Prior Authorization and Utilization Review — Behavioral Health and Related Services
Governs prior authorization, concurrent review, and notification requirements in New York State for Fidelis Care Medicaid/CHP/HealthierLife, with special rules for OMH- and OASAS-licensed behavioral health and SUD programs affecting providers, facilities, and members.
OMH licensed inpatient mental health treatment for all ages in NYS is not subject to prior authorization effective 06/01/2021; facilities must notify insurer within 2 business days of admission.
OASAS licensed inpatient SUD services in-network/in-state are not subject to prior authorization or concurrent utilization review for first 28 days provided specific notification and LOCADTR processes are followed, effective 01/01/2020.
Certain behavioral health outpatient authorizations removed; most outpatient behavioral health services no longer require authorization, with enumerated exceptions (psych testing, developmental testing, outpatient ECT, partial hospitalization, IOP beyond initial days, ABA rules).
Prior authorization for certain surgical and cardiac/ENT procedures delegated to TurningPoint Healthcare Solutions effective 9/20/2021 (services on or after 10/4/2021).
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