Skip to main content

Provider and Facility Reference Manual

Section 11 - Physician Practice Policies


All Practice Guidelines and Administrative Policies for providers can be viewed in pdf format on our website.

Behavioral Health Practice Guidelines

Clinical practice guidelines for the treatment of attention deficit hyperactivity disorder (ADHD) and depression promote best practice for diagnosing and managing these conditions. Both guidelines are reviewed and updated annually. The ADHD guideline is based upon the published American Academy of Pediatrics guideline on ADHD. Similarly, the depression guideline is based upon the published recommendations of the American Psychiatric Association.

Practice Guidelines and Standards of Care for HIV

Blue Cross Blue Shield has adopted the New York State Department of Health AIDS Institute's guidelines and criteria for medical care of adults, children and adolescents with HIV infection.

For HIV Guidelines go to: hivguidelines.org or nyhealth.gov/diseases/aids

Confidentiality of HIV-related Information

Each health care provider is required to develop policies and procedures (P & P) to assure confidentiality of HIV-related information.  

P& P must include:

  • initial and annual in-service education of staff, contractors
  • identification of staff allowed access and limits of access
  • procedure to limit access to trained staff (including contractors)
  • protocol for secure storage (including electronic storage)
  • procedures for handling requests for HIV-related information
  • protocols to protect persons with or suspected of having HIV infection from discrimination

NYSDOH Requirements for HIV Counseling and Testing, and Care of HIV Positive Individuals

Early identification of Human Immunodeficiency Virus (HIV) infection and entry into care can help HIV infected persons live longer, healthier lives. In addition, identifying infection can help prevent the spread of the disease through education.

The New York State Department of Health (NYSDOH) has requirements regarding HIV counseling, testing and reporting. Established guidelines help increase HIV testing, ensure entry into care and increase laboratory reporting.

An HIV test is the only way to determine whether someone has HIV. The decision to have an HIV test is voluntary.

All practitioners and providers must comply with the HIV confidentiality provisions of Title 27-F of the New York State Public Health Law.


Routine HIV Testing in Medical Settings

HIV testing should be a routine part of medical care and other services. Recent data indicate that routine HIV testing may be cost effective, even in areas with seroprevalence lower than one percent.

HIV testing MUST be offered to all persons over the age of 13 receiving hospital or primary care services, with limited exceptions noted in the law. The offering must be made to those inpatient persons seeking services in emergency rooms, persons receiving primary care as an outpatient at a clinic, or from a physician, physicians’ assistant, nurse practitioner or midwife.

Health care providers in NYS are encouraged to routinely discuss HIV with their patients, regardless of their perceived risk, and to have a low threshold for recommending HIV testing since not all infected persons are aware of or willing to disclose their risk.

There are three exceptions to the requirement to offer HIV testing:

  • If the individual is being treated for life-threatening emergency;
  • If the individual has previously been offered or has previously been tested for HIV(unless otherwise indicated due to more recent risk behavior);
  • If the individual has been determined by the attending provider to lack mental capacity to consent.
HIV information

Documentation Requirements

According to the Public Health Law, the following elements pertaining to HIV testing should be documented in the patient medical record:

  • The patient was advised that HIV testing is being done
  • If the patient declines the HIV test
  • For patients with confirmed HIV infection, the name of the provider/facility with whom the follow-up appointment was made


How often does the offer of HIV testing need to be repeated?

In addition to offering HIV testing once in the course of routine care, testing should be offered annually to patients whose behavior indicates elevated risk. In order to promote early identification, HIV testing may be offered as frequently as every three months to patients with identified risk behaviors. Since many people choose not to disclose their risk behaviors, providers should consider adopting a low threshold for recommending HIV testing.


Requirement for Written or Oral Patient Informed Consent to HIV Testing

Effective November 28, 2016, amendments to the New York State Public Health Law removed the requirement for written or oral informed consent prior to ordering an HIV-related test, including elimination of written consent for HIV testing in New York State correctional facilities, and removing references to consent forms. The objective of the update is to eliminate barriers to HIV testing and make HIV testing comparable to the manner in which other important laboratory tests are conducted. HIV testing remains voluntary and patients have the right to refuse an HIV test, but obtaining written or oral consent for testing is no longer required in any setting. Patients must be advised orally that an HIV test is going to be performed. If the patient objects to the HIV test, this should be noted in the patient’s medical record. HIV test requisition forms submitted to laboratories do not require provider certification of informed consent.

Important Points:
Prior to conducting diagnostic HIV testing, information about HIV must be provided orally, in writing, through signage or in any other patient-friendly audio-visual format. Placing the NYSDOH HIV testing clinic poster in a visible location or providing patients with the NYSDOH patient brochure on HIV testing are simple ways of conveying this information to patients. The key points of information that must be provided are:

  • HIV testing is voluntary and all HIV test results are confidential (private)
  • HIV can be transmitted through unprotected sex, sharing needles, child birth or breastfeeding
  • Treatment for HIV is very effective, has few or no side effects and may involve taking just one pill once a day
  • Partners can keep each other safe by knowing their HIV status and getting HIV treatment, or taking HIV pre-exposure prophylaxis (PrEP). Not sharing needles and practicing safer sex will help protect against HIV, hepatitis C and other STDs
  • It is illegal to discriminate against a person because of his or her HIV status and services are available to help address discrimination
  • Anonymous HIV testing (without giving your name) is available at certain public testing sites
  • HIV testing is a routine part of health care, but you have the right to decline an HIV test; testing will not be performed if you object; if you wish to decline HIV testing, inform the health care provider
  • If the patient declines the offer of an HIV test, this should be noted in the patient’s medical record
  • For patients diagnosed as living with HIV, the health care provider administering testing must arrange, with the consent of the patient, an appointment for HIV medical care; simply providing the name of a care provider is not sufficient; a specific appointment with a provider who offers HIV care should be provided

These new provisions apply to all HIV testing in New York State and not just for testing as offered to people over the age of 13 in clinical settings.

For additional information, please visit the Department’s website nyhealth.gov

Questions may be sent to hivtestlaw@health.state.ny.us.

