Commitment from CDPHP, Our Physicians and Providers
CDPHP maintains a comprehensive, proactive quality management program to ensure that our members receive high-quality, cost-effective care and service. The program is coordinated by the health plan but greatly relies on the commitment of CDPHP physicians and other providers. Practitioner and providers allow the use of performance data for quality improvement activities.
Please review our latest Quality Management Program Evaluation for a better understanding of our quality enhancement activities and the ways in which you, as a participating practitioner, are integral to this process.
What We Promise Our Members
Members receive details on what is covered and how they should access care. Review a Member Handbook to see our member appeals process, rights and responsibilities, and more.
We Care About Our Members’ Feedback
Each year we assess survey members and compile a report regarding their satisfaction with the care delivered by their primary care physicians.
We Cover Preventive Care
Review our Preventive Care Guidelines for an overview of the range of wellness services we recommend and cover for our members.
We Make Updated Clinical Guidelines Available
Please use the secure login to access CDPHP clinical practice guidelines on topics such as ADHD, depression, HIV, hypertension, obesity, and more.
CDPHP Access Standards
We requires participating primary care physicians and OB/GYNs to be available 24 hours a day, seven days a week or provide access to an on-call physician.
Here are the specific appointment access guidelines:
- 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
We monitor our network providers to be sure they meet these quality access standards.
Utilization Management
Our utilization management team carefully reviews and approves certain covered services to assure they are appropriate and delivered in the appropriate care setting. Bariatric surgery, organ transplants, and out-of-network care (for plans that do not already cover it) must be preauthorized.
To request authorization for a service or ask about our utilization management process, simply call (518) 641-4100 or 1-800-274-2332 between 8 a.m. and 6 p.m., Monday through Friday.
Follow-up calls by UM staff are made during normal business hours unless otherwise agreed upon. In an urgent situation, you can reach a UM nurse after hours or on a weekend or holiday. Dial one of the above phone numbers and advise the answering service of your need to speak with a UM staff member.
Resource coordination decisions are based on appropriateness of medical care and service, as well as a member’s contractual agreement with CDPHP. Each request is evaluated for medical necessity and compliance with our guidelines.
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.
Make an Educated Decision About Your Care
The CDPHP Pharmacy and Therapeutics (P&T) committee meets regularly to review new drug products and update our formulary accordingly. You can visit our formularies at any time to review our plan formularies, including details on tier status, prior authorization requirements, and quantity limits for select drugs. You will also find information on our relationship with Caremark Specialty Pharmacy Services to supply specific high-cost biotech and injectable drugs to our members who need them.