Prior Authorization in Behavioral Health Services
Explore key insights into the Prior Authorization process for Behavioral Health services, including challenges, requirements, and the role of Medical Necessity Review. Learn about the importance of documentation, provider contracts, and essential services needing authorization.
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Presentation Transcript
Behavioral Health Informational Forum February 2, 2022
Prior Authorization Progresses What s New and How Will it Work? 2 March 20, 2025
How It Was? Majority of Providers did not hold a direct contract with YCCO ( non-par status). Providers submitted clinical documentation along with a request for authorization for all service requests. March 20, 2025 3
Beginning January 1, 2022 An increased number of Providers have a direct YCCO contract or are currently in the process of contracting As a result, there are a greater number of Providers who can use the auto auth process in CIM Non-contracted providers and providers delivering services that are found on the Prior Authorization list will still need to submit authorization requests March 20, 2025 4
Prior Authorization Getting a consistent understanding of the language Prior Authorization versus Medical Necessity Review? The Utilization Management team conducts a Medical Necessity Review in response to a Prior Authorization request Does a Prior Authorization guarantee payment? No, the Medical Necessity Review establishes whether medical necessity was present within the documentation provided. It doesn t address things like member eligibility or whether the Provider submitted the claim correctly. March 20, 2025 5
Prior Authorization Things that can create challenges in the Prior Authorization request process includes: Was not submitted in a timely fashion Documentation is incomplete, overly vague, and/or unreadable Provider does not respond to request for additional information in a timely fashion Requested service does not pair with the diagnosis March 20, 2025 6
What needs Prior Authorized https://yamhillcco.org/wp-content/uploads/YCCO-BH-PA-Grid.xlsx- External_Provider-Copy_01072022.pdf A prior authorization grid is available on the YCCO website Primary services requiring Providers PA for all include: Inpatient, sub-acute, residential, detox, day treatment, PHP, IOP, ECT, TMS, IIBHT, Psych/Neuropsych evals, and ABA March 20, 2025 7
Auto Authorization YCCO contracted Providers may enter auto auths into CIM for services that do not require prior authorization for in-network providers Providers need to enter the auto auths in a correct and timely fashion for claims to process successfully March 20, 2025 8
Questions ? March 20, 2025 9
