NY Manual
SHP Manual

New York Provider Manual
9.3 Program Overview | 10.1 Overview of Services and the Provider Network

 9.4 Utilization and Medical Management Guidelines

Authorization of Services

Authorization for traditional in-network outpatient behavioral health services provided by Healthfirst providers is not required.

Traditional outpatient Behavioral Health Services , as defined by Healthfirst for this purpose, include individual, group, and family therapy and medication management, provided alone or in any combination, to treat a behavioral health condition in a manner consistent with established clinical guidelines and provided at a frequency not exceeding five (5) hours a week.

Admissions and the following outpatient services: ECT, neuropsychological testing, partial hospital program, intensive outpatient treatment, and day treatment, are subject to utilization and medical-necessity review to ensure that the most appropriate treatment and level of care is being provided. Authorization from the Healthfirst Behavioral Health Unit or the delegated Behavioral Health care management organization as outlined in Section 9.1 is required. Providers affiliated with the Behavioral Health care management organization operate under a delegated arrangement with Healthfirst and must comply with that organization’s authorization policies and procedures, as well as with those of Healthfirst.

General Requirements

Providers must obtain authorization for all admissions, selected outpatient services, and out-of-network care. The following information must be supplied when requesting authorization of services:

• Healthfirst Provider ID number

• Member’s name and Healthfirst ID number

• Attending/requesting provider’s name and telephone number

• PCP’s name (if not the attending/requesting provider)

• Diagnosis and ICD-10 Code

• Procedure(s) and CPT-4 Code(s) and procedure date(s)

• Services requested and proposed treatment plan

• Clinical documentation to demonstrate medical necessity

• For inpatient admissions: hospital/facility name, expected date of service, and expected length of stay

Please be sure that ALL the above information is available when calling in the request.

Authorization of Services When Care Is Managed by Healthfirst

Providers must contact the Healthfirst Behavioral Health Unit at 1-888-394-4327 to speak with a Clinical Intake Coordinator to ensure that all care is appropriately authorized.

Authorization status may be checked on our website at www.healthfirst.org. After requesting an authorization, providers are given a notification number that can be used to obtain authorization status. This notification number can be used within two (2) to three (3) business days after Healthfirst has received all the medical-necessity information.

Healthfirst Treatment Principles

Healthfirst has developed eight (8) general treatment principles and guidelines for outpatient behavioral health services. They are consistent with established clinical practice and standards for behavioral health treatment. The principles are as follows:

• Therapeutic Environment: An appropriate therapeutic environment must include face-to-face, in-person contact between the therapist and the member.

• Duration of Therapy Sessions: Individual therapy sessions should ordinarily be a minimum of thirty

(30) minutes, customarily forty-five (45) minutes, unless they are only for medication management by a psychiatrist. Group/family/couple therapy sessions are usually required to run between forty-five (45) and ninety (90) minutes, unless they are for crisis intervention. Crisis intervention sessions ordinarily should not exceed two (2) hours per day for individual therapy or three (3) hours per day for family therapy.

• Individual Psychotherapy: Only one (1) therapist may provide individual psychotherapy to a member; therefore, separate claims should not be submitted when two (2) or more therapists are treating the same member concurrently. Ordinarily, no more than two (2) family members should receive individual therapy from the same provider. When more than two (2) family members require treatment, the provider would be expected to use family therapy as the treatment of choice.

• Composition of Therapy Group: Group therapy sessions usually consist of four (4) to 10 (ten) members, unless they are multifamily or multicouple groups.

• Electroconvulsive Therapy (ECT): Psychotherapy should not be rendered within 24 hours of ECT. Conventional practice does not recognize more than one (1) ECT treatment per day or more than 12 (twelve) ECT treatments in a 30 (thirty)-day period. Indications for a greater number of treatments should be discussed with a Healthfirst psychiatrist.

• Pharmaceuticals: The use of prescription medications should follow national professional standards.

• Contraindications for Psychotherapy: Psychodynamic psychotherapy is generally considered inappropriate for members with a sole diagnosis of organic brain syndrome, substance abuse or chemical dependence, or developmental disorders.

• Documentation: Documentation regarding the member’s progress should reflect movement toward defined treatment goals with measurable objectives. When a member’s diagnosis or treatment plan is changed, the documentation should include clinical information substantiating the reasons for the change.