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Chronic & Complex Conditions
UNI-MBR-MDM-INP-Managing Conditions intro
Total Health Management
We can help you understand your condition, learn about treatment options, and understand the importance of following your doctor's plan. There are no additional fees to participate in these programs.
UNI-MBR-INP-Managing Conditions Accordion
Our clinical criteria listed below are evidenced based decision making guidelines. We also use guidelines from CMS (Centers for Medicare and Medicaid Services) and eMedNY when applicable.
LOCDATR 3.0 is a clinical tool Univera Healthcare uses for all substance use disorder medical necessity reviews except for substance use partial hospital (see ASAM).
Substance use reviews for inpatient detoxification, rehabilitation and residential levels of care will use the following questionnaire to document clinical information when determining medical necessity. This questionnaire will be used when the outcome of LOCADTR results in a discrepancy for the level of care being requested by the provider. The questionnaire is to ensure that all pertinent clinical information is documented to make the appropriate medical necessity determination.
- Substance Use Disorder Inpatient Rehabilitation & Residential QuestionnaireOpen a PDF
- Substance Use Disorder Inpatient Detoxification QuestionnaireOpen a PDF
For Substance Use Disorder Partial Hospital Program requests outside of New York State, Univera Healthcare uses the ASAM Criteria to complete medical necessity reviews.
A partial hospitalization program (PHP) request is considered 20 or more hours per week, sometimes also known as “day rehab,” because the patient can spend evenings at home.
The ASAM criteria is the most widely used and comprehensive set of guidelines for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions in the United States.
The Behavioral Health Department also uses the corporate medical policy called “Partial Hospitalization for Substance Use Disorders,” to make its decision.
Our plan also has a Behavioral Health Advocate who is available to help you understand a decision, how to ask for an appeal or find a participating provider. To talk to the Behavioral Health Advocate, please call 1-844-809-7518 (Members with Medicaid, Child Health Plus, or HARP plans should call 1-844-635-2662).
Members with a primary substance use diagnosis are given an approval for the first 14 days of inpatient detoxification, rehabilitation, and residential treatment at any New York State OASAS facility licensed to provide these services. Licensed providers are required to notify the plan within the first 48 hours of admission. Coverage of additional days will be reviewed for medical necessity.
For members with a primary opiate diagnosis, services are approved upon provider notification without the need for a medical necessity review. After validating patient information and eligibility, approvals are given to the facility within the same day if the precertification is requested by 2 p.m., otherwise an approval is given within 24 hours.
To learn more, please call a Behavioral Health Advocate at 1-844-809-7518 (Members with Medicaid, Child Health Plus, or HARP plans should call 1-844-635-2662). Coverage of additional days and retrospective reviews require medical necessity review. Services received at facilities outside of New York State require pre-certification and will be reviewed for medical necessity.
Information about substance use disorder treatment resources in New York State is also available at the website of the New York State Office of Alcoholism and Substance Abuse Services.