Review and update annually and submit for EOHHS approval, at a minimum, its Behavioral Health Services authorization policies and procedures; Develop and maintain Behavioral Health Inpatient Services and 24-Hour Diversionary Services authorization policies and procedures, which shall, at a minimum, contain the following requirements: If prior authorization is required for any Behavioral Health Inpatient Services admission or 24-Hour Diversionary Service, assure the availability of such prior authorization 24 hours a day, seven days a week; A plan and a system in place to direct Enrollees to the least intensive but clinically appropriate service; A system to provide an initial authorization and communicate the initial authorized length of stay to the Enrollee, facility, and attending physician for all Behavioral Health emergency inpatient admissions verbally within 30 minutes, and within 2 hours for non-emergency inpatient authorization and in writing within 24 hours of admission; Processes to ensure placement for Enrollees who require Behavioral Health Inpatient Services when no inpatient beds are available; A system to concurrently review Behavioral Health Inpatient Services to monitor Medical Necessity for the need for continued stay, and achievement of Behavioral Health Inpatient treatment goals; Verification and authorization of all adjustments to Behavioral Health Inpatient Services treatment plans and 24-Hour Diversionary Services treatment plans; Processes to ensure that treatment and discharge needs are addressed at the time of authorization and concurrent review, and that the treatment planning includes coordination with the PCP; Retrospective reviews of the medical records of selected Behavioral Health Inpatient Services admissions and 24-Hour Diversionary Services cases to assess the Medical Necessity, clinical appropriateness of care, and the duration and level of care; Prior authorization shall not be required for Inpatient Substance Use Disorder Services (Level 4), Acute Treatment Services (ATS) for Substance Use Disorders (Level 3.7), and Clinical Support Services for Substance Use Disorders (Level 3.5), as defined in Appendix C;
Review and update annually and submit for EOHHS approval, at a minimum, its Behavioral Health Services authorization policies and procedures; Develop and maintain Behavioral Health Inpatient Services and 24-Hour Diversionary Services authorization policies and procedures, which shall, at a minimum, contain the following requirements: If prior authorization is required for any Behavioral Health Inpatient Services admission or 24-Hour Diversionary Service, assure the availability of such prior authorization 24 hours a day, seven days a week; A plan and a system in place to direct Enrollees to the least intensive but clinically appropriate service; A system to provide an initial authorization and communicate the initial authorized length of stay to the Enrollee, facility, and attending physician for all Behavioral Health emergency inpatient admissions verbally within 30 minutes, and within 2 hours for non-emergency inpatient authorization and in writing within 24 hours of admission; Processes to ensure placement for Enrollees who require Behavioral Health Inpatient Services when no inpatient beds are available; A system to concurrently review Behavioral Health Inpatient Services to monitor Medical Necessity for the need for continued stay, and achievement of Behavioral Health Inpatient treatment goals; Verification and authorization of all adjustments to Behavioral Health Inpatient Services treatment plans and 24-Hour Diversionary Services treatment plans; Processes to ensure that treatment and discharge needs are addressed at the time of authorization and concurrent review, and that the treatment planning includes coordination with the PCP; Retrospective reviews of the medical records of selected Behavioral Health Inpatient Services admissions and 24-Hour Diversionary Services cases to assess the Medical Necessity, clinical appropriateness of care, and the duration and level of care; Prior authorization shall not be required for Inpatient Substance Use Disorder Services (Level 4), Acute Treatment Services (ATS) for Substance Use Disorders (Level 3.7), and Clinical Support Services for Substance Use Disorders (Level 3.5), as defined in Appendix C;