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Utilization Management

GLO-PRV-Behavioral Health-Utilization Management

Our Behavioral Health Utilization Management teams are licensed and/or certified experts in mental health and substance use disorders. Our team consists of psychiatrists, master level clinical social workers, registered nurses and psychiatrists with years of experience and extensive knowledge and training. The utilization management teams ensure members are receiving medically necessary services at the most appropriate level of care. Our plan has a Behavioral Health Advocate who is available to help you understand a decision, how to ask for an appeal or understand the clinical criteria. 

Providers should contact Provider Service when calling in a request for services, if the service is on the prior authorization list.

  • For Commercial and Medicare contracts call 800-363-4658
  • For Safety Net (Medicaid, Health & Recovery Plan (HARP), Child Health Plus, and Essential Plan) 844-694-6411.
  • To talk to a Behavioral Health Advocate for Commercial, Essential Plan, or Medicare; call toll free 1-844-809-7518.
  • To talk to a Behavioral Health Advocate for Safety Net (Medicaid, Health & Recovery Plan (HARP), and Child Health Plus); call toll free: 1-844-635-2662.

All UM decisions are based on Clinical Criteria.

GLO-PRV-Behavioral Health Resources - Accordion Content

  • Traditional outpatient mental health counseling/therapy services do not require prior authorization. However, there are some services that do require a prior authorization including but not limited to: psychological testing, mental health partial hospital programs, mental health intensive outpatient services. 
  • Some HARP outpatient services and Safety Net (Medicaid, Health & Recovery Plan (HARP), Child Health Plus, and Essential Plan) also require prior authorization. 
  • Prior to meeting with the member, providers should determine the member's eligibility, benefits and check to see if prior authorization is necessary.
  • Providers must ask members to give written consent for sharing medical information with his or her PCP and other practitioners (as necessary). Providers must coordinate care with the PCP and other practitioners to ensure that the patient receives appropriate and uninterrupted care, and to strengthen system-wide continuity between medical and Behavioral Health care. 

Referral and review process

  • Most member policies require plan authorization for inpatient mental health services. In this case, a participating Behavioral Health provider or other provider must obtain authorization by notifying Provider Service within 48 hours of the admission.
  • The facility calls Provider Service to verify eligibility and benefits and to report that the member is receiving inpatient treatment. A member of the facility's clinical staff must then contact Behavioral Health with clinical information to support the inpatient admission.
  • A Behavioral Health staff reviewer conducts the appropriate review to determine medical necessity, appropriate level of care, and appropriate length of stay. Behavioral Health staff reviewers assess services in accordance with nationally recognized criteria and Health Plan medical policies.
  • During the patient's stay, Behavioral Health will conduct concurrent reviews as deemed necessary. Following each review, the Health Plan will send a notice to the hospital and the member indicating denial or approval of services, and the length of service approved.
  • If, at any time, the reviewer concludes that the inpatient admission or hospital stay does not meet Behavioral Health criteria, he/she will inform a Medical Director who will make a determination or will arrange for a clinical discussion with the member's attending physician.

Inpatient Substance Use Treatment

For New York State OASAS (office of Alcoholism and Substance Use Services) providers, who participate with the member’s insurance contract, prior authorization is not required for inpatient substance use levels of care. Notification is required within 48 hours of the members admission

  • Fourteen days of any inpatient substance use service will be approved once the member is verified.
  • Concurrent reviews will be conducted using LOCADTR 3.0 Concurrent review Module on day 15, if the provider is requesting continued stay.
  • Providers outside of New York State and member contracts with limitations may require prior authorization and a medical necessity review.

Outpatient Substance Use Treatment

  • Members do not need referrals or prior authorization to obtain coverage for traditional outpatient substance use services under most plans (contact Provider Service to determine member eligibility).
  • Out of New York State Substance Use partial hospital program admissions require prior authorization and require medical necessity review based on ASAM (American Society of Addiction Medicine) criteria.
  • Family Treatment - A participating substance use provider may bill the Health Plan to obtain payment for treating the family of a person with a substance use disorder. The person with a substance use disorder does not have to be in treatment in order for the family member to access this benefit.

Personalized Recovery Oriented Services (PROS)

Personalized Recovery Oriented Services (PROS) is a comprehensive recovery-oriented program for individuals with severe and persistent mental illness. Through a single plan of care, the program model integrates treatment, support, and rehabilitation in a manner that facilitates the individual's recovery. The PROS model is person-centered, strength based, and comprised of a menu of group and individual services designed to assist a participant to overcome mental health barriers and achieve a desired life role. As PROS is individualized, a person can participate in one service or multiple services as needed. Examples of goals for program participants are to: improve functioning, reduce inpatient utilization, reduce emergency services, reduce contact with the criminal justice system, increase employment, attain higher levels of education, and secure preferred housing.
For more information on PROSOpen a PDF

Assertive Community Treatment (ACT)

Assertive Community Treatment (ACT) is an evidence-based practice which strives to deliver compressive and effective services to individuals who are diagnosed with severe mental illness and whose needs have not able to be met thorough traditional clinic services. ACT provides an integrated set of other evidence-based treatment, rehabilitation, case management, and support services delivered by a mobile, multi-disciplinary mental health treatment team. ACT supports recipient recovery through a highly individualized approach that provides recipients with the tools to obtain and maintain housing, employment, relationships and relief from symptoms and medication side effects. The nature and intensity of ACT services are developed through the person-centered service planning process and adjusted through the process of daily team meetings.
For more information on ACTOpen a PDF

CFTSS

Children and Family treatment Support Services (CFTSS) are mental health and substance use services, available with NYS Children’s Medicaid, give children/youth (under age 21) and their families the power to improve their health, well-being and quality of life. These services strengthen families and help them make informed decisions about their care. These children's services helps identify mental health and substance abuse early. Services are provided at home or in the community. Utilization of these support services can help prevent the need for emergency room visits, hospital stays or out of home placements. CFTSS includes therapy services, rehabilitation services, and family peer support services.

First Episode Psychosis (FEP)

A transformational goal of the Managed Care expansion for behavioral health services is to foster reliance on specialized expertise for the assessment, treatment, and management of special populations, such as individuals experiencing a first episode of psychosis. An abundance of data accumulated over the past two decades supports the value of early intervention with services to help maximize recovery following a first psychotic episode. ExcellusUnivera identifies our members, using claim data as well as referrals from providers, that have had a first episode of psychosis, attempts to connects them to the appropriate services and continues to follow them for a 3-year time period.

View FEP in our Clinical Practice Guidelines

HCBS

Home and Community Based Services (HCBS) provide opportunities for Medicaid beneficiaries with mental illness and/or substance use disorders who are enrolled in a Health and Recovery Plan (HARP) to receive services in their own home or community. A person must be deemed eligible to receive HCBS using the HCBS Eligibility Assessment tool. There is also a person-centered HARP Plan of Care (POC) that is associated with each recommended HCBS. HCBS's include community rehabilitation services, vocational services, crisis respite services, education support service, empowerment service - peer support service, habilitation/residential support service, and family support & training service