Authorization and Utilization Management — Behavioral Health and Related Services
Defines prior authorization, utilization review, and service-specific authorization rules for Fidelis Care members and participating providers, including special COVID-19 guidance and changes to behavioral health and substance use disorder inpatient review processes in New York State.
OMH licensed inpatient mental health treatment for members under age 18 in NY participating in network are not subject to prior authorization and not subject to concurrent review during the first 14 days if notification and processes are followed.
OASAS licensed inpatient SUD facilities in NY participating in network are not subject to prior authorization and are exempt from concurrent utilization review for the first 28 days if notification and LOCADTR processes are followed.
All inpatient admissions require authorization; emergency department stabilization is not authorized but post-stabilization inpatient services do require authorization.
Authorization delegation: certain orthopedic and spinal procedure authorizations delegated to TurningPoint Healthcare Solutions effective 12/23/2019.
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