CurrentOptumPolicy N/A

Inpatient OASAS-Certified SUD Providers — NY notification requirements

Governs notification and use of LOCATDR criteria for in-network OASAS-certified inpatient substance use disorder (SUD) facilities in New York; affects in-network NY facilities and guidance on authorization processes for other plans and out-of-network providers.

Policy Summary

PayerOptum

PolicyInpatient OASAS-Certified SUD Providers — NY notification requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2017

Next Review DateN/A

Key ActionNotify Optum within 48 hours of a medically necessary in-network OASAS-certified SUD inpatient admission to avoid prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48 hoursnotify after admission

24 hoursnotify after discharge/step-down

14 daysclinical review threshold

NYapplicable state

Coverage and Medical Necessity

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Admission and notification: For in-network OASAS-certified SUD inpatient admissions in New York, prior authorization is not required provided the facility notifies Optum within 48 hours of the medically necessary admission.48 hours

Notification replaces prior authorization for initial inpatient admission per this notice.

Concurrent review and LOCATDR use: Facilities must apply LOCATDR criteria to determine ongoing medical necessity, to manage step-down care, and during concurrent review; for inpatient stays >14 days contact Optum for clinical review.>14 days

Step-downs and discharges must be communicated to Optum.

Discharge/step-down notification: If a patient steps-down or is discharged for any reason, facilities must notify Optum as soon as possible but no later than 24 hours from the time of discharge.24 hours

Authorizations for inpatient cannot be issued until discharge has occurred.

What Providers Must Do

Prior Authorization

Prior authorization and notification

Prior authorization is not required for in-network OASAS-certified SUD inpatient admissions if Optum is notified within 48 hours of the medically necessary admission. This exception applies only to in-network, OASAS-certified facilities in New York; out-of-network facilities (including those outside NY) must obtain prior authorization.

Notify Optum within 48 hours of admission to avoid prior authorization requirement
Out-of-network facilities continue to require prior authorization

Note

LOCATDR for step-down care and concurrent review

During concurrent review, facilities must apply LOCATDR criteria to manage ongoing care and to plan appropriate step-down to lower levels of care. If a patient remains at the inpatient level for more than 14 days, contact Optum for clinical review. Prior authorization may be required for lower levels of care depending on the level and the member's benefit plan.

Apply LOCATDR criteria for step-down decisions and during concurrent review
Contact Optum for clinical review when inpatient stay > 14 days
Lower levels of care may require prior authorization based on member benefits

Note

Notification methods and contact information

Follow the required notification processes for the member's plan: complete and return the OASAS form (Fax: 1-877-339-8399 or Email: NYHARPAuthorizations@uhc.com) for applicable Medicaid and Essential Plan memberships; for Standard Medicaid under age 21 or many commercial plans, call the number on the back of the member's insurance card. For questions about whether the legislation applies to a commercial plan, call Optum to confirm.

OASAS form return: Fax 1-877-339-8399 or Email NYHARPAuthorizations@uhc.com
Standard Medicaid (under 21) and many commercial plans: call the number on the member's card
If unclear whether legislation applies to a plan, contact Optum or the Network Manager

Denial Risk

Notification timing and impact on authorization

Timely notification affects authorization. Failure to notify Optum within the required timeframes (48 hours for admission; within 24 hours of discharge or step-down) or failure to contact Optum as specified may affect authorization processing. Notify Optum as soon as possible and no later than 24 hours after discharge (including AMA). Remember: authorizations for inpatient cannot be issued until discharge has occurred.

Notify within 48 hours of admission to qualify for no prior authorization (in-network OASAS-certified)
Notify no later than 24 hours after discharge or step-down (including against medical advice)
Authorizations for inpatient level cannot be issued until discharge is recorded

Inpatient Level-of-Care Determination

Inpatient

Inpatient level-of-care criteria and concurrent review expectations

LOCATDR application at admission: Apply LOCATDR criteria to determine medical necessity for all SUD inpatient admissions and services.

This is required by legislation and applies at admission.

Concurrent review and step-down management: Use LOCATDR during concurrent review to manage step-downs to lower levels of care when indicated; prior authorization for lower levels may be required depending on the member's benefit plan.

Facilities expected to apply LOCATDR criteria throughout the inpatient stay.

Prolonged inpatient stay review: Contact Optum for clinical review if the inpatient stay exceeds 14 days.>14 days

Concurrent review will determine appropriateness of continued inpatient care and step-down planning.

Key Terms and Definitions

LOCATDR — definition and criteria

TermLOCATDR

DefinitionLOCATDR criteria: required level-of-care guidelines to determine medical necessity for all Substance Use Disorder (SUD) admissions and services at all levels of care.

ScopeApplies to determination of medical necessity for SUD admissions and services across all levels of care under New York legislation.

Use caseMust be applied at admission and during concurrent review to inform ongoing medical necessity, step-down decisions, and discharge planning.

Related provider actionFacilities are expected to apply LOCATDR when assessing patients and communicating with Optum per notification and review requirements.

Background and Legislative Context

The New York LOCATDR requirement mandates that facilities apply LOCATDR criteria to determine medical necessity for all substance use disorder (SUD) admissions and services across levels of care. For in-network, OASAS-certified inpatient providers in New York, applying LOCATDR at admission and during concurrent review is an expected facility responsibility to support appropriate placement and step-down decisions.

Under the legislation effective January 1, 2017, in-network OASAS-certified facilities must notify Optum and use LOCATDR to document medical necessity; notification timelines and concurrent review requirements are used to replace or inform prior authorization processes for initial inpatient admissions where applicable.

Facilities are expected to use LOCATDR both at admission and throughout the inpatient stay to inform ongoing medical necessity, step-down planning, and discharge decisions; when inpatient care extends beyond expected durations providers must engage Optum for clinical review per the concurrent review process.