Expansion of Minor Consent for HIV Treatment and Preventive Services

2017 amendments to NYSDOH’s regulations allow minors to consent to their own HIV treatment and HIV preventive services such as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) without parental/guardian involvement (10 NYCRR Part 23). Part 23 has long established the legal capacity of minors to consent to treatment and preventive services for sexually transmitted diseases (STDs). Provisions in Part 23 require that the Commissioner of Health promulgate a list of sexually transmitted diseases. The 2017 amendments to 10 NYCRR Part 23 added HIV to the list of STDs, thereby bringing minor capacity to consent to HIV treatment and preventive services on par with other STDs. In addition, under Part 23, medical or billing records may not be released or made available to the parent or guardian without the minor patient’s permission.

After being diagnosed, young people currently face barriers that can prevent or delay access to care, including denial and fear of their HIV status, misinformation, HIV-related stigma, low self-esteem, lack of insurance, homelessness, substance use, mental health issues, and lack of adequate support systems. Because of these factors, many young people need the ability to consent to their HIV treatment. Updates to regulation help ensure that more young people have optimal health outcomes and prevent transmission of HIV to others. In addition, minors will now have the ability to consent to HIV-related preventive services, including PrEP and PEP just as they can consent for other reproductive or sexual health related services. 

Post-test Counseling and Requirements to Link Newly Diagnosed Patients to HIV Care

When testing indicates a diagnosis of HIV infection, the person ordering HIV testing or their representative must provide the patient the final interpretation of diagnostic testing, and, with the patient’s consent, schedule an appointment for follow-up HIV medical care.

IMPORTANT NOTE: A person with laboratory evidence of acute or early HIV infection (i.e. detectable HIV antigen and virus, but no evidence of HIV antibodies) has a high likelihood of passing the virus to sexual or needle-sharing partners and should be counseled about how to avoid passing the virus to others.

Patient educations should be provided that addresses:

  • That the diagnosis means the person is living with HIV, a lifelong health condition
  • That people can live a healthy life with HIV;  HIV treatment is effective, has few or no side effects and may involve taking just one pill once a day
  • That financial assistance is available, if needed, for HIV medical care and HIV medications
  • That the patient can pass HIV to sexual or needle-sharing partners and strategies for avoiding transmission; including information about mother-to-child transmission
  • The importance of notifying sexual or needle-sharing partners to prevent further transmission and to promote access of exposed persons to HIV testing, health care and prevention services
  • The range of partner notification options and available partner services programs
  • That names and other information about the patient is not shared during the partner notification process
  • That known contacts, including a known spouse, are reported to the health department
  • The risk of domestic violence and performance of domestic violence screening using the NYSDOH-approved domestic violence screening protocol
  • That HIV-related information is confidential;  information may be shared with medical providers to provide needed care but may not be shared with others without patient authorization to release confidential HIV-related information
  • That a minor who has been diagnosed with HIV may consent to their own HIV treatment (if applicable)
  • That patient authorization to release confidential HIV-related information may be revoked at any time
  • That discrimination against persons with HIV in the areas of employment, housing, public accommodations, health care and social services is prohibited by law
  • That all cases of HIV infection are reported to the health department
  • That if a person with HIV appears to be out of care, he or she may be contacted by the medical provider or health department staff to address barriers to entry into care and promote engagement in care

IMPORTANT NEW INFORMATION: Undetectable equals Untransmittable (U=U): There are many important reasons to start HIV treatment as soon as possible.  In addition to getting treatment to support your own health, a person living with HIV who is on HIV treatment and virally suppressed for 6 months or longer has effectively no risk of passing HIV to a partner through sex.

A person who tests negative for HIV infection must be informed of the result and provided information concerning the risk of acquiring HIV through sexual and needle-sharing activities. Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) should be discussed as prevention options. This information may be in the form of written materials such as the NYSDOH document titled Information for Patients with a Negative HIV Test Result. The negative test result and required information do not need to be provided in person. Other mechanisms such as email, mail, and phone may be used as long as there is an established protocol. Alternative methods of delivering results must be discussed with the patient. It is not appropriate to tell patients that if they are not contacted, they may assume their test was negative.

Patients with potential recent exposure to HIV present diagnostic challenges due to the "window period," or the length of time after infection that it takes for antibodies or the virus to be detected by HIV diagnostic tests. More information about the window period for various types of tests can be found at www.hivguidelines.org. Clinicians should be familiar with the testing process used by the laboratory conducting testing for their patients because recommendations for retesting patients with recent exposure will vary depending on the test used.

A person with inconclusive or incomplete HIV diagnostic testing results, i.e., when the HIV Diagnostic Testing Algorithm did not produce an overall valid or conclusive result, shall be informed that the test result was inconclusive or incomplete and have an additional specimen collected as soon as possible. In these cases, the entire algorithm should be repeated. More information is available at:

The New York State Health Department may be able to assist if you have difficulty locating a patient in need of additional testing to resolve inconclusive HIV diagnostic testing. 

Universal Recommendation for Testing of Pregnant Women

New York’s regulatory framework for preventing mother-to-child transmission (MTCT) of HIV has proven highly effective and remains unchanged. The only exception is that the 2017 updates to HIV testing do remove the requirement to obtain consent for HIV testing in writing or orally. All pregnant women must be offered HIV testing as a clinical recommendation as early as possible during pregnancy. Third-trimester testing is recommended for all pregnant women in NYS who tested negative for HIV earlier in their pregnancy. When being offered HIV testing, the woman should be provided the key points of information and informed of her right to decline the test. Pregnant women who are diagnosed as living with HIV should be linked to treatment as soon as possible to protect their health and prevent transmission of HIV to the newborn.

