Frequently Asked Questions
General
Referral Process
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
Do CDPHP members need to see their PCP before seeing their specialist?
Primary care coordination is required for the following plan types: HMO, Non Group, Healthy New York, Child Health Plus, Family Health Plus, Select Plan (managed Medicaid), CDPHP Medicare Choices HMO, and HMO-type CDPHN (self-insured) plans.
Are there CDPHP plans that do not require the member to check with the PCP before going to an in-network specialist?
Yes, the following CDPHP plan types do not require a PCP or referrals: EPO, PPO, High Deductible PPO.
Does the PCP need to file paperwork with CDPHP or obtain a referral number when referring a member to an in-network specialist?
No special paperwork is required by CDPHP. However, the PCP should communicate with the specialist regarding the clinical issues and nature of the referral, as well as what they seek from the referral.
Since we do not have to bill with an authorization number, how will CDPHP identify who referred the patient?
Specialists should include the name and National Provider Identifier (NPI) of the referring provider in the appropriate field on their claim forms, or the appropriate loop and segment of their 837 HIPAA transaction.
Should the specialist check with CDPHP members to be sure a PCP referred them?
Members should inform their specialist of the referring physician. If they don’t, please ask!
How is a specialist expected to know the NPI of the referring physician?
As of June 28, 2009, CDPHP is providing the NPI of all network physicians in Find-A-Doc.
Does CDPHP still provide the referral/authorization forms?
No. As of July 1, 2009, these forms are not needed and will not be available.
What about Specialist Treatment Waivers?
CDPHP no longer requires or provides Specialist Treatment Waivers. It is up to the specialist office to ensure that patients have been referred by a PCP. For patients who were not referred, you may have them sign a standard referral waiver created by your office.
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/.