Appropriateness Criteria Codes HHSA and HHSC
- Codes also available in the following format (PDF)
Appropriateness Codes and Criteria
September 2024
This chart lists the codes and criteria used for initial eligibility (Adults and Children) and annual appropriateness (Children). Please refer to the HH0016 Eligibility Requirements for Health Home Services and Continued Eligibility in the Health Home Program policy for requirements that outline the steps to be taken to ensure individuals meet criteria for Health Home enrollment and continued enrollment.
This chart was revised September 2024 and effective for implementation September 1, 2024.
| Appropriateness Code |
Appropriateness Criteria | Program | Comments Required (Y/N)? |
|---|---|---|---|
| 10 | ADVERSE EVENTS RISK: Current H-code in EMEDNY (HARP Eligible/Enrolled) |
Adults | N |
| 11 | ADVERSE EVENTS RISK: Current POP flag in PSYCKES | Adults | N |
| 12 | ADVERSE EVENTS RISK: Current Quality or HH+ flag in PSYCKES or equivalent from RHIO or MCO | Adults | N |
| 13 | ADVERSE EVENTS RISK: Member currently involved with mandated preventive services and/or direct referral from Child Protective Services/Preventive Services Program, County Local Departments of Social Services, Administration for Children's Services (for New York City), Special Education Program, Schools (e.g., children suspension, truancy, grade failure/repeat grade or summer school). Must specify provider of service and date of referral. | Children | Y |
| 14 | ADVERSE EVENTS RISK: Member recent inpatient/Emergency Department/psychiatric hospital/Detox/Skilled Nursing/Crisis Stabilization within the last 6 months. Must specify name of institution and date of release | Children | Y |
| 15 | ADVERSE EVENTS RISK: Member recent out of home placement (foster care, relative, Residential Treatment Facility (RTF), Residential Treatment Center (RTC), Qualified Residential Treatment Program (QRTP), Community Residence, Residential Crisis, etc.) within the last 6 months. Must specify name of institution and date of release | Children | Y |
| 16 | ADVERSE EVENTS RISK: Member recently diagnosed with a terminal illness/condition within the last 6 months. Must specify condition and date diagnosed | Children | Y |
| 17 | ADVERSE EVENTS RISK: Member received an initial Disability Determination (SSI or DOH Disability Certificate/letter) within the last 6 months | Children | N |
| 18 | ADVERSE EVENTS RISK: Released from Jail/Prison/Juvenile detention, involved with Probation, PINS, Family Court within the last 6 months. Must specify name program and date of release/court/probation | Children | Y |
| 19 | HEALTHCARE RISK: During the last 3 months, the member has been unable to schedule and keep their healthcare appointments (medical, psychiatric, etc.) and they do not know who their provider(s) is and how to contact their provider(s). Must describe the issue. | Both | Y |
| 20 | HEALTHCARE RISK: Member does not have at least one (1) of the following: Primary Care Provider, mental health provider, substance use provider, or provider to treat their Single Qualifying Condition (Complex Trauma, Sickle Cell Disease, Serious Emotional Disturbance/Serious Mental Illness, or HIV) or physical disability related to a neurologic, muscular, or neuromuscular condition. | Both | N |
| 21 | HEALTHCARE RISK: Member has not seen their provider (e.g., PCP, BH, etc.) in the last year | Both | N |
| 22 | READMISSION/RECIDIVISM RISK: Released from inpatient Medical, Emergency Department, Crisis Stabilization, Residential Treatment Setting, Psych, or Detox within the last 6 months. Must specify name of institution and date of release | Adults | Y |
| 23 | READMISSION/RECIDIVISM RISK: Released from Jail/Prison or other justice program within the last 6 months. Must specify name program and date of release | Adults | Y |
| 24 | SOCIAL DETERMINANTS RISK: Current Intimate Partner Violence/Current Family Violence in the home of the member | Both | N |
| 25 | SOCIAL DETERMINANTS RISK: Member is experiencing food insecurity (due to financial limitations, ability to shop, access food site, dietary restrictions, etc.) and needs one of the following:
|
Both | N |
| 26 | SOCIAL DETERMINANTS RISK: Currently homeless (HUD 1, 2, or 4) & for Transitional Age Youth, has no stable living arrangement (living with different friends/family) | Both | N |
| 27 | There is no criterion currently assigned to this code. | N/A | N/A |
| 28 | SOCIAL DETERMINANTS RISK: Member has had a change in guardianship/caregiver within the last 6 months | Both | N |
| 29 | SOCIAL DETERMINANTS RISK: Member is concurrently Health Home appropriate due to caregiver/guardian enrolled in Health Home. Must specify the Health Home/Care Management Agency enrolled with. | Children | Y |
| 30 | SOCIAL DETERMINANTS RISK: Member (or caregiver, if Member is a child) needs and does not have one (1) of the following needed entitlements:
|
Both | N |
| 31 | SOCIAL DETERMINANTS RISK: Recent institutionalization or nursing home placement of member's primary support person within the last six (6) months and there is no other person to provide the same level of support. | Adults | N |
| 32 | TREATMENT NON-ADHERENCE RISK: Member/care team member report of non-adherence…Must specify WHICH medication(s) and/or treatment(s) are involved | Both | Y |
| 33 | TREATMENT NON-ADHERENCE RISK: PSYCKES flag related to non-adherence or equivalent from RHIO or MCO | Both | N |
| 34 | Direct referral from Managed Care Organization (MCO), Local Government Units (LGU), Single Point of Access (SPOA), or county Local Department of Social Services. | Both | N |
| 35 | Direct referral from Adult Protective Services | Adults | N |
| 36 | There is no criterion currently assigned to this code. | N/A | N/A |
