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For Members

Managing Conditions

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 1-800-421-1220) or email.
Hours: 8:00 a.m. - 4:30 p.m., Monday - Friday.

Asthma Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure Coronary Artery Disease (CAD) Depression Diabetes

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.

  • View our Medical Policies
  • View InterQual® Criteria
  • Level of Care for Alcohol and Drug Treatment Referral (LOCADTR)

    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 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.

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:

  • Acute detoxification: 5 days;
  • Inpatient rehabilitation: 14 days; and
  • Residential: 14 days.

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.

 

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