Women who present to the labor/delivery setting with no history of HIV testing during their current pregnancy should be counseled with the recommendation for HIV testing. If the mother declines testing in labor/delivery, the mother should be informed that her newborn will be tested immediately at birth without her consent. All newborns, including those tested at birth, are routinely tested for HIV through the New York State Newborn Screening Program. Documentation of the woman’s prenatal HIV testing should be forwarded to the delivering hospital and a copy of the mother’s HIV test history results should be placed in the newborn’s medical record to ensure administration of medications during labor/delivery and initiation of medication to the infant for the first four-six weeks of life or until the infant is definitively excluded from HIV infection. To access the latest regulations visit:

Acute HIV infection during pregnancy

The acute HIV infection in pregnancy guidelines recommend the following:

  • Confirmation of preliminary positive expedited HIV test results
  • Vigilance for acute HIV infection in pregnant women who present with a compatible clinical syndrome, even if a previous HIV antibody test during current pregnancy was negative
  • Evaluation for acute HIV infection in pregnant or breastfeeding women who present with a febrile “flu” or “mono” like illness, or rash that is not otherwise explained
  • Immediate screening for suspected acute HIV infection by obtaining an HIV serologic screening test in conjunction with a plasma HIV RNA assay (a fourth-generation HIV antigen/antibody combination test is the preferred serologic screening test, if available)
  • Repeat HIV RNA testing from a new specimen to confirm the presence of HIV RNA if HIV RNA or antigen was detected in the absence of HIV antibody
  • Baseline genotypic testing and initiation of ART while waiting for the results of resistance testing

Rapid Test Technology

Rapid HIV antibody tests that can provide a preliminary* result during a single appointment are recommended. Individuals may be more likely to be tested for HIV if they know that the appointment, inclusive of counseling, consent and testing, will be relatively brief.

*Further testing is always required to confirm a reactive (preliminary positive) screening test result.

Consent for rapid HIV testing can be oral and noted in the medical record.

  • Offering of testing during labor and delivery for those who do not have documented third trimester HIV test results
  • Availability of expedited testing of pregnant women who present for delivery without documentation of a negative HIV test

In Labor and Delivery Settings, recommendations are:

  • Adoption of point of care rapid HIV testing in labor and delivery settings
  • Availability of expedited HIV test results prior to delivery to allow maximum benefits of intrapartum ARV prophylaxis for the fetus
  • Steps to follow when expedited HIV testing yields a preliminary positive result
  • Steps to follow when definitive test results indicate HIV infection is present
  • Steps to follow when HIV infection has been definitely excluded in the mother

Additional information about rapid testing is available at the Department of Health's:


Additional Maternal-Pediatric HIV Prevention and Care Program
 


AIDS Institute NYSDOH Counseling and Testing Resources

Numbers to call for HIV information, referrals or information on how to obtain a free HIV test without having to give the client’s name and without waiting for an appointment are available.  

For counseling call 1-800-872-2777

For testing call 1-800-541-AIDS

Special initiatives are available to providers who want to arrange for a program presentation or possible anonymous HIV counseling and testing at their sites. Providers should contact the regional coordinator of the Anonymous HIV Counseling and Testing Program at the appropriate toll-free number listed above.


NYSDOH AIDS Institute Resource Directory

The NYSDOH AIDS Institute has a resource directory intended for use by individuals seeking services and as a referral tool for providers. This directory is arranged by region, with each organization listed under the region it services, and then by the service(s) it provides. This directory can be found at the Department of Health.


Partner Services and the Role of Partner Services Program

Medical providers or their designee must explain to all newly diagnosed patients the importance of notifying any sexual or needle-sharing partners that they may have been exposed to HIV. Partner services is a cornerstone of HIV prevention efforts that provides an opportunity for sexual or needle sharing contacts of a person living with HIV to be offered testing in a timely manner, and if diagnosed with HIV infection, be linked into care. Every physician or other person authorized to order diagnostic testing is required to report HIV and AIDS diagnoses to the health department. This report must include identifying information about any contacts known to the clinical provider or provided to the clinical provider by the patient. The HIV/AIDS Provider Portal may be used to report cases (including partners) and to request assistance from the health department with partner notification. As part of post-test counseling, the following must be provided to the patient:

  1. An explanation of the importance of notifying sexual or needle-sharing partners to prevent further transmission, and to promote early access of exposed persons to HIV testing, health care, and prevention services
  2. A description of notification options and assistance available to the protected individual
  3. A discussion about the risk of domestic violence and screening for domestic violence prior to partner notification in accordance with NYSDOH domestic violence screening protocol
  4. The fact that known contacts, including a known spouse, will be reported to the health department; that protected persons will also be requested to cooperate in contact notification efforts of known contacts and that protected persons may name additional contacts they wish to have notified with the assistance of the provider or authorized public health officials
  5. An explanation that the name and other information about the person living with HIV will be protected during the contact notification process

The NYSDOH Partner Services Program and the NYC Health Department Contact Notification Assistance Program (C-NAP) provide a wide range of services, including: performing notifications; assisting patients with decision making; and consulting with health care providers. In some situations, Partner Services specialists can meet with the patient at the same time that the laboratory results are given to assist with post-test counseling and development of a partner notification plan. Additional NYSDOH/NYC Department of Health and Mental Hygiene (NYCHMH) services may be available, such as assistance in locating persons who test positive but who do not return for their results. For more information about partner services and how to contact partner services programs throughout NYS, visit:

IMPORTANT POINT:
In recognition of the need for ongoing partner services beyond the time of initial diagnosis of HIV, the 2016 updates to the NYSDOH Regulations formally prioritized partner services for people who were previously diagnosed with HIV who are at elevated risk of transmitting the virus to others. Several factors are considered as evidence of elevated risk of transmitting the virus to others.  Those factors include that the individual:

  1. is not engaged in health care services
  2. is not virally suppressed
  3. has had a recent STD or
  4. has recently moved back to NYS from another jurisdiction.

In addition, the updated NYSDOH Regulations remove the requirement that data on the partners of HIV cases be destroyed after three years. The NYSDOH or local health department will establish a new policy for record retention and disposition.


Health Care Provider HIV Reporting Requirements

New York State Public Health Law Article 21 requires the reporting of persons with HIV infection and AIDS to the NYSDOH. The law also requires that reports contain the names of sexual or needle-sharing partners known to the medical provider or whom the patient wishes to have notified. Under the federal HIPAA Privacy Rule, public health authorities have the right to collect or receive information “for the purpose of preventing or controlling disease” and in the “conduct of public health surveillance…” without further authorization. This provision of HIPAA regulations authorizes medical providers to report HIV/AIDS cases to the NYSDOH or NYC Health Department without obtaining patient permission.

