Guiding Principles for the Review and Approval of Clinical Review Criteria for Mental Health Services
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Requirements and standards that utilization review agents (UR Agents), HMOs, and insurers must meet when submitting clinical review criteria for mental health services to the NYS Office of Mental Health for review and approval; governs utilization review practices used to determine coverage for mental health treatment in New York State.
No material clinical or coverage changes in this revision.
Standards and Approval Criteria
Standards for approval and acceptable clinical review criteria
State approval standards and prohibited requirements for clinical review criteria used in utilization review for mental health services.
Includes requirement to revise or replace criteria that inappropriately limit coverage.
These prohibitions apply whether explicitly stated, implied, or used in practice.
Different mental health services may have different criteria, but within a service they must be the same.
UR Agents are encouraged to follow OMH Best Practices Manual triggers.
For children/adolescents these domains must be considered in a developmentally appropriate way and include caregiver engagement.
Policies must provide for remediation and pre-service testing.
Conditional approvals may be issued; conditional approvals require cooperation to be extended.
Reviewer need not have identical credentials but should be similarly trained/experienced.
The State will not approve clinical review criteria that require providers to demonstrate imminent danger to self or others as a prerequisite for admission to or continued inpatient mental health care. The absence of imminent danger alone must not be used to deny admission or continued stay, although the presence of imminent danger is sufficient to support admission or continued inpatient care.
Prior authorization may not be required for inpatient admissions originating from a hospital emergency department when an emergency department physician determines the patient needs inpatient care to stabilize and treat an emergency condition as defined in Insurance Law § 4902(a)(8) and Public Health Law § 4902(1)(h). Blanket prior authorization requirements for ED admissions that meet this standard will not be approved.
The State will not approve criteria that are designed to inappropriately limit coverage for generally accepted mental health treatment. Clinical review criteria must be comparable to—and not more stringent than—criteria for medical or surgical services within the same categorical classification; criteria that effectively impose more restrictive requirements (including blanket concurrent review or demands for evidence of treatment benefit or active participation as prerequisites for continued care) will be rejected and must be revised.
Provider Responsibilities and Operational Rules
Do not require prior authorization for ED-determined inpatient admissions
Prior authorization may not be required for inpatient admissions from a hospital emergency department when an ED physician determines inpatient care is needed to stabilize and treat an emergency condition; such prior authorization requirements will not be approved.
Assess multiple domains when deciding level of care
Level-of-care criteria must consider multiple clinical and contextual domains and favor the safer/more intensive level when there is doubt between levels of care.
- Risk of harm
- Functional status
- Co-morbidity
- Level of stress and support in the recovery environment (environment)
- Treatment and recovery history
- Engagement/resiliency (acceptance and engagement for children/adolescents, including caregivers)
- Availability of community services — inability to offer a less intensive level in a timely manner must not justify downgrading care
Submit criteria to OMH and cooperate with state review
UR Agents must submit clinical review criteria and any new or revised criteria to OMH at least 60 days before implementation and must cooperate with state review requests and communications; the health plan remains responsible for timely submission and coordination.
- Submit new or revised criteria to OMH no later than 60 days prior to implementation
- Do not implement new/revised criteria without prior state approval
- Respond to OMH review requests and communicate with the state review team
Document IRR testing, remediation, and pre-service testing
UR Agents must document procedures for inter-rater reliability (IRR) testing at least annually, provide remediation for poor IRR performance, and perform pre-service IRR testing for new staff with a minimum pass rate of 85%.
- Annual IRR testing requirement
- Minimum pass rate: 85%
- Remediation procedures for poor IRR results
- Pre-service IRR testing for all new utilization review staff
Avoid criteria that are more stringent than medical/surgical standards
Do not use clinical review criteria that are more stringent than comparable medical/surgical criteria or that are designed to inappropriately limit generally accepted mental health treatment; such criteria will not be approved and must be revised or replaced.
Forbidden preconditions for inpatient admission or continued stay
Prohibited preconditions for inpatient admission include requiring demonstration of imminent danger, requiring prior authorization for ED admissions deemed to need inpatient stabilization, and requiring evidence of active participation or benefit as a prerequisite for continued inpatient care; criteria imposing these conditions will not be approved.
- Requiring demonstration of imminent danger to self or others as a prerequisite for admission or continued inpatient care
- Requiring prior authorization for inpatient admissions when an ED physician determines inpatient care is needed to stabilize an emergency condition
- Requiring evidence of active participation in treatment or demonstrated benefit as a prerequisite for continued inpatient care
- Blanket concurrent review for all inpatient mental health care (unless concurrent review is applied equally to all medical/surgical inpatient care)
Inpatient, Residential, and Outpatient Criteria Principles
Care Coordination, Discharge Planning, and Treatment
Care coordination and discharge planning
Key Definitions
Policy Background and Statutory Context
This document reflects statutory changes requiring the Office of Mental Health to review and approve evidence-based, peer-reviewed clinical review criteria used in utilization review for mental health services so that coverage determinations are consistent with accepted medical practice and parity requirements. Insurers, HMOs, and their utilization review agents remain responsible for submitting criteria for state review and ensuring approved criteria comply with these standards.
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