Chronic & Complex Conditions

We use the policies and guidelines below to help decide how to approve your care. We also use guidelines from the Centers for Medicare and Medicaid Services (CMS) and eMedNY, when appropriate.

Medicare members

• Medicare Local Coverage Determination (LCD)Opens a dialog
  Medicare uses Local Coverage Determination (LCD) as an adjunct to National Coverage Determination (NCD) as published by the Centers for Medicare and Medicaid Services for all reviews where there are published NCD and LCDs. When there are no applicable NCD and LCDs available, Change Health InterQual Behavioral Health or Univera Healthcare Corporate Medical Policies will be applied.
• Medical Policies
• Prescription Drug Policies
• InterQual^® Criteria - requires a free One Healthcare ID account, or access directly through your member account
• InterQual^® Criteria

Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 is a web based level of care determination application. NYS OASAS in partnership with The National Center on Addiction and Substance Use at Columbia University developed this tool to determine the most appropriate level of care for substance use disorder.

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 CriteriaOpen a PDF 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.

A behavioral health advocate is available to assist you in understanding this decision as well as the process for pursuing appeals, and in identifying participating providers. To request assistance from the behavioral health advocate, please call 1-844-809-7518 (TTY 711) Monday through Friday 8 a.m. to 5 p.m. ET.

Improving access to substance use treatment

Members with a primary substance use diagnosis are given an approval for the first 28 days of inpatient detoxification, rehabilitation, and residential treatment at any New York State Office of Addiction Services and Supports (OASAS) facility licensed to provide these services. Licensed providers are required to notify the plan within 2 business days of admission. Coverage of additional days will be reviewed for medical necessity. To learn more, please call a behavioral health advocate at 1-844-809-7518 (TTY 711). 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 NYS Office of Addiction Services and Supports.

• Prohibition on preauthorization for inpatient admissions of children under the age of 18. No preauthorization and/or concurrent review requirements of the first 14 days of inpatient treatment may be conducted of an admission of a member under age 18 to a participating hospital licensed by the New York State Office of Mental Health.
• Provide a written discharge summary to both Univera Healthcare and the patient upon discharge.

All other members

Get help understanding a decision

Confused about a behavioral health decision? Our behavioral health advocate can help you understand the details of a decision and explain how to ask for an appeal. Call 1-844-809-7518 (TTY 711) Monday through Friday from 8 a.m. to 5 p.m. ET. If you have Medicaid, Child Health Plus, or a Health and Recovery Plan (HARP), call 1-844-635-2662 (TTY 711).

Need help understanding other care decisions? Call the number on the back of your member card or call Customer Care at 1-800-499-1275 (TTY 711).

General policies and criteria

• Medical Policies
• Prescription Drug Policies
• InterQual^® Criteria - requires a free One Healthcare ID account, or access directly through your member account
• InterQual^® Criteria

Substance use disorder care

Inpatient substance use disorder care

You are approved for up to 28 days of inpatient care at a New York state facility approved by the Office of Addiction Services and Supports (OASAS) if you have a primary diagnosis of substance use disorder. Your provider decides on the level and amount of care you need. They must tell us within two business days that you have entered a treatment facility. Note: You need prior approval to get care at an out-of-network facility, including facilities outside New York state.

For care past 28 days, we review information from your provider about your progress to that point. This information may include details about your medications, withdrawal symptoms, and general wellbeing. We put these details into an online, evidenced-based tool called Level of Care for Alcohol and Drug Treatment Referral (LOCADTR). LOCADTR is used by all health insurance companies in New York and helps to determine if a continued stay is appropriate.

Your provider may also put their information into LOCADTR. If our LOCADTR results match with your provider’s results, your continued care is approved. If our results are different, we contact your provider for more information and use the questionnaires below to help us understand why your provider may be asking for more care.

• Inpatient Rehabilitation & Residential QuestionnaireOpen a PDF
• Inpatient Detoxification QuestionnaireOpen a PDF

Outpatient substance use disorder care

In most cases, you do not need approval for outpatient substance use disorder. You can get care from any provider or facility in our network.

Partial hospitalization program (PHP) requests for substance use disorder

Substance use PHPs involve 20 or more hours of care per week but do not make you to stay overnight. We use national criteria from the American Society of Addiction Medicine (ASAM) when making decisions about substance use disorder PHPs outside New York state. ASAM CriteriaOpen a PDF are the most widely used and comprehensive set of guidelines for these programs. Keep in mind that not all plans provide coverage for substance use PHPs. If you have questions about your plan’s benefits, please call the number on the back of your member card or call Customer Care at 1-800-499-1275 (TTY 711).

Mental health care

Inpatient mental health care

Your provider decides on the level and amount of care you receive at inpatient mental health facilities within New York state. This includes acute care in a hospital as well as care in a 24-hour intensive residential setting. Keep in mind that any facility you enter must be approved by the Office of Mental Health. Your provider must tell us within two business days that you’ve entered a treatment facility. We then review a list of New York state-identified triggers to see if they apply to your situation. These triggers help us understand if you may need extra support. They also affect the amount of care you’re approved for. Throughout your inpatient stay, we have collaborative calls with your provider to assess and provide interventions based on your needs.

After your initial approval period, we review information from your provider about your progress to that point. This information may include details about your medications, symptoms, and general health. We review these details using InterQual criteria and our corporate medical policies to determine if a continued stay is appropriate.

You need prior approval for inpatient mental health care outside New York state. For this approval, we review information from your provider about the level and amount of care they want you to have. This information may include details about your medications, symptoms, and general health. We review these details using InterQual® criteria to determine if a stay is appropriate.

After you leave inpatient treatment, your provider sends us a copy of your discharge summary. You should also receive a copy of this summary. We use this summary to follow up to make sure you have the resources and support you need.

Outpatient mental health care

In most cases, you do not need approval for outpatient mental health care. You can get care from any provider or facility in our network.

Partial hospitalization program (PHP) and intensive outpatient program (IOP) requests for mental health care

Your provider decides on the level and amount of care you receive at PHP or IOP facilities within New York state. Keep in mind that any facility you enter must be approved by the Office of Mental Health. Your provider must tell us within two business days that you’ve entered a PHP or IOP facility. We then review a list of New York state-identified triggers to see if they apply to your situation. These triggers help us understand if you may need extra support. They also affect the amount of care you’re approved for. Throughout your treatment, we have collaborative calls with your provider to assess and provide interventions based on your needs.

You need prior approval for mental health PHP or IOP care outside New York state. For this approval, we review information from your provider about the level and amount of care they want you to have. This information may include details about your medications, symptoms, and general health. We review these details using InterQual criteria to determine if this care is appropriate.