The Medical Provider HIV/AIDS and Partner/Contact Report Form (PRF) (DOH-4189) must be completed within 14 days of diagnosis for persons with the following diagnoses or with known sex or needle-sharing partners:

  • Initial/New HIV diagnosis - First report of testing documenting HIV diagnosis
  • Previously diagnosed HIV (non-AIDS) - Applies to a medical provider who is seeing the patient for the first time
  • Initial/New diagnosis of AIDS - Including <200 CD4 cells/μL or an opportunistic infection (AIDS-defining illness)
  • Previously diagnosed AIDS - Applies to a medical provider who is seeing the patient for the first time
  • Known sex or needle-sharing partners of persons with diagnosed HIV infection

Clinicians seeing for the first time a patient previously diagnosed with HIV or AIDS should report to the NYSDOH using the PRF. The rationale is that this is often the only indication the NYSDOH receives of a patient new to New York, but not newly diagnosed, and perhaps not in need of extensive Health Department Partner Services. Additionally, particularly for the well suppressed patient who moves into NYS, the report by the clinician can be the only indication that the person is in fact HIV positive.

Information regarding electronic reporting via the HIV/AIDS Provider Portal (see below) or paper forms are available from the NYSDOH at 518-474-4284; clinicians located in NYC, call 212-442-3388. In order to protect patient confidentiality, faxing of reports is not permitted.


HIV/AIDS Provider Portal

The HIV/AIDS Provider Portal is an electronic system that enables clinicians to: 1) meet their reporting requirements electronically 2) provide a mechanism for clinicians statewide to notify the NYSDOH that a patient needs linkage to Health Department Partner Services and 3) submit inquiries for patients with diagnosed HIV infection who are thought to be in need of assistance with linkage to or retention in HIV medical care. A NYSDOH Health Commerce System (HCS) Medical Professionals account is required. After logging into the HCS at https://commerce.health.ny.gov/, select “Refresh My Applications List” on the left side and then under “My Applications” select HIV/AIDS Provider Portal. Follow the prompts to set up an account.


Laboratory Reporting Requirements

Laboratory reporting of suspected or confirmed positive findings or markers of HIV infection is mandated under New York State Public Health Law. Guidance has been prepared in an effort to assist permitted clinical laboratories and blood banks in meeting their obligations to report HIV-related laboratory test results, as well as other communicable disease markers. The guidance is available on the Wadsworth Laboratory website.

HIV laboratory reporting is an essential source of information for New York’s HIV surveillance efforts and maintaining high quality, complete data is critical to tracking progress toward National HIV/AIDS Strategy retention and care measures and New York’s effort to end the epidemic.  To keep pace with advances in HIV care, testing technologies and disease monitoring, there have been some important changes to HIV laboratory reporting requirements. Laboratories and blood/tissue banks performing tests for screening, diagnosis or monitoring of HIV infection for NYS residents and/or NYS health care providers (regardless of patient residence) shall report the following laboratory tests or series of tests used in the diagnosis of HIV infection:

  • All reactive/repeatedly reactive initial HIV immunoassay results AND all positive, negative or indeterminate results from all supplemental HIV immunoassays performed under the second or third step in the diagnostic testing algorithm, including HIV-1/2 antibody differentiation assay, HIV-1 Western blot, HIV-2 Western blot or HIV-1 Immunofluorescent assay
  • All HIV nucleic acid (RNA or DNA) detection tests (qualitative and quantitative), including tests on individual specimens for confirmation of nucleic acid-based testing (NAT) screening results
  • All CD4 lymphocyte counts and percentages, unless known to be ordered for a condition other than HIV
  • HIV genotypic resistance testing via the electronic submission of the protease, reverse transcriptase and integrase nucleotide sequence
  • Positive HIV detection tests (culture, P24 antigen)

All HIV-related laboratory reporting, including by NYC providers and for NYC residents, should be made directly to the NYSDOH, submitted electronically via the NYSDOH Electronic Clinical Laboratory Reporting System (ECLRS).

To improve the quality of data, and in keeping with changes that allow for enhanced use of surveillance data to improve linkage and retention in care, laboratories are required to report results using patient identifying, demographic and locating information, as well as the requesting provider and facility ordering the lab test. The 2016 update requires that when labs report HIV-related test results, the following information should be included:

  • Patient name, date of birth, and other identifying information;
  • Patient demographic information, e.g., sex at birth, race/ethnicity, etc.
  • Patient address and telephone number
  • Provider ordering the test and facility name
  • Complete provider and facility address and telephone number
  • Provider and facility National Provider Identification

For a complete list of this information and instructions on how to report required data elements, please call 518-474-4284 or contact BHAELab@health.state.ny.us.

Care of HIV Positive Individuals

The NYSDOH AIDS Institute's clinical guidelines pertaining to HIV prevention and the medical management of adults, children, and adolescents with HIV infection can be found on the Department of Health.

All clinical care settings should be prepared, either on-site or with a confirmed referral, to support patients in initiating antiretroviral therapy (ART) as rapidly as possible after diagnosis.

A new HIV diagnosis is an immediate call to action for every provider who engages with that individual, to assure the rapid initiation of antiretroviral treatment (RIA). New York State Department of Health (NYSDOH) HIV Clinical Guidelines state that treatment is recommended for all patients with a confirmed HIV diagnosis regardless of their CD4 cell count or viral load. All providers serving persons with HIV should establish systems which strive for the same-day initiation of HIV treatment, even while initial lab work is pending. While same-day initiation of treatment may not always be possible, it is ideal that patients be started on treatment within three days. In the outpatient setting, in no instance should treatment initiation take longer than 30 days.

