Quality Commitment

We Work Hard to Assure Quality Care For Our Members

CDPHP maintains a quality management program that monitors the care our members receive and proactively works to improve our plan each year. Please learn more by reading our annual Quality Management Program Evaluation and reviewing some of the other features on this page.

Each year, we conduct the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and the Healthcare Effectiveness Data and Information Set (HEDIS) survey to see how our members rate the quality of care they receive. Check out the most recent results.

Educate Yourself About Your Benefits
Do you know your member rights and responsibilities? They are listed in your member handbook, along with our appeals process and other helpful tips for using your health coverage and interacting with CDPHP.

Use Our Secure Online Tools
Use the secure login box to the right to access your online account. You’ll see in-depth details on your coverage, including the status of your claims. You may request an ID card or change your PCP (if your plan requires one) and find information about prior authorizations.

Assess Your Own Health Status
Caring for you is a team event, and you are the captain. Inform yourself about your health risks and opportunities by taking a Personal Health Assessment (PHA). Look for a link to this simple online survey the next time you log into your secure account.

Do You Have Feedback For Us?
We value input from our members, employers, brokers, and providers regarding our quality programs. Anyone who wishes to provide feedback or ask for additional information may do so by emailing the CDPHP quality management department or by contacting us.

A member may file a formal complaint by completing the Member Complaint form or by calling member services. Providers may contact provider services to submit feedback or request additional information. Employers or brokers may contact their sales representative.

CDPHP Access Standards

Prompt access to medical attention is important to your overall well-being, so CDPHP monitors our network providers to be sure they meet certain access standards. CDPHP primary care physicians and OB/GYNs must be available 24 hours a day or provide access to an on-call physician.

Guidelines for medical visits:

  • Emergency care – immediately
  • Urgent Care – Within 24 hours
  • Non-urgent sick visits – Within 48 hours
  • Routine Primary Care / Preventative Care Appointments – Within four weeks
  • Initial prenatal visit, first trimester – Within three weeks
  • Initial prenatal visit, second or third trimester – Within one week
  • Initial family-planning visit – Within two weeks
  • Initial newborn visit – Within two weeks of hospital discharge

Tip: When calling for an appointment, always give information about your condition in order to get an appointment time that fits your needs.

Guidelines for behavioral health treatment:

  • Mental health or substance abuse follow-up after hospitalization – within seven calendar days of request/discharge
  • Non-urgent initial or routine visits – Within 10 business days
  • Urgent care appointment – Within 48 hours 
  • Care for non-life threatening emergency – Within six hours
  • Emergency – Immediate access
  • After-hours access – Telephone response within one hour 

Tip: If you are having difficulty making an appointment within these time frames, please call the Behavioral Health Access Center at 1-888-320-9584, Monday through Friday, 8 a.m. to 6 p.m. When calling after-hours, press “1” to be transferred to a licensed mental health professional.

Your Guide to Utilization Management

Our utilization management team carefully reviews and approves services to assure they are appropriate and covered by your individual plan. Certain services such as bariatric surgery, organ transplants, and out-of-network care (if your plan does not already cover it) must be preauthorized. You or your doctor may request authorization by calling the CDPHP resource coordination department at 1-800-274-2332. Each request is evaluated for medical necessity and compliance with our guidelines.

Need More Information or Requesting Authorization?
If you have questions about CDPHP utilization management policies, please call (518) 641-4100 or 1-800-274-2332 between 8 a.m. and 6 p.m., Monday through Friday. If the call is after hours or on a weekend or holiday, tell the answering service you have an urgent need and a CDPHP nurse will return your call right away. Otherwise, a representative will return your call during normal business hours.

Pay Incentives are Not Used to Withhold Care
Under our managed care plans, you will not be denied necessary coverage. CDPHP has a resource coordination department to develop, review, approve, and implement programs to assure that members receive necessary medical care.

Our policies are as follows:

  • Resource coordination decisions are based on appropriateness of medical care and service, as well as a member’s contractual agreement with CDPHP.
  • We do not pay practitioners or other representatives conducting utilization review for denials of coverage or service.
  • Practitioners, providers, and employees who make utilization decisions are advised about the risks of denying necessary care.

CDPHP Translation Service

Our translation service can help you better understand your health insurance. Are you a non-native English speaker having difficulty understanding your CDPHP benefit plan? We can help. Call our member services department at the number on your ID card and we will arrange for a translator to help answer your questions.

Use Find-A-Doc to find out what languages are spoken at our network physicians' offices.

Make an Educated Decision About Your Care

We provide you with updated information on physician and hospital quality so you have the tools needed to make educated decisions about the options within our network.

Members Surveyed About Their Doctors
CDPHP conducts an annual survey of randomly selected members regarding their satisfaction. One of the questions is to rank their overall satisfaction with primary care physicians on a scale of 0 (worst) to 10 (best). Overall, members report a very high level of satisfaction with our participating PCPs.  

Physician Recognition, Rewards and Reimbursement
CDPHP is committed to recognizing and rewarding physicians who deliver high-quality, efficient care. Read about our physician incentive programs and our recognition program for physicians who are highly rated by our members.

CDPHP provides reimbursement to physicians and hospitals based on performance. If you would like information on what percentage of the overall reimbursement to our physicians or hospitals is based on performance, please contact us. We cannot provide information on individual physicians or hospitals.

Research and Compare Statistics on Quality, Experience, and Outcomes

Before choosing a hospital, it is important to do your research and compare statistics on quality, experience, and outcomes. The following are links to reputable websites offering information submitted by hospitals. Nevertheless, some of this information is subjective in nature and the data may be subject to error. We encourage you to discuss this information with your doctor before making a decision.

Tell us what you think of the Hospital Quality information above. We invite you to complete a brief survey to help us improve.

For More Information
If you would like to know more about the information above or would like a more detailed description of any of the programs or methodology, you may e-mail quality1@cdphp.com. Please include your name, member number, address, and telephone number or e-mail address so that we may provide a prompt response. Physicians and other providers may contact provider services. Employers may contact their sales representative. Members may call member services. For information on what percentage of the overall reimbursement to our hospitals is based on performance, please contact us. We cannot provide information on individual hospitals.