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OASAS Inpatient SUD Treatment and OMH Inpatient MH Treatment
2/10/2020 • Posted by Provider Relations

Effective 01/01/2020, OASAS licensed inpatient substance use disorder (SUD) treatment and
OMH licensed inpatient mental health (MH) treatment authorization requirements have been updated in our authorization grids for all product lines of business. 

OASAS Licensed Inpatient Substance Use Disorder Treatment:

Effective 01/01/2020: Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services (Inpatient SUD) provided by facilities in New York State that are licensed, certified or otherwise authorized by OASAS and participating in Fidelis Care’s provider network are not subject to prior authorization review by Fidelis Care. In addition, Inpatient SUD services are not subject to concurrent utilization review during the first twenty-eight (28) days of the inpatient admission, provided that the facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two (2) business days of the admission.  The facility may fax or email the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org.  All Inpatient SUD services require facilities to perform daily clinical review of the patient. This does not require a facility to conduct a LOCADTR concurrent review module every day. In addition, all Inpatient SUD facilities must periodically consult with Fidelis Care starting on or just prior to the fourteenth (14th) day of treatment to ensure that the facilities are using the LOCADTR tool to ensure that the inpatient treatment is medically necessary for the patient. Inpatient SUD services may be subject to utilization review after the 28th day from admission or upon discharge using the LOCADTR clinical review tool. Prior to the member’s discharge, facilities must provide the member and Fidelis Care with a written discharge plan as determined using the LOCADTR clinical review tool.  Further, prior to discharge, facilities must indicate to Fidelis Care whether the services included in the discharge plan are secured or determined to be reasonably available.  All services may be reviewed retrospectively to assess the clinical necessity of the care. 

Facilities that are outside of New York State, facilities that are not licensed, certified or otherwise authorized by OASAS, and facilities that are outside of Fidelis Care’s provider network, continue to be required to request prior authorization review for Inpatient SUD services. All Inpatient SUD services provided by such facilities are subject to concurrent review throughout the admission.

Providers with questions regarding these changes are encouraged to call Fidelis Care, during regular business hours, at 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health.

OMH Licensed Inpatient Mental Health Treatment:

Effective 01/01/2020: Inpatient mental health treatment for members under age 18 provided by OMH licensed hospitals in New York State that are participating in Fidelis Care’s provider network are not subject to prior authorization review by Fidelis Care. Fidelis Care will not conduct concurrent utilization review during the first 14 days of inpatient admissions provided that the facility: i) notifies Fidelis Care of both the admission and the initial treatment plan within two business days of the admission by completing the OMH developed “Two-Day Notification and Initial Treatment Plan” form and submitting it to Fidelis Care by fax (718-896-1784), or by email to Mental_Health_Admission@fideliscare.org; ii) performs daily clinical review of the patient, and iii) participates in periodic consultation with Fidelis Care to ensure that the facility is using the evidence-based and peer reviewed clinical review criteria utilized by Fidelis Care which is approved by OMH and appropriate to the age of the patient to ensure medical necessity.  All services may be reviewed retrospectively using the clinical review criteria of the plan which is approved by the office of mental health. 

Inpatient mental health services provided to members age 18 and older require prior authorization review by Fidelis Care and are subject to concurrent review throughout the admission. Out-of-State and Out-of-Network providers continue to be required to request prior authorization review for inpatient mental health treatment for members of all ages. All inpatient mental health services provided by such facilities are subject to concurrent review throughout the admission. Providers with questions regarding these changes are encouraged to call Fidelis Care, during regular business hours, at 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health.

Authorization Grids

If you have any questions regarding these changes, you are encouraged to call Fidelis Care, during regular business hours, at 1-888-FIDELIS (1-888-343-3547), extension 16072 for the Behavioral Health team.

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Each day, Fidelis Care's Utilization Management (UM) Department makes decisions on many health insurance claims. These decisions are based only on appropriateness of care and the existence of coverage. 

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