On April 1, 2014, Public Health Law Section 2135 was amended to promote linkage and retention in care for HIV-positive persons. The law allows the New York State Department of Health (NYSDOH) and New York City Department of Health and Mental Hygiene (NYC DOHMH) to share information with health care providers for the purposes of patient linkage and retention in care. The NYSDOH AIDS Institute recommends that health care providers take a multi-pronged approach to support their patients’ retention in care, including but not limited to the following:

  • Have a proactive patient plan: do not wait for a lapse in care to discuss what to do if the patient becomes lost-to-care.
  • Create a patient-centered atmosphere, where all members of the medical care teams, e.g., reception staff, phlebotomists, medical providers, promote patient engagement, linkage, and retention in care.
  • When acceptable to patients, expand authorization dates on Authorization for Release of Health Information and Confidential HIV-Related Information forms (DOH-2557) to at least two years. Extending consent timeframes allows collaboration across sectors.
  • Have DOD-2557 consent forms on file for every patient. This will permit you to contact community based organizations (CBOs) and others in the event of a lapse in care. Examples of CBOs that can help return patients to care include but are not limited to: HIV/AIDS CBOs; Health Homes and their downstream providers; food and nutrition programs; shelters; substance use treatment facilities; housing providers; mental health providers; prenatal care providers, etc.
  • Encourage patients to add your practice’s name to any releases they sign with other organizations.
  • Work with patients to update releases prior to when the releases expire (if applicable).
  • Become a member of your area’s Health Home network(s) if you have not already done so, visit Find A Health Home

Leverage existing resources for patient re-engagement.

  • Use information from the Regional Health Information Organization (RHIO), if available, to determine if the patient is in care with another provider or if updated personal contact information is available.
  •  Conduct a health insurance benefits check, if available, on the patient to determine if s/he changed insurance or is in care with another provider.
  • If the patient is in a Managed Care plan, the plan will have updated contact information, recent use of care, and medications on file. If this is a Medicaid Managed Care Plan, the plan can identify which Health Home the patient may be enrolled in and this information may be useful to your follow-up efforts.
  • If your patient is enrolled in a Health Home and has signed a release, contact the Health Home to determine whether the patient is actively enrolled. If yes, request assistance to contact or re-engage the patient in care.
  • If your patient has Medicaid but has not been enrolled in a Health Home, contact the Health Home to make an “upstream referral.” The patient will be referred to a provider who may conduct outreach to the patient’s home.
  • Try multiple modes of contact (phone, text, letter, email, and social media) at varying times of the day/week to reach the patient (special consideration for social media sites – contact patient from an agency social media account and not a staff person’s personal account).
  • If your patient uses other services within the facility (e.g., WIC, dental, child’s provider), place an alert on the Electronic Medical Record (EMR) to reconnect to the HIV Primary Care Provider and, if pregnant, to her prenatal care provider.
  • As authorized in patient releases and/or medical charts, work with emergency contacts and other agencies/providers to determine whether they have had recent patient contact.
  • Conduct a home visit if resources allow. If you have a peer program, utilize peers to provide outreach to the patient’s home.

Use external systems to expand your search when you cannot find a patient.

Review public records such as:

Pregnant women and exposed infants lost-to-care require immediate action for re-engagement.

HIV-positive pregnant women and their exposed infants are a priority when identified as lost-to-care and require immediate action for re-engagement. Reengagement in care is especially important for HIV-positive pregnant women who are in their third trimester due to possible increasing viral loads from being non-adherent to ART, leading to increased risk of transmitting HIV to their infants. Ensuring exposed infants are engaged in care is critical during the first 4-6 months to ensure appropriate antiretroviral and opportunistic infection prophylaxis, as well as definitive documentation of the infant’s HIV infection status.

If routine attempts for reengagement of the HIV-positive pregnant woman or her exposed or infected infant(s) are not successful, please contact the NYSDOH Perinatal HIV Prevention Program at (518) 486-6048 or submit a request via the NYSDOH HIV/AIDS Provider Portal (see below) for assistance. NYC providers should call the NYC DOHMH Field Services Unit at (347) 396-7601 for assistance with reengagement of pregnant women.

For providers based in NYS outside of NYC:

After exploring the investigation tools and strategies listed above and if patient follow-up is warranted, the Bureau of HIV/AIDS Epidemiology (BHAE) may be able to provide information regarding a patient’s care status through the NYSDOH HIV/AIDS Provider Portal. The HIV/AIDS Provider Portal is an electronic system which enables clinicians to:

  1. Meet their reporting requirements electronically;
  2. Provide a mechanism for clinicians statewide to notify the NYS DOH that a patient needs linkage to Health Department Partner Services; and,
  3. Submit inquiries for patients with diagnosed HIV infection who are thought to be in need of assistance with linkage to or retention in HIV medical care.

A NYSDOH Health Commerce System (HCS) Medical Professionals account is required. To apply for an HCS Medial Professions account, visit NYS Department of Health.

Pre-exposure Prophylaxis (PrEP)

In May 2014, the Centers for Disease Control and Prevention (CDC) released its guidelines for the use of daily pre-exposure prophylaxis (PrEP) for the prevention of HIV infection. The following CDC PrEP documents are available:

The New York State Health Department urges providers to adhere to CDC and New York State guidelines with their patients on PrEP by:

  • Testing for HIV every three months using a laboratory-based, ideally 4th generation HIV test;
  • Assessing for signs of acute HIV infection at every visit;
  • Having a low threshold for testing for acute HIV and STI’s; and
  • Encouraging patients on PrEP (or on HIV treatment) to use condoms as often as possible.

Visit Pre Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP) for more information.

Reporting of Suspected Seroconversion

Providers who manage patients on PrEP are strongly encouraged to immediately report any cases of suspected PrEP/PEP breakthrough HIV infection as follows:

  1. NYC: Report cases to the New York City Department of Health and Mental Hygiene by calling 212-442-3388 and following the directions detailed in the attached Health Alert, or
  2. Remainder of state: Report cases to New York State Department of Health by calling 518-474-4284 or using DOH-4189 and contacting the local Partner Services Program to discuss the case.

State law requires that providers report all cases of HIV infection as soon as possible but no later than 14 days after diagnosis. Rapid case reporting is critical, because it allows health departments to investigate the case and engage field staff to:

  1. Conduct outreach to the patient’s social network;
  2. Make HIV testing available to exposed partners; and,
  3. Reduce secondary transmission by expediting linkage to care and PrEP/PEP referrals.

Tuberculosis Facts and Internet Resources

Tuberculosis (TB) is a bacterial disease usually affecting the lungs. TB is spread through the air and can affect anyone of any age. Treatment can be complicated and often includes taking medication for three to nine months.

