Frequently Asked Questions
General
Referral Authorization
Prescriptions
HIPAA Privacy
General
How long do I have to submit claims to CDPHP?
Claims must be submitted in a timely fashion, generally no more than 90 days from the date of service. Please refer to your CDPHP participating provider agreement for full information.
What is the address to submit claims?
The claims address is:
CDPHP, P.O. Box 66602, Albany, NY 12206-6602.
How long do I have to request a claim adjustment?
Six months from the adjudication date of the claim. Note that resubmitting the claim with the same information as the original claim is not considered a request for adjustment.
How do I submit claim appeals to CDPHP?
Practitioners and providers must complete the Provider Review Form. Participating hospital facilities must complete the Hospital Review Form. Complete the required information on the top portion, choose the appeal category that best addresses your inquiry, attach all supporting documentation, and mail to CDPHP, Provider Service Correspondence Department, 500 Patroon Creek Blvd., Albany, NY 12206-1057.
CDPHP can also provide purple envelopes with the Provider Service Correspondence Department address preprinted for your Hospital and Provider Review Forms.
What forms does CDPHP provide and how do I order them?
CDPHP offers a variety of administrative forms and supplies as a free service to our providers. The following items can be ordered by calling CDPHP at (518) 641-3521 or downloading the Provider Distribution Program order form and faxing it to (518) 641-5950:
- “Covering for” labels
- “To/From” mailing labels
- Provider review form
- Hospital review form
- CDPHP claim form
- Dental claim form
- Chart labels
- Specialist and PCP& OB/GYN patient treatment waivers
- #10 provider services’ envelopes
- Provider directories
- Provider office administration manuals (POAM)
- Provider benefit grid packets
If you are a PCP, OB/GYN, or specific specialist that is allowed to refer members for physical therapy services, you can reorder authorization forms by calling 1-800-705-0273.
How do I know which CDPHP plan my patients are covered under?
The member identification card is the best place to start. View examples of member identification cards.
How do I know which CDPHP products I participate in?
Contact Provider Services if you have questions regarding the networks in which you participate.
When I refer my CDPHP patients to specialists, how do I know if the specialist participates in the member's benefit plan?
Check the appropriate provider directory for that member's benefit plan, access Find-a-Doc or call the Provider Services Department.
Referral Authorization
How do I know if I can authorize my patients to seek care from a CDPHP specialist?
Physicians who are approved to issue authorization forms received Referral/Authorization forms that contain a 15-digit authorization number.
Approved PCPs can issue authorization forms to participating specialists based on the member's medical needs. OB/GYN physicians approved to issue authorization forms can issue authorizations for the following conditions:
- Evaluation of breast mass.
- Gynecological oncology.
- Infertility/gynecological endocrinology.
- Urological evaluation for infertility of patient's spouse (one visit).
- Gynecological dermatological conditions.
- Urological conditions.
- High-risk pregnancy (refer to perinatologist).
- Genetic counseling.
- Termination of pregnancy.
In general, primary care physicians, orthopedic surgeons, neurosurgeons, physiatrists, podiatrists, hand surgeons, vascular surgeons, pulmonolgists, neurologists, and rheumatologists may be approved to issue authorizations for physical therapy services. Your Provider Office Administrative Manual provides more detailed information on referral authorizations.
What is the significance of the 15-digit authorization number?
Here's an example of an authorization code and what it signifies: F10001615250002.
F = first digit - indicates authorization.
10001615 = digits 2-9 - indicates the referring physicians CDPHP ID#.
250002 = digits 10-15 - sequence and check sum #'s used by CDPHP to validate the authorization number.
When do I complete an authorization form?
The PCP or approved referring physician completes the form when the member requires medical care from a participating specialist and the member's plan requires referrals.
What additional information does CDPHP consider when I issue an authorization form?
The member must have active coverage with CDPHP and the member's contract must cover the services. All CDPHP medical policies continue to apply.
Why is it so important that I give the specialist the 15-digit authorization number?
The specialist office will indicate the 15-digit authorization number on their claim form upon submission and CDPHP will verify that the authorization number is valid.
How should I transfer the authorization number to the specialist?
Acceptable methods are:
- Telephone the specialist office when scheduling the appointment on behalf of the member.
- Fax the form to the specialist office prior to the appointment.
- Mail the form to the specialist office prior to the appointment.
- Ask the member to deliver the "Referred to physician" copy of the form at the time of the appointment.
Do I send a copy of the authorization form to CDPHP?
No, CDPHP does not receive a copy of the form.
Who decides the duration and number of visits authorized?
The PCP or referring physician determines the length and number of visits authorized based on medical necessity. There is adequate space on the authorization form for the PCP to include the diagnosis and other communication to the specialist.
What services require prior authorization by CDPHP?
Certain services continue to require prior authorization by CDPHP's Resource Coordination Department. In these situations a referral/authorization form is not the appropriate procedure to refer the member. Please contact the Resource Coordination Department at (518) 641-4100 or 1-800-274-2332 to obtain prior authorization for:
- Non-participating physician and provider care.
- Inpatient hospital admissions.
- DME.
- Home care.
- Other procedures for which resources coordination requires prior authorization.
A complete list of services that require prior authorization is available in Online Health™.
What if I question the information on the authorization form when I see the patient?
The specialist should contact the PCP/referring physician regarding any questions concerning the information on the authorization form.
I am a specialist. Where do I put the authorization number on my claim form?
If billing on a HCFA 1500 form, put the 15-digit number in field 23. If billing on a UB92 form, put the 15-digit number in field 63.
What if a member self refers without contacting the PCP first?
If a member informs the specialist office that they elected not to contact the PCP and want to be treated without the PCP's authorization, the specialist should indicate SELF in field 23 of the HCFA claim form or field 63 of the UB92 claim form. CDPHP also suggests that the specialist office ask the member to sign the CDPHP specialist waiver form. Please remember that some members are allowed to self-refer for certain services, and an authorization form is not always needed.
How do I order more forms?
A re-order form is included in each shipment for your use when re-ordering additional forms. To re-order additional forms call 800-705-0273, or fax your re-order form to (518) 877-8031 or mail the re-order form to CDPHP, P.O. Box 704, Clifton Park, New York 12065. Please allow 10 business days to receive additional forms.
Prescriptions
What if my patient requires a drug that needs prior authorization?
The medical exception process must be followed and the request approved before your patient can fill their prescription. Complete the Medical Exception form and submit to the CDPHP Pharmacy Department for review.
HIPAA Privacy
Where can I learn more about the HIPAA Privacy Rule?
For additional information on the HIPAA Privacy Rule, please visit the Office for Civil Rights' Web site at www.hhs.gov/ocr/hipaa/.