Chronic & Complex Conditions

From this point forward, in order to review clinical criteria, you will need to log on to your member account, using your username and password.

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.

• 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 Excellus BCBS Corporate Medical Policies will be applied.
• View our Medical Policies
• View our Drug Policies
• View InterQual^® Criteria - requires a free One Healthcare ID account, or access directly through your member account
• View InterQual^® Criteria

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.

• Level of Care for Alcohol and Drug Treatment Referral (LOCADTR)

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, 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.

• American Society of Addiction Medicine (ASAM) CriteriaOpen a PDF

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.