Blue Cross Blue Shield Medical Record Review Standards

The Medical Record Review must be conducted and completed for specific medical specialties due to Regulatory Requirements. These medical specialties include, without limitation, the primary care specialties (internal medicine, family practice, pediatrics, geriatrics, and general practice), obstetrics-gynecology, and high volume mental health specialists.

A structural review is conducted to verify that the physical components of the medical record (structure, legibility, and completeness) are acceptable and meet Blue Cross Blue Shield quality standards. 

Information Exchange Policy for Primary Care Physicians/Specialists/Facilities

This information exchange policy ensures our practitioners and facilities have the needed health care information to provide coordinated quality health care services to our members. All practitioners, including behavioral health and facilities providing health and behavioral care services to our members, must ensure timely exchange of pertinent medical information. (Consent may be addressed with the member by the office privacy policy or by separate consent to share information).

Time frames for this information exchange shall be within 30 calendar days of initial assessment; annually if concurrent care continues for more than twelve (12) months, or more frequently if the member's clinical condition or treatment changes significantly and within seven (7) calendar days of medication change. The guidelines are supported by New York State Mental Health Law, New York State Public Health Law, Centers for Medicare & Medicaid Services (CMS) standards, and the National Committee for Quality Assurance (NCQA) Standards for Accreditation and HIPAA regulations.

Those affected by the policy are primary care practitioners, specialists and pertinent ancillary practitioners, health care and home care facilities, surgical, laboratory, and diagnostic centers.

The guidelines are as follows:

Minimum Information to be exchanged:

Primary Care:  

The primary care practitioner is required to provide the specialist with pertinent medical information. This should include but is not limited to:

  • Office notes
  • Discharge summaries
  • A formal letter summarizing medical history
  • Diagnostic test reports
  • Other pertinent consult reports and information
     

Specialist:

The specialist is required to provide the member's pertinent medical information to the primary care practitioner, in order to promote optimal coordination of care, regardless of the member's referral method. This should include but is not limited to:

  • Diagnosis
  • Consultation report or treatment notes
  • Diagnostic reports
  • Plan of treatment
  • Medications prescribed or medication changes
  • Other pertinent consult reports and information
  • Concurrent care management reports when applicable
     

Facility (including Urgent Care Centers):

Facilities involved in the member's care are required to provide the primary care practitioner with the following:

  • Discharge summaries (within 24 hours of facility discharge)
  • Diagnostic reports
  • Emergency room summaries/reports/notes
  • Concurrent care management reports (homecare, skilled, rehab, etc.)

 

Behavioral Health Specialists:

Exchange of information may be to another behavioral health practitioner and/or the member’s primary care practitioner with an appropriate signed consent from the member. This includes but is not limited to:

  • Diagnosis
  • Medications prescribed or medication changes
  • Any significant risk status or issues
  • Stress related factors
  • Treatment recommendations
  • Frequency of treatment
  • Significant coordination of care issues/medical compliance issues

Medical Record Transfer Policy for Primary Care/Specialists

This record transfer policy ensures that members receive timely continuity of care when changing primary care and/or specialist provider. The guidelines are as follows:

The policy is followed when the:

  • Primary care/specialist/behavioral health practitioner leaves the network.
  • Primary care/specialist/behavioral health practitioner retires or leaves a practice.
  • When a member makes a change to another primary care/specialist/behavioral health practitioner.

Procedure:

  • The member must sign a HIPAA-approved medical record release to transfer the record to another physician.
  • The primary care/specialist/behavioral health practitioner must provide to the member the provider’s office policy for the release of medical records and, if applicable and permitted by law, what the cost is to the patient.
  • The primary care/specialist/behavioral health practitioner is required to send the medical record to the new primary care/specialist/behavioral health practitioner within ten (10) business days of the release. Medical record transfers will be processed more quickly if the member’s medical condition warrants it.

Note: Charging a member for the copying of their medical record is subject to the restrictions contained of Section 17 of New York’s Public Health Law. Any charge, if permissible, must be reasonable and cannot exceed $.75 per page per New York State Law. Moreover, a member cannot be charged for records requested to support an application, claim or appeal for any government benefit or program. A member cannot be denied access to their medical record information solely because he/she is unable to pay.

Medical Record Retention Policy

All participating, practitioners and facilities, including behavioral health practitioners are required to maintain medical and billing records on all covered persons receiving covered services in accordance with the terms and conditions of the participating practitioner’s/facility’s participation agreement, including but not limited to the terms below.

Procedure:

  1. The medical record includes but is not limited to:
    1. History and physicals
    2. Demographics
    3. Allergies and adverse reactions
    4. Reports from referring practitioners
    5. Current medication list/medication orders/reconciliation
    6. Discharge summaries
    7. Records of emergency care, hospital care and medical procedures
    8. Diagnostic reporting/preventive services and risk screening
    9. Telephone logs
    10. Progress records (documentation of clinical findings and evaluation for each visit)
    11. Office notes
    12. Flow sheets/problem lists
    13. Immunization documentation
    14. Advance directives
  2. The medical record and personally identifiable health information is confidential as applicable to state and federal laws regarding confidentiality of medical records, including without limitation, the Health Insurance Portability & Accountability Act (HIPAA) of 1996.
  3. Records shall be maintained in accordance with prudent record keeping procedures and as required by practice standards and law.
  4. Records  for all covered persons must be maintained for the greater of:
  • For covered persons (other than persons enrolled in Medicare Advantage or Medicaid prepaid coverage plans or children’s health program agreements between the health plan and CMS), for no less than seven (7) years following termination, four (4) years past the age of majority, or seven (7) years past the date of service, whichever is longer.
  • For covered persons enrolled in a Medicare Advantage contract, for no less than eleven (11) years following conclusion or termination of the applicable Medicare Advantage contract from the date of completion of any audit by CMS, the U.S. Department of Health and Human Services, the comptroller general and/or their designee, whichever is later, unless  any of the following:
    • CMS  determines that there is a special need to retain a particular record or group of records for a longer period and notifies the health plan or the participating practitioner/facility at least thirty (30) days prior to the normal disposition date.
    • CMS determines there is a reasonable possibility of fraud or similar fault by the health plan or the participating practitioner/facility, in which case the retention period may be extended for six (6) years from the date of any resulting final resolution of the termination, dispute, or fraud or similar fault.
    • CMS determines that there is a reasonable possibility of fraud, in which case it may inspect, evaluate and audit the health plan and/or the participating practitioner/facility at any time.
  • The time period required pursuant to applicable law

