Authorization and Utilization Rules — Behavioral Health, SUD, Imaging, Therapies, and Enteral/Drug PA
Governs prior authorization, utilization review, and coverage operational changes across inpatient and outpatient behavioral health, SUD, imaging, therapies, DME, and specialty drugs with special rules for NYS OMH and OASAS licensed facilities and delegated vendors.
OMH licensed inpatient mental health treatment in NYS is not subject to prior authorization effective 06/01/2021, with notification and limited concurrent review requirements.
OASAS licensed in-state inpatient SUD services are not subject to authorization review and are exempt from concurrent utilization review during the first 28 days when notification and LOCADTR submission requirements are met.
Authorization delegation to TurningPoint Healthcare Solutions, LLC for many surgical and other procedure codes (effective 9/20/2021 for DOS on or after 10/4/2021) and to National Imaging Associates (NIA) for many radiology and outpatient therapy services (effective 9/20/2021/10/1/2021 as noted).
Authorization has been delegated to National Imaging Associates, Inc. (NIA) for radiology services effective 10/1/2021.
Effective 10/1/2021, outpatient therapy (PT/OT/ST) services after the initial evaluation require authorization through NIA.
Authorization requirements for radiation therapy services delegated to NIA effective 10/1/2021.
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