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Chronic & Complex Conditions

EXC-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.

Call our Member Care Management Team at 1-800-860-2619 (TDD/TTY 1-800-662-1220) or email.
Hours: 8:00 a.m. - 4:30 p.m., Monday - Friday.

EXC-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.

LOCADTR 3.0 is a web based level of care determination application. NYS OASAS in partnership with The National Center on Addiction and Substance Abuse 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.

For Substance Use Disorder Partial Hospital Program requests outside of New York State, Excellus BCBS 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).

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 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.

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.

  • 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 Excellus BlueCross BlueShield and the patient upon discharge.