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 routine in-network outpatient behavioral health services provided by Healthfirst providers is not required.

Routine 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.  

Authorization is required for admissions, all out-of-network care, and select outpatient services such as: ECT, neuropsychological testing, and others. Authorization from the Healthfirst Medical Management Department or the delegated Behavioral Health Care Management organization is required. Providers affiliated with the delegated Behavioral Health Care Management organization operate under a specific arrangement with Healthfirst and must comply with that organization’s authorization policies and procedures, as well as with those of Healthfirst.

All Behavioral Health services for FIDA members, including routine services with in-network providers, require authorization.  
There are services that do not require prior-authorization, particularly for treatment of Substance Use Disorders, such as Medically Supervised Outpatient Withdrawal, Outpatient Clinic Opioid Treatment Program, and Intensive Outpatient Substance Use Disorder Treatment. However, in order for Healthfirst to assist with coordination of care and transition planning, it is requested that providers notify Healthfirst when providing these services so that any assistance needed with treatment planning can take place on behalf of the member.
Heathfirst utilizes McKesson's InterQual Criteria for Mental Health admissions and LOCADTR 3.0 for Substance Use disorder patient placement decisions for Medicaid Mainstream and Health and Recovery Plan (HARP) members. Healthfirst has complete criteria for CDT, PROS, and ACT, as supplied by NY State to be utilized for Medicaid Mainstream and HARP members. InterQual, the criteria utilized for CDT, PROS, and ACT contains decision support criteria for initial, ongoing, and discharge review. HARP members will additionally receive a conflict-free assessment conducted by a Health Home Care Manager; the Community Mental Health Assessment (InterRai). If, as a result of the assessment they are found eligible to receive Home and Community Based Services (HCBS), Healthfirst will offer two referrals for each recommended service to the member, and will authorize and review the delivery of the HCBS according to the NYS HCBS guidelines for ongoing care.

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)
·     ICD-10 Code (beginning 10/1/2015) 
·     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 of the above information is available when calling in the request.

Authorization of Services When Care Is Managed by Healthfirst

Providers must contact the Healthfirst Intake Unit, at 1-888-394-4327, to speak with an Intake Coordinator to ensure that all care is appropriately registered with complete information related to the request. All requests will then be reviewed by a Healthfirst Behavioral Health clinician.

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 Medical Management 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 Groups: Group therapy sessions usually consist of four (4) to ten (10) members, unless they are multi-family or multi-couple 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 twelve (12) ECT treatments in a thirty (30)-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.