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) criteria for psychological testing and Transcranial Magnetic Stimulation (TMS) reviews. When there is not a LCD for other services, the criteria defaults to Change Health InterQual (for mental health reviews), OASAS LOCADTR (for Substance Use (SU) reviews other than SU Partial Hospital (PHP), and American Society of Addiction Medicine (ASAM) for SU PHP reviews. Effective 7/1/22 Medicare Advantage will use applicable National Coverage Determinations and Local Coverage Determination in relation to Mental Health Services for Medicare members.
• View our Medical Policies
• View InterQual^® Criteria - requires a free One Healthcare ID account, or access directly through your member account
• View InterQual^® Criteria

LOCDATR 3.0 is a clinical tool Univera Healthcare uses for all substance use disorder medical necessity reviews except for substance use partial hospital (see ASAM).

• 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, Univera Healthcare 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.