The NH Healthy Families ABA InterQual transition June 2026 change retired CP.BH.104 for medical-necessity review. The plan transition notice applies InterQual Behavioral Health criteria to initial and concurrent ABA authorization requests across applicable codes. Existing submission requirements remain, and CP.BH.105 documentation requirements remain in force. Practices should update the criteria source while keeping clinical recommendations, documentation, authorization, and payment as separate decisions.

Retire the old criteria at the correct boundary

For requests governed by the June 1 change, CP.BH.104 no longer supplies the plan's medical-necessity review criteria. Archive its version and effective period so older decisions, appeals, and audits remain reproducible. Point new and concurrent requests to the current InterQual route and preserve the date the criteria were accessed. Avoid deleting the historical policy or applying the new source to an earlier decision without a controlling instruction.

Record the criteria state per request: request type, submission date, requested service dates, current authorization period, decision date, criteria name and version, access date, reviewer, and supporting evidence. If the transition notice leaves an in-flight case unclear, preserve both possible sources and obtain written plan guidance. Keep the request held at the administrative gate while qualified clinicians address any immediate continuity or safety concern.

Keep the prior-authorization route intact

The notice says providers continue submitting requests under existing prior-authorization requirements. Preserve the member and product, request type, service and codes, provider, location, requested dates and units, current form, portal or fax route, attachments, receipt, case number, deadline, and decision. A criteria-source change does not itself create a new form, guarantee portal behavior, or excuse missing submission evidence.

Apply the change to initial and concurrent review

InterQual applies to both initial and concurrent requests. Define the event precisely. An initial request, continuation, modification, retroactive issue, appeal, and claim may use different evidence and timing. For concurrent review, lock the current authorization end date, submission window, progress evidence, plan version, requested change, continuity risk, and decision. Do not wait for an expiration simply because the criteria library changed.

Preserve CP.BH.105 documentation controls

The plan expressly says CP.BH.105 is unaffected. Keep documentation completeness as its own gate, including authorship, service facts, clinical content, signatures when required, progress evidence, and relationship to billed units. A request meeting InterQual criteria can still have a documentation or claim problem. A complete record likewise does not establish medical necessity, authorization, coverage, or payment.

Build an evidence crosswalk without copying proprietary criteria into an uncontrolled template. For every request question, link the source assessment, treatment plan, progress measure, direct observation, client or family input, coordination record, and qualified author. Label unavailable evidence and disagreements. Operations may flag a missing artifact, but the clinician owns its interpretation and the payer owns the coverage determination.

Protect access to proprietary criteria

Use InterQual through the licensed, plan-approved route and follow its access and use terms. Record enough metadata to reproduce which criteria were applied without pasting restricted content into broadly accessible records. Limit credentials by role, remove access when duties change, and keep exported case evidence in the authorized clinical or payer workflow.

If the practice cannot access the applicable criteria, contact the plan and document the request, response, and interim submission instructions. Do not guess at hidden criteria or rewrite a clinical recommendation based on remembered wording.

Respect state, contract, and EPSDT requirements

NH Healthy Families says determinations continue under the New Hampshire Medicaid managed-care contract, EPSDT when applicable, and state and federal rules. Use the state ABA provider notice for state-program context and the plan's current policy page for the live route. When sources differ, preserve both and seek written clarification. A proprietary criteria tool does not displace controlling law or the member's notice rights.

Keep clinical authorship outside the payer tool

A qualified clinician assesses the person and recommends care within scope, with client and family involvement and accessible communication. The payer applies its coverage criteria. Operations can map evidence and identify missing fields. It should not rewrite clinical goals, dosage, risk, or rationale to imitate a criterion. If the payer's decision differs from the recommendation, preserve both and route the notice, records, review, or appeal process.

Validate the decision and next action

Save the full decision notice, requested and approved services, codes, units, dates, stated criteria basis, receipt date, continuity information, and review or appeal route. Compare the notice with the submitted request and current authorization. An approval should still be reconciled to provider capacity and a safe, accessible schedule. A partial approval or denial should reach the clinician and member or authorized representative promptly through an accessible communication process.

Track request acceptance, authorization, service delivery, claim acceptance, adjudication, and payment as separate outcomes. InterQual use proves only that a criteria process was applied as documented; it does not establish every later state.

A fictional criteria-transition audit

Elena locks 23 NH Healthy Families request configurations spanning May through July. Eighteen use the correct criteria source, request type, product, service dates, documentation rule, state context, receipt, and decision owner. Two post-June requests still cite CP.BH.104, one May appeal lost the historical version, one concurrent request lacks the authorization end date, and one confuses documentation completeness with approval. Initial readiness is 18 of 23, or 78.3%.

Use a version-controlled request checklist

Verify the member and product, request type, service dates, criteria source and access date, historical CP.BH.104 version when relevant, current CP.BH.105 requirements, state source, EPSDT status when applicable, plan recommendation, requested codes and units, form, route, receipt, decision, notice, records access, review deadline, and recheck trigger. Monitor the plan policy page for later revisions.

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