Access to Medical Records

Participating Physician shall maintain and make available, upon request and at no charge, Participating Physician's books, records and papers and covered Person medical records that relate to the provision of health care services to Covered Persons and copies thereof to Health Plan, appropriate state and federal authorities and their authorized representatives, for purposes that include, but are not limited to, determining payment issues; facilitating audits; assessing quality of care, quality improvement or Medical Necessity; complying with various reporting requirements, e.g. HEDIS® and NCQA, outcome studies and demand management programs; and determining the appropriateness of care provided to Covered Persons. Participating Physician further agrees to provide Covered Persons, or their duly authorized representatives, copies of their medical records promptly upon written request.

Participating Physician acknowledges that, consistent with applicable law, the consent contained in Covered Person's Coverage Plan is sufficient consent for the disclosure of the Covered Person's medical records to Health Plan.  Upon request, Health Plan shall be permitted to review and audit such records at the Participating Physician's office and to inspect Participating Physician's facilities.

Participating Physician agrees to make such records and facilities available, upon request, to appropriate state and federal authorities and their authorized representatives, including, but not limited to, the New York State Department of Health, for the purposes of inspection and photocopying, at no charge to such regulatory authorities.

Participating Physician acknowledges and agrees that Health Plan, or its designee, may use statistical samples and other appropriate external audit and fraud and abuse detection practices and methods in conducting audits pursuant to this section.

Access to Care Policy

Access to care policy for physician appointments is established to ensure that HealthNow New York, Inc members have timely accessibility to health and behavioral care services. Services are provided in a culturally competent manner and are accessible to all enrollees. These guidelines are supported by the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA) Standards for the Accreditation of Health Plans and the New York State Medicaid Standards for Participation. The guidelines are as follows:

Primary Care
 

  • After-hours access including emergent life threatening and urgent conditions in new and established patients: practitioner should employ a 24-hour, 7-days-a-week “on call” telephone resource that includes access to a “live voice” via an answering service, answering service with the option to page the practitioner, an advice nurse with access to the practitioner, access to the practitioner auto-pager or an answering machine/voicemail system with appropriate after hours instructions for patients.
  • The patient should either receive an immediate response or be instructed on what to do to obtain services after hours and on weekends. Answering machine/voicemail instructions should include an anticipated timeframe in which the patient could expect a return call. Patient calls cannot be routinely referred to an emergency room.
  • Urgent medical or behavioral problems: An appointment should be scheduled within 24 hours, based on symptoms and physician judgment.
  • Follow-up after an emergency or hospital discharge for medical, mental health or substance abuse conditions: An appointment should be scheduled within five (5) days of discharge or as clinically indicated.
  • Non-urgent sick visits: an appointment should be scheduled within 48 to 72 hours, based on symptoms and physician judgment.
  • Non-acute, symptomatic conditions in new and established patients: an appointment should be scheduled within one (1) to four (4) weeks based on symptoms and physician judgment.
  • Routine, non-urgent or preventive care visits: an appointment should be scheduled within four (4) weeks.
  • Adult base line and routine physicals: an appointment should be scheduled within twelve (12) weeks.
  • Specialist referrals (non-urgent and non-behavioral health): within four (4) to six (6) weeks.
  • Provider visits to make health, mental health and/or substance abuse assessments for the purpose of making recommendations regarding recipient’s ability to perform work when requested by LDSS should be scheduled within ten (10) days of request by Medicaid Managed Care enrollee.
  • Well child care: an appointment should be scheduled within four (4) weeks of request.

Behavioral Health Care
 

Behavioral health practitioners include Psychiatrists, Independent Psychiatric Nurse Practitioners, Psychologists, Clinical Social Workers, Licensed Mental Health Counselor, Community Mental Health Centers, and Chemical Dependency Treatment Centers.

  • After-hours access including emergent life threatening and urgent conditions in new and established patients: Practitioner should employ a 24-hour, 7 days a week “on-call” telephone resource, which may include: access to a “live voice” via an answering service, answering service with the option to page the practitioner, access to the practitioner auto-pager, or an answering machine/voice mail system with appropriate after-hours instructions for patients on what to do to obtain services. Instructions may include referral to a community 24-hour crisis services hotline. Emergent patient calls may be referred to an emergency room or to a community 24-hour crisis services hotline. 
  • Emergent life threatening issues are triaged immediately.
  • Emergent non-life threatening behavioral health conditions: assessment and care should be rendered within six (6) hours. 
  • Urgent Behavioral Health problems: An appointment should be scheduled within 24 hours, based on symptoms and physician judgment.
  • Follow-up after an emergency or hospital discharge for medical conditions: An appointment should be scheduled within five (5) days of discharge or as clinically indicated.
  • An initial routine, non-urgent mental health or substance abuse visits: should be scheduled within ten (10) business days of request or as clinically indicated.
    • Follow-up routine behavioral health care appointments, for adults and pediatric members are scheduled to monitor/evaluate progress and/or changes that may have occurred since a previous visit. Follow–up visits are scheduled based on individual member need, condition and practitioner assessment/treatment plan: established, stable medication management visits may be scheduled every three (3) to six (6) months
    • For members with depression, at higher risk or newly diagnosed, visits may be scheduled as often as weekly or biweekly based on practitioner assessment and treatment plan
    • Counseling or psychotherapy visits with a non-prescribing practitioner may be scheduled once monthly 
  • Provider visits to make health, mental health and/or substance use disorder assessments for the purpose of making recommendations regarding recipient’s ability to perform work when requested by the LDSS should be scheduled within ten (10) days of request


