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.
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.
The New York State Office of Alcoholism and Substance Abuse Services (OASAS) has created an online tool to make recommendations as to the appropriate level of care for individuals in need of substance use disorder treatment based on an individual's risks and resources. The Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) is a clinical tool used with a provider's full assessment. LOCADTR was effective for the Medicaid and Child Health Plus products starting on 7/1/16 and for our Commercial, Federal Employee Program (FEP) and Medicare products effective 9/1/16.
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.
LOCADTR does not constitute medical advice. Treating practitioners are responsible for the medical advice and for the treatment of their patients. As a result, we recommend that you review these criteria with your doctor to fully understand how the criteria related to your situation.
For Inpatient Substance Use Reviews including inpatient detoxification, inpatient rehabilitation and residential levels of care; the following questionnaire will be used 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.
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 844-809-7518.
Effective immediately, for our members with a primary diagnosis of moderate or severe opioid disorder, we will automatically approve all new requests received from New York providers for coverage (including preauthorization, if required) for an initial length of stay for the following services at any New York State facility licensed to provide such services without the need for a medical necessity review:
Requests for coverage of any additional days, or for services at facilities outside of New York State, will continue to be reviewed in accordance with our standard clinical review policies and procedures. To learn more or to request assistance from a Behavioral Health Advocate, please call 1-844-809-7518.
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.