N.Y. Comp. Codes R. & Regs. tit. 14, § 584.22 – Medical necessity for access to residential treatment facility services.

(a) Prior to admission and no sooner than 14 days after admission, the Office of Mental Health of the commissioner’s designee may evaluate the medical necessity and quality of residential treatment facility services for each child that is an applicant or recipient of medical assistance pursuant to title 11 of article 5 of the Social Services Law. If the Office of Mental Health or commissioner’s designee determines that residential treatment services are no longer appropriate, the determination of the Office of Mental Health or commissioner’s designee shall be reported to the residential treatment facility and the child, or the child's legally authorized representative. Such determination shall not be effective retroactively.
(b) Medical necessity for access to residential treatment facility services shall only be determined if the following criteria are met:
1. (1) attainment of at least the 5th birthday but not the 21st birthday;
2. (2) intelligence quotient equal to or greater than 51;
3. (3) criteria for voluntary admission as defined in section 9.13 of the Mental Hygiene Law;
4. (4) a current primary diagnosis of a designated mental illness;
5. (5) criteria for serious emotional disturbance;
6. (6) criteria for severity and intensity of need for access to residential treatment facility services. Severity and intensity of need criteria shall be determined in accordance to standards and procedures set by the Office of Mental Health or commissioner's designee. Severity and intensity of need criteria shall meet certification of need requirements for admission of a child to a residential treatment facility that is an applicant or recipient of medical assistance pursuant to title 11 of article (5) of the Social Services Law. The criteria shall include:
  1. (i) ambulatory care resources and other out of home interventions available in the community, do not meet the treatment needs of the individual child as evaluated in accordance to standards and procedures developed by the Office of Mental Health or commissioner's designee;
  2. (ii) the individual child is experiencing severity of psychiatric need which requires proper care and treatment of the child’s psychiatric condition on an inpatient basis under the direction of a physician to improve the individual's condition or prevent further regression so that services will no longer be needed, as evaluated in accordance to standards and procedures developed by the Office of Mental Health or commissioner's designee;
  3. (iii) care and treatment in a residential treatment facility can reasonably be expected to improve the child's condition or prevent further regression so that services will no longer be needed, provided that a poor prognosis shall not in itself constitute grounds for a denial of determination of eligibility if treatment can be expected to effect a change in prognosis, as evaluated in accordance to standards and procedures developed by the Office of Mental Health or commissioner's designee.
(c) Medical necessity for access to residential treatment facility services delivered by a residential treatment facility unit(s) developed in collaboration with the Office of Mental Health and the Office of People with Developmental Disabilities, to serve children with a designated mental illness and an intellectual and/or development disability, shall be exempt from medical necessity criteria paragraph (b)(4) of this section.
(d) Evaluations of medical necessity shall include an evaluation of educational needs. When an assessment of a child’s educational needs is required and is not available from a committee on special education, the office of mental health or commissioner’s designee shall request such assessment from the appropriate committee on special education, in accordance with Education Law section 4003.5. For the purposes of this Part, the appropriate committee on special education shall be the committee on special education of the school district of residence at the time of the application for eligibility.
(e) Notifications on evaluations and determinations of medical necessity for access to residential treatment facility services shall be made to the local governmental unit of the county in which the child resides.
(f) In order to be eligible to admit to a residential treatment facility, a child must have an authorization to access residential treatment facility services based on an evaluation and determination of medical necessity, completed in accordance with standards and procedures established by the Office of Mental Health or commissioner's designee and as applicable, in accordance with Federal regulations.
(g) Authorization for access to residential treatment facility services shall not be granted unless a child meets the medical necessity criteria pursuant with subdivision (b) of this section.