Utilization management for OMH-authorized long-stay inpatient units (Second Chance at NYP and St. Joseph's Intermediate Care Unit)
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This memorandum directs managed care plans regarding concurrent review and denial practices for admissions to two specific OMH-authorized intermediate care inpatient units (NYP Second Chance and St. Joseph's Intermediate Care Unit) treating individuals with serious mental illness; it affects plans managing Medicaid members admitted to those units beginning October 1, 2015.
No material clinical or coverage changes in this revision.
Coverage and Admission Guidance
Initial 120-day non-denial guidance
Covered with modified utilization management for the initial period
Plans should still conduct concurrent review and support discharge planning; costs are included in 2016 capitation and stop-loss provisions apply
No explicit clinical exclusions are specified in the memorandum. The request applies to new admissions to the two named OMH-authorized intermediate care units (NYP Second Chance program and St. Joseph’s Intermediate Care Unit) beginning October 1, 2015. The memo does not list patient-level diagnostic or clinical exclusion criteria that would limit the operational guidance.
The memorandum specifically requests that managed care plans (HARPs and MMCOs) refrain from issuing medical necessity (NMN) denials for the first 120 days of inpatient care for any new admission to the two units on or after October 1, 2015. The memo does not define alternative conditions or separate NMN pathways that would apply within that initial 120-day period.
Plan and Provider Operational Requirements
120-day initial denial relief
For any admission to the two named OMH-authorized intermediate care units on or after October 1, 2015, plans are requested not to issue medical necessity denials during the first 120 days of inpatient care; concurrent review should continue during this period.
NYS operational request for initial admissions
NYS asks that HARPs and MMCOs refrain from issuing medical necessity denials for the initial 120 days of care for new admissions to these units and to continue concurrent review and discharge planning support.
- This guidance applies to admissions on or after October 1, 2015, until further notice.
- Costs for these long hospitalizations are included in the 2016 capitation rate and stop-loss provisions apply.
Concurrent review and discharge planning
Plans should perform concurrent reviews for members admitted to these units and advise and support discharge planning activities throughout the stay.
- Concurrent review activities should continue during the initial 120-day non-denial period.
- Discharge planning support is expected to help transition patients back to community care.
Initial 120-day denial restriction
Plans are requested to refrain from issuing medical necessity denials for the initial 120 days of inpatient care for any new admission to these two units (effective October 1, 2015) until further notice.
- This is an operational request from NYS directed at HARPs and MMCOs.
- Standard utilization management and medical necessity determinations may resume after the 120-day initial period.
Program and Population Context
These two OMH-authorized intermediate care units provide long-term inpatient care for individuals with serious mental illness and complex needs, and serve as part of the continuum of care to reduce State Psychiatric Center census and improve community tenure. Because lengths of stay are often long, usual utilization review practices may result in early medical necessity denials when clinical response is slow. In response, New York State requested that plans refrain from NMN denials for the initial 120 days of any new admission to these units (admissions on or after October 1, 2015), while continuing concurrent review and supporting discharge planning; costs for these hospitalizations were included in the 2016 capitation rate and stop-loss protections were noted.
Key Definitions
Inpatient Level of Care
Services and Therapeutic Approaches
Inpatient psychiatric care
Service types and utilization management expectations for inpatient psychiatric care in the named units
These OMH‑authorized units accept patients often transferring from State Psychiatric Centers or re‑entering the community; nearly all admissions are Medicaid (non‑duals).
Although concurrent review continues, NYS requests refraining from medical necessity denials for the first 120 days of a new admission (effective October 1, 2015) after which standard utilization management may resume.
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