when acute services are needed and notify the plan with relevant clinical information as soon as possible and no later than 24 hours after emergency admission. Consent refusal for mobile crisis evaluation excludes the service and may result in denial.

• AMCI: 24/7, up to 3 days for adults; YMCI: 24/7, up to 7 days for youth <21.
• When AMCI/YMCI unavailable within one hour at site, hospital behavioral health clinician may perform evaluation.
• Providers must attempt timely notification to the plan (clinical info within 24 hours).

YMCI — Service Availability & Scope

YMCI availability and scope: YMCI operates 24/7/365, provides mobile/community and telehealth responses when clinically appropriate, and offers up to seven days of crisis intervention for youth under 21, including on-site face-to-face response, psychiatric consultation, urgent psychopharmacology, development of safety plans, and linkage to continuum services. Admission requires prior phone triage attempts and evidence that less-intensive triage/stabilization were insufficient.

• YMCI must accept voluntary ambulance or law‑enforcement drop‑offs and coordinate with YCCS/CBHC.
• Admission prerequisites: failed phone triage, immediate need for intervention, and presence of risk/impairment per admission criteria.

Prior Authorization — ABA Initial Assessment & Treatment

Applied Behavior Analysis (ABA) initial assessment and treatment require prior authorization. Initial assessment authorization prerequisites include confirmed ASD/Down Syndrome diagnosis, multidisciplinary diagnostic evidence, medical screening, and submission of an initial treatment plan within 45 days. Initial treatment authorization requires comprehensive history, functional assessments, FBA/BIP when treating behaviors, measurable ABA goals, parent/caregiver involvement plan, treatment intensity justification, and documentation that no more conservative/less costly medically appropriate services are available.

• Within 45 calendar days of assessment auth, up to 12 hours of assessment completed to inform initial plan.
• Initial treatment plan must include goals, service component breakdown (LABA vs technician hours), cultural/linguistic considerations, and titration/step‑down plan.
• Conservative-alternative requirement: document that less‑intensive services (school IEP, early intervention, S/L/OT, CBHI) are not suitable or available.

Prior Authorization — EIBI Assessment

Early Intensive Behavioral Intervention (EIBI) assessments for children under three may require prior authorization for assessment. Providers should seek authorization as indicated to allow prompt initiation of services once diagnosis is confirmed; EIBI admission requires referral from Early Intervention and confirmed ASD diagnosis. If an authorization is required, it may be obtained before family selects a specific provider in most cases.

• Admission prerequisites: referral from EIP and confirmed ASD diagnosis (DSM-5-TR referenced).
• If prior auth required, it can often be obtained prior to specific provider selection.

CSP Admission Verification & CSP-HI Billing

CSP admission verification (effective Jan 1, 2025+): for CSP-JI/CSP-HI admissions, clinical criteria may be verified by diagnosis or member attestation. For members enrolled in an Accountable Care Partnership Plan or Primary Care ACO, medical necessity may be demonstrated either by meeting CSP clinical criteria or via an approved Health Needs Based Criterion as verified by diagnosis or member attestation. CSP-HI billing may begin up to 120 days before move‑in and may continue after move-in until plan determines services are no longer medically necessary. CSP-HI cannot fund housing goods (e.g., deposits, furnishings).

• For CSP-HI: member must meet chronic homelessness or high acute service use thresholds and have identified PSH with move-in within 120 days.
• Billing window: providers may bill CSP-HI as early as 120 days pre-move; continue billing post‑move until plan ends medical necessity.

Escalation Requirement & Exclusion Triggers — High-Intensity Inpatient

High-Intensity (Acute) Exclusion & Escalation Requirements: Members who can be safely treated at a less-intensive level are excluded from Acute High-Intensity inpatient services. For escalation to High-Intensity care, general inpatient criteria must be met and less‑intensive interventions must have been considered and tried when clinically appropriate; document attempts and rationale for escalation. Exclusion triggers include primary non-psychiatric problems, medical conditions requiring medical/surgical setting, medical comorbidities not manageable in specialty setting, cognitive/ developmental conditions without acute DSM-5-TR diagnosis, and certain legal statuses requiring forensic programs.

• Escalation requires documentation that less-intensive services were insufficient and that the member meets High-Intensity admission criteria (e.g., need for specialized milieu, enhanced staffing).
• Exclusion: safe management in less-intensive setting is sufficient to deny High-Intensity admission.

Exclusion Conditions that Trigger Non-Authorization

Common exclusions across diversionary and community services: receiving similar services already, lack of voluntary consent, being in an inappropriate setting (hospital, PRTF, SNF, residential) and not ready for discharge, imminent risk requiring higher level of care, medical or developmental conditions precluding benefit, or guardianship/consent issues. Specific programs (TCU, FS&T, ICC/IHT/IHBS, IHBS, FIT, CPS, DBT, C-L psychiatry, CSP-JI) have tailored exclusion criteria consistent with these general principles.

• TCU exclusions: youth at imminent risk to self/others, lack of guardian consent, complex medical/developmental conditions, or need for more-intensive long-term placement.
• FS&T exclusions: no expectation of progress, environment unsafe, or needs already met by other services.
• IHBS/IHT/ICC exclusions: residential/hospitalized status, not ready for community return, unsafe environment, or duplicative services.
• FIT exclusions: consent missing, concurrent services that preclude FIT, age limits, or not evaluated by YMCI/ED when required.

