CurrentOptumPolicy N/A

New York: SUD & Under-18 MH Admission Notification and Review Requirements

Defines notification, review, and clinical criteria requirements for in-network OASAS-certified SUD facilities and inpatient/residential mental health facilities treating patients under 18 in New York; affects in-network providers and specifies when out-of-network prior authorization still applies.

Policy Summary

PayerOptum

PolicyNew York: SUD & Under-18 MH Admission Notification and Review Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionNotify Optum within 2 business days of medically necessary SUD or under-18 MH admissions and apply LOCADTR or CASII/ESCII as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 business daysnotify Optum of admission

24 hoursnotify Optum of discharge

day 14SUD collaborative contact

28 daysSUD review threshold

14 daysunder-18 MH review threshold

Admission, Review, and Discharge Criteria

Clinical and notification criteria for admissions, concurrent review, step-downs, and discharge reporting.

Notification: Notify Optum within 2 business days of a medically necessary admission.

Applies to SUD admissions (all ages) and Mental Health inpatient & RTC admissions for members under age 18.

At admission and during stay: Apply LOCADTR to determine medical necessity for all Substance Use Disorder (SUD) admissions and services at all levels of care.

Per legislation; LOCADTR is the required level-of-care tool for SUD.

At admission and during stay: For Mental Health admissions for members under age 18, Optum will recognize CASII/ESCII for medical necessity determinations.

Use CASII/ESCII as the assessment tool for under-18 MH admissions.

Concurrent review and step-down: Following notification, apply LOCADTR or CASII/ESCII as appropriate to manage care, including stepping down to lower levels of care when indicated.

Policy Summary

PayerOptum

PolicyNew York: SUD & Under-18 MH Admission Notification and Review Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionNotify Optum within 2 business days of medically necessary SUD or under-18 MH admissions and apply LOCADTR or CASII/ESCII as applicable.

SourceLink

On This Page

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Prior Authorization and Notification Requirements

Prior Authorization

Prior authorization required for out‑of‑network facilities; in‑network facilities follow notification process

Out-of-network facilities, including those outside of New York, must continue to seek prior authorization. In-network, OASAS‑certified facilities in New York and in‑network inpatient/residential mental health facilities treating members under age 18 follow the notification and clinical processes described in this policy and should call Optum or use the PAAN portal to determine whether prior authorization is required for a specific admission.

Applies to out‑of‑network facilities (including those outside NY): prior authorization is required.
In‑network, OASAS‑certified NY facilities and in‑network MH facilities for under‑18 follow the notification process and may not require prior authorization per legislation — contact Optum to confirm applicability.

Assessment Tools and LOC Criteria

LOCADTR (SUD level-of-care criteria)

DefinitionLOCADTR — level of care criteria used to determine medical necessity for all Substance Use Disorder (SUD) admissions and services at all levels of care

Use at admission and during stayApply LOCADTR at admission and throughout the stay to determine and manage medical necessity, including step-down decisions

Concurrent review triggerFor SUD inpatient stays >28 days, contact Optum as clinical review may be required

CASII / ESCII (under‑18 mental health assessment tools)

Recognized assessment toolsCASII/ESCII — assessment tools Optum will recognize for medical necessity determination for Mental Health admissions for members under age 18

ApplicationApply CASII/ESCII at admission and during the stay to manage clinical needs and step-down decisions for under‑18 MH IP/RTC admissions

Concurrent review triggerFor under‑18 MH inpatient/RTC stays >14 days, contact Optum as clinical review may be required

OpenPayer

New York: SUD & Under-18 MH Admission Notification and Review Requirements

Admission, Review, and Discharge Criteria

Coding and Review Thresholds

Prior Authorization and Notification Requirements

Assessment Tools and LOC Criteria