OB and GYN Care
   

  • After-hours access including emergent life threatening and urgent conditions in new and established patients: Practitioner should employ a 24-hour, 7 days a week “on-call” telephone resource, which should include access to a “live voice” via an answering service, answering service with the option to page the practitioner, an advice nurse with access to the practitioner, access to the practitioner auto-pager, or an answering machine/voice mail system with appropriate after-hours instructions for patients. 
  • The patient should either receive an immediate response or be instructed on what to do to obtain services after hours and on weekends. Answering machine/voicemail instructions should include an anticipated timeframe in which the patient could expect a return call. Example: "An after-hours phone call from an appropriate practitioner within an hour of the member contacting the organization." Patient calls cannot be routinely referred to an emergency room.
  • Urgent medical: An appointment should be scheduled within 24 hours, based on symptoms and physician judgment.
    • Non-acute, symptomatic conditions in new and established patients: an appointment should be scheduled within one (1) to four (4) weeks based on symptoms and physician judgment.
    • Routine, non-urgent or preventive care visits: an appointment should be scheduled within four (4) weeks. Members have direct access to a women’s health specialist for covered routine and preventive services.
  • Initial Family Planning: within two (2) weeks.
  • Initial prenatal visits: during first trimester, an appointment is scheduled within three (3) weeks of diagnosis of the pregnancy, within two (2) weeks during the second trimester, and within one (1) week during the third trimester.
  • Initial visits for newborns to their primary medical home: an appointment should be scheduled within two (2) weeks of hospital discharge.
  • Postpartum visit: should be scheduled twenty-one (21) to fifty-six (56) days after delivery.

 

General Guidelines 
 

  • Members with an appointment should not routinely be made to wait longer than one (1) hour.
  • Telephone access for physician offices:
    • Phones should be answered promptly.
    • If the office has an automated telephone directory, there should be a prompt for emergency situations that allows the caller to speak to someone.
    • If the office has an answering machine/voice mail system is required to have the appropriate after-hours instructions which must include a specific, reasonable time-frame the patient can expect a return call.
    • If the caller is to be placed on hold, the person answering the telephone must assess for an emergency before placing the caller on hold.
    • A caller should not be on hold for more than three (3) minutes without someone checking on them.
  • Adherence to this policy is monitored during the provider attestation review, after-hours audits, as well as member complaint evaluations and member satisfaction surveys.
  • Corrective action is instituted as necessary for practitioners who do not achieve a compliant after-hours audit or attestation review. Health Care Quality Improvement (HCQI) Department staff coordinates follow up with the practitioner office and Provider Support Department as needed.
  • Also, refer to Policy PRV011: Practitioner Office Site Evaluation and Availability Survey/Medical Record Keeping

 

Patient Confidentiality in the Practitioner's Office

A patient confidentiality policy for practitioner’s offices, including behavioral health practitioners, ensures privacy of health information for Blue Cross Blue Shield members. These guidelines are supported by the NCQA Standards for Accreditation. Adherence is evaluated during the practitioner onsite review and through evaluation of member complaints. The guidelines are as follows:

  • Staff should avoid discussing patient cases where they can be over heard by others.
  • When voices can be heard easily through exam room walls, adding sound proof panels or soft music can help but is not required.
  • Arrange office space to allow privacy for your patients who are paying bills and making appointments.
  • Ensure computer screens that contain patient information are protected from general view.
  • Ensure all patient care is provided out of sight from other patients (weighing, lab draws, etc.).
  • Avoid listing patient telephone number or reason for visit on the sign-in sheet.
  • Office staff receives periodic training in patient information confidentiality .Have an office Confidentiality Policy for staff to read and sign.
  • Ask your patients to sign a HIPAA-compliant Authorization to Release Information form prior to releasing medical records to anyone (other physicians, Department of Health etc.).
  • Information containing the HIV/AIDS status, or substance abuse, must have a separate release form stating the practitioner has the permission of the patient to send that information.
  • Blue Cross Blue Shield may obtain members’ medical records, as all members sign an agreement regarding this upon enrollment with Blue Cross Blue Shield. Providers are not required to release a patient’s HIV and substance abuse information to Blue Cross Blue Shield without patient authorization
  • Set in place a protocol for sending and receiving confidential information via fax.
  • Ensure medical record files are organized and stored in a secure manner that allows for easy retrieval by authorized personnel only. Records should not be accessible to the public.
  • Ensure electronic medical records are secured by individual passwords for each practitioner/staff member.
  • Keep medical records the staff is working on out of view of others.

Monitoring: Quality Assurance Reporting Requirements (QARR)

QARR consists of measures from the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS), Center for Medicare and Medicaid Services (CMS) QRS Technical Specifications, and New York State-specific measures. The products that these reporting requirements apply to are Commercial PPO/POS, Essential Plan, Qualified Health Plans and Medicaid. To enhance its ability to monitor measure compliance, NYS continually revises its Quality Assurance Reporting Requirements, adding or modifying measures to provide more comparable and complete information. QARR measures may be modified or changed annually, to reflect both advances in the technology and methodology of measuring quality and new program priorities. 

The NYS Department of Health uses the QARR measures and Medicaid encounter data to determine any patterns that may indicate that a particular healthplan is not providing appropriate services. If it is determined that a healthplan does not achieve an acceptable performance rate, they can be subjected to corrective measures. More specifically, any healthplan that does not achieve an acceptable rate of compliance will be required to perform a root cause analysis and to develop an improvement plan approved by the NYSDOH.

Health Care Proxy

It is a Medical Record Documentation Standard that primary care physicians have documentation of discussing the need for a health care proxy/advanced directive, or a copy of the completed form, for each adult patient (age 18 and over.)

To obtain information about the form, review frequently asked questions, and obtain a copy of the Health Care Proxy Form and instructions for completion, or to obtain a copy of the form in English, Spanish, Chinese, or Russian, visit: https://www.bcbswny.com/content/dam/BCBSWNY/Provider/public/forms/patient-care/patient-care-forms-logic-gate/health-care-proxy-form.pdf  

Office Compliance Attestations

A review of primary care physicians, obstetrics/gynecology physicians, mental health specialists’ and oncology office locations must be conducted and completed as a requirement of participation. The physician attestation review addresses, at a minimum: access to services, waiting area amenities, safety and adequacy of equipment, treatment area and after-hours telephone calls. The physician attestation review form and evaluation process are used for this purpose.