CBAT — Documentation Expectations

CBAT documentation expectations: multidisciplinary individualized treatment plan, frequent review and updates, family/caregiver involvement (including family therapy), daily medication monitoring when indicated, nursing and psychiatric availability, discharge planning beginning at admission with active efforts documented to reintegrate to home/school/community or identify alternative placement.

• Document active family involvement, medication reconciliation/monitoring, psychological testing if needed, and discharge planning from day one.

Assessment & Utilization History Documentation

Assessment and utilization history documentation requirements: ASAM dimension assessment for SUD levels, DSM-5-TR/ICD diagnoses, prior treatment history (inpatient stays, ED/MCI encounters, engagement attempts), and evidence of prior less-intensive interventions when required for step-up decisions.

• Include timeline of prior services/utilization and objective evidence supporting need for current level of care.

Required Documentation for Initial & Continuing Authorization

Required documentation for initial and continuing authorization (across applicable services): current treatment plan with measurable goals and objectives, summary of services requested and intensity rationale, data demonstrating progress (e.g., behavior graphs, session notes), updated assessments at required intervals (e.g., every six months for ABA), coordination attempts with other providers and agencies, consent, and safety/risk management plans.

• For ABA: 6-month plan updates, data showing change from baseline, daily session notes, parent involvement evidence, and utilization at ≥75% of approved hours unless mitigated.
• For all services: documentation of coordination attempts and discharge planning starting at admission.

AMCI Documentation Requirements

AMCI documentation (Adult Mobile Crisis Intervention): crisis assessment, collateral contacts, coordination with other providers, short-term crisis counseling notes, medication evaluation and prescriptions as applicable, and linkage/referral documentation.

• Document crisis assessment findings, risk/safety plan, and follow-up arrangements.

Care Coordination & Discharge Planning Documentation

Care coordination and discharge planning: active discharge planning must begin at admission for 24-hour and diversionary services. Documentation must show coordination with PCPs, specialty providers, state agencies, schools, and prior treatment teams; include attempts when collaboration is unsuccessful; and show linkages to outpatient follow-up and natural supports.

• Record attempts to coordinate care and reasons when coordination cannot be completed.
• Discharge planning should include reintegration plans to home/school/community or identification of alternative placements.

Required Documentation — CPS / ABA

Required documentation for CPS and ABA services: CPS must document face-to-face, telephonic, and collateral contacts, active wellness/treatment planning, coordination with other providers, and ongoing discharge planning. ABA documentation must include comprehensive assessment data, FBA/BIP when treating problem behaviors, measurable goals, parent training records, session notes, graphs of progress, and evidence supporting intensity and conservative-alternative considerations.

• CPS: document wellness plan activities, coordination, and when medically necessary facilitate psychopharmacologic access.
• ABA: include two direct observations, standardized assessments, FBA/BIP, treatment intensity justification, titration/step‑down plan, and conservative alternatives search.

Psychiatric Consultation Documentation & Exclusion Risk

Psychiatric consultation (C-L psychiatry) documentation: clinical history, mental status exam, safety/stability assessment, medication recommendations when appropriate, and an active treatment plan. Exclusion: consultation not clinically indicated (i.e., member can be safely maintained without psychiatric consultation).

• Document sources of collateral information, rationale for consultation, and recommended follow-up.

CSP-JI / CSP-HI Admission Documentation

CSP-JI / CSP-HI admission documentation: verify justice involvement when applicable, document barriers to community tenure and that member meets general CSP clinical criteria (diagnosis or attestation). For dates of service on/after Jan 1, 2025, ACO/ACP plan enrollees may alternatively verify with Health Needs Based Criteria. Document housing status, imminence of housing (PSH move-in within 120 days) for CSP-HI, and acute service utilization thresholds when applicable.

• CSP-HI: document chronic homelessness or frequent acute service use thresholds and PSH identified with planned move-in within 120 days; document consent.
• For CSP-TPP: document eviction risk and court status per eligibility rules.

Step Therapy Rules, Intensity & Step-Down Planning

Step therapy rules: not applicable to the majority of behavioral health levels of care in this chapter. Instead, clinical authorization focuses on medical necessity, exclusions, concurrent services, consent, and court status rather than formal step‑therapy sequences. However, many community services require attempts of less‑intensive interventions before stepping up (document prior less-intensive attempts and ongoing eligibility).

• Providers must document prior attempts at less‑intensive services when the policy requires step‑up justification (e.g., IHBS, Co-Occurring Enhanced RRS, FIT eligibility).
• Intensity and step-down planning: requests must reflect the least intensive level capable of achieving goals and include a titration plan for step‑down.

Step-Up Requirements & Triage Before YMCI

Program-specific step-up requirements: IHBS and other intensive home/community services require evidence that less‑intensive interventions were tried and failed. FIT is indicated only when outpatient, IHT, or ICC are insufficient; triage/phone diversion attempts are required before YMCI engagement. Document prior service attempts and rationale for escalation.

• Record phone triage attempts and diversion efforts prior to YMCI referral.
• For IHBS: document unsuccessful trials of less‑intensive behavioral interventions.

ABA — Intensity, Conservative-Alternative & Titration Planning

ABA intensity, conservative-alternative, and titration requirements: requested intensity must be individualized, data-driven, and reflect the least-intensive level capable of achieving goals. Include a titration/step‑down plan and criteria to adjust intensity. Demonstrate consideration of conservative/less-costly alternatives and why they are unsuitable.

• Titration plan: specify how and when hours will be decreased and how generalization will be supported.
• Conservative alternatives: document search and rationale (IEP, early intervention, S/L/OT, CBHI, reduced ABA hours).