Quality Standards | New York Medicaid

Your health is important to us.

We work hard to make sure you can get great care when you need it. We do this by:

Having programs and services to make sure you get quality healthcare.

Supporting pregnant members and new parents with tools and information.

Finding local programs in your community to help you get the services you need.

Hosting events to help you learn how to get the most out of your plan.

Following state and federal rules.

Looking at our quality reports to find new ways to offer better care.

Learn more about Quality Management

Have questions about our Quality Management program? Call us. We can talk to you about:

What quality management is.

How we are doing and what our goals are.

How we are working to make things better for you.

We can also send you information on our Quality Management program.

Call 800-300-8181 (TTY 711).

Helping you manage all the moving pieces in NY

As an Anthem Blue Cross and Blue Shield HP member, we offer you many different types of services. Your care manager works with you and your provider to set up a plan of care. You may already be working with a care manager and know how to contact them.

If you think you need care management services or need help contacting your care manager, call us at 800-300-8181 (TTY 711).

Our care managers may also call if:

You or your doctor thinks care management might help you.

You’ve just gotten out of the hospital and need help with follow-up visits to other providers.

You’re going to the emergency room (ER) often for nonurgent care that could be handled by your provider.

You call our 24/7 NurseLine and need more follow-up for ongoing care.

You have serious physical problems and need more help.

You have behavioral health problems and need more help working with your providers.

Your care manager can also help with:

Setting up healthcare services.

Getting referrals and prior authorizations (approvals).

Checking your plan of care.

If we call you, a nurse or social worker will:

Always identify themselves with their name, title, and position with Anthem.

Tell you about what we offer.

Talk to you about your health and how you’re handling different parts of your life.

How we make choices on care and services

Sometimes, we need to make choices about how we pay for care and services. This is called Utilization Management (UM).

Our UM program:

Looks at what, when, and how much of our services are medically needed.

Always strives for the best possible health outcomes for our members.

Our UM program does not:

Tell doctors to withhold or give you fewer services limiting or denying care.

Stop certain people from getting services.

Reward doctors for limiting or denying care.

Getting in touch with our Utilization Management staff

Some Anthem services and benefits need prior approval. This means your provider must ask Anthem to approve the services they want you to have. Services that don’t need approval are:

Emergency care

Care needed after a hospital stay

Our Utilization Review team looks at approval requests. The team decides if:

The service is medically needed.

The service is one that is included in your Anthem benefits.

What should I do if Anthem hasn’t approved my request?

You or your provider can ask us to take another look at services that:

Are not approved.

Have been limited in the amount or length of time from what was requested.

We’ll let you and your provider know when we get your request.

Have questions about an approval or a denial?

Call Member Services at 800-300-8181 (TTY 711). Our Utilization Review team or your care manager can help answer your questions.

Your opinion matters

Every year, we survey our members about the benefits we offer. If you get a survey in the mail, by email, or by phone, please complete it. Your input helps us make your plan better.

New technology in medicine and care

To make sure we’re using the latest medical treatment and equipment to help you feel your best, our medical director and providers review the latest:

Medical treatment and services.

Behavioral health treatment and services.

Medicines.

Equipment.

They also look at the most up-to-date medical and scientific research. With all this data, they consider:

If changes are safe and helpful.

If changes offer the same or better results than what is used today.

This work is done to help us decide if a new treatment or care should be added to your benefits.

You have rights and responsibilities

As an Anthem member, you have rights and responsibilities that are listed in your member handbook.

Need a handbook mailed to you?

Request a handbook via live chat with Member Services.

Your benefits and how to get medical care

Are you looking to learn more about our services and benefits? Review your member handbook for information about:

Preventive healthcare: Find out how to help prevent many health issues and how to live a healthier life.

Preventive healthcare for women: Learn how to access women’s health specialists for regular and preventive healthcare services.

Benefits and access to care: Find out more about your benefits and how to get medical care.

Language help: Learn how to receive our information in the language you use at home.

Care management: Learn how a care manager can help you get care for health issues.

Member rights and responsibilities: Read about your rights and responsibilities.

Notice of Privacy Practices: Learn more about how we keep your private information safe.

Medical necessity: Find out how we decide if care is right for you based on the right coverage and correct levels of care and service.

Advance directives: Learn more about your right to use an advance directive (living will). You can contact your provider for advance directive forms and more information.

Behavioral health (mental health and substance use disorder services)

If you or a family member needs help with behavioral health issues, call Anthem Member Services at 800-300-8181 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. and on Saturday from 9 a.m. to 5 p.m. Eastern time. We’ll help you find a behavioral health specialist who can assist your needs.

You can also find a provider with our Find a Doctor tool. You don’t need a referral from your primary care provider (PCP) to see a behavioral health specialist in your plan.

Your benefits include medically necessary services such as:

Inpatient behavioral health services.

Outpatient behavioral health services.

Partial hospitalization.

Treatment and rehabilitative services.

Review your member handbook to learn more about your benefits.

There are some treatments and services your behavioral health specialist must ask Anthem to approve before you receive care.

For information about services that need preapproval, visit our Referrals & Preapprovals page or refer to your member handbook. You can also contact Member Services at 800-300-8181 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. and on Saturday from 9 a.m. to 5 p.m. Eastern time.

Our Notice of Privacy Practices

The notice tells you about how we may use and share your health data. It also tells you how to get this data. The notice follows the Privacy Rule set by the Health Insurance Portability and Accountability Act (HIPAA). Review your member handbook or visit our Privacy page to find our Notice of Privacy Practices. Live chat with a representative or call Member Services at 800-300-8181 (TTY 711) and let them know if you want a copy of the Notice of Privacy Practices mailed to you.

Not a kid anymore? It may be time for a new PCP.

As you become an adult, your healthcare needs start to change. If you’re seeing a pediatrician, you may want to find a primary care provider (PCP) who treats adults.

Adult PCP offices include:

Family practice

General practice

Internal Medicine

Start by asking your current PCP for a recommendation for a new adult PCP. We’re here to help, too. You can change your PCP at any time. It’s easy with our Change Your PCP tool. Or call Member Services at 800-300-8181 (TTY 711).