Medical Necessity Criteria for NYS Regulated Health Insurers
When conducting utilization review of mental health services, health insurance plans regulated by New York State (NYS), including Medicaid Managed Care plans, must use medical necessity criteria and level of care tools that are:
- evidenced based
- peer reviewed
- age appropriate
- approved by the Office of Mental Health (OMH)
OMH CRITERIA INFORMATION
OMH provides guidance and tools for health insurance plans to use for these reviews.
OMH Medical Necessity Criteria Guiding Principles
OMH Best Practices Manual for Utilization Review for Adult and Child Mental Health Services
Health Plan Clinical Review Criteria: Submission Instructions
Health Plan Clinical Review Criteria: Submission Coversheet
Clinical Review Criteria for the Treatment of Gender Dysphoria
Summary of Review and Approval of Clinical Review Criteria – May 2023
INPATIENT PSYCHIATRIC STAYS FOR CHILDREN AND YOUTH (UNDER AGE 18)
NYS law prohibits NYS-regulated health insurance plans from requiring preauthorization, or from performing concurrent review, during the first 14 days of an inpatient admission for the treatment of a mental health condition of an individual under the age of 18.
This law applies when a child or youth under the age of 18 is admitted to a psychiatric inpatient unit at an OMH-licensed facility that is part of their health insurance plan’s provider network.
- The facility has to notify the health insurance plan about the admission and treatment plan within two business days but does not need to request prior authorization before providing treatment.
- The facility should continue to work with the health insurance plan to provide needed care.
Under this law, it is the responsibility of the inpatient hospital provider to make sure all care provided and billed for is medically necessary.
If the health insurance plan later determines the care was not medically necessary, members will not have any financial obligation to their healthcare provider for the treatment other than any copayment, coinsurance, or deductible otherwise required under the policy.
OMH has developed guidance for health insurance plans and hospitals that provide inpatient mental health care for individuals under the age of 18.