Provider Manual
Amida Care Formulary
Medical Record Review Standards and Criteria

Health Care Proxy Forms:
English Spanish Chinese Russian

Transgender Coverage Information:

Clinical Guidelines and Coverage Criteria for the Treatment of Gender Dysphoria
Transgender Drug Formulary
Referral Guide
TGNC Attestation Form: English/Spanish
TGNC Documentation Verification Form: English/Spanish

Provider Modification Form
When you are changing your practice name, address, phone numbers, e-mail, billing company, or other practice information, you only need to complete this single form and send it via:
Email: providerservices@amidacareny.org, fax: 646-786-1803, or US mail: Amida Care, Inc. c/o Provider Services 14 Penn Plaza, 2nd Floor. New York, NY 10122.
AC Fax Form for Case Submission
This form is only for Medical UM requests.
NYCDOHMH Universal Reporting Form (URF)
Communicable disease reporting and the Universal Reporting Form (URF). For any questions or to report cases immediately, call the DOH Provider Access Line at 1-866-NYC-DOH1 or, after hours, the Poison Control Center at 1-800-222-1222.

For questions about specific Amida Care policies or requirements, please contact us at: 1-800-556-0674.

Live Your Life Undetectable Program Information and Forms

The Live Your Life Undetectable (LYLU) program helps Amida Care members living with HIV become virally suppressed. Participants who enroll in the program with an undetectable viral load or who become undetectable (<200 copies/ml) through participation will receive a financial incentive of $100 for each quarter (three-month period) that they stay undetectable.

Below you will find links to the information and resources you’ll need to support your patients who are eligible for this program:

Live Your Life Undetectable Program Adjustments for Q2 2020 in Response to COVID-19
LYLU Provider Training Deck: The information presented during the provider training webinars can be downloaded here, as a refresher or for those who are not able to participate live.
LYLU Quick Reference Guides:
- Provider Benefits
- Provider FAQs
Forms: Required for patient enrollment, assessment, and ongoing reporting.
- LYLU Participant Enrollment and Consent (Enrollment) – Review and discuss program requirements with patient and complete form electronically with and on behalf of patient. A completed and signed form is required for patient enrollment. English / Spanish
- RHIO Consent (Enrollment) – Review RHIO benefits with patient and complete electronically with and on behalf of patient. English/Spanish
- LYLU Comprehensive Needs Assessment (Enrollment) – This assessment (or an equivalent) will help you decide which LYLU supportive services are most appropriate for your patients. An assessment is strongly encouraged but not required for program enrollment. English / Spanish
- LYLU Provider Quarterly Attestation (Ongoing Reporting) – This form must be completed by you or your staff and submitted each calendar quarter for each Amida Care LYLU Program enrolled patient to be eligible to receive their $100 incentive.

ShareFile Guide: All forms must be completed electronically, printed, signed, scanned, and securely submitted to Amida Care via the ShareFile system. This Quick Reference Guide gives you easy three-step instructions on setting up your ShareFile account.

Clinical Practice Guidelines

HIV/AIDS
Asthma
COPD
Diabetes
- ADA Practice Guidelines
Hypertension
- American College of Cardiology/American Heart Association (ACC/AHA), summary version.
- Update from the American College of Cardiology
Pediatrics and Adolescents
Perinatal
- New York State Guidelines for Perinatal Care
- New York State AIDS Institute: Preventing Perinatal HIV Transmission
Gynecology and Obstetrics
- NYS AIDS Institute
- National Institutes of Health (NIH)
- American College of Obstetricians and Gynecologists (ACOG)
- Women’s Preventive Services Initiative (WPSI) charts in English and Spanish can be accessed here.
Behavioral Health/Substance Use
- Carelon Behavioral Health Clinical Practice Guidelines
- New York State – Carelon Behavioral Health Clinical Practice Guidelines

NOTE: Amida Care partners with Carelon Behavioral Health to manage behavioral health care and to provide a network of physicians, other licensed professionals, community agencies, and inpatient and outpatient facilities for a full spectrum of behavioral health services that includes mental health and substance use disorder services. Carelon Behavioral Health adopts guidelines for Behavioral Health that are consistent with current standards of care. Amida Care reviews and adopts the behavioral health clinical practice guidelines as recommended by our partner Carelon Behavioral Health.

Transgender/GNC Health
- WPATH Standards of Care : (v8 published Sept 2022)
- Endocrine Society guidelines
- Amida Care Plan Resources
Prevention / Screenings
- United States Preventive Services Task Force (USPSTF)
  USPSTF has over 50 screenings with an A or B rating; some of the recommendations which are especially applicable to our members include: Cervical cancer, Colon cancer and Lung cancer

Provider Tips for Optimizing HEDIS Results

Gender Affirming Surgery Clinical Criteria

Facial Feminization Surgeries
Feminizing Body Contouring
Feminizing Fillers Lip/Cheek
Masculinizing Body Contouring
Masculinizing Fillers Brow/Mandible
Feminizing Hair Removal
Feminizing and Masculinizing Hair Transplant
Surgeon Revision PA Submission Checklist

Please email GIST@amidacareny.org to request access to the Gender-Affirming Surgery Clinical Criteria.

Behavioral Health

Carelon Behavioral Health Provider Toolkit
Resources to help providers with identification, information and treatment steps for behavioral health care and conditions.

Pediatrics and Adolescents

Children’s Transition/Transformation
- Project TEACH: New York State
- Transition Age Youth (TAY): Kids Transitioning to Adulthood
- First Episode Psychosis (FEP): What Is It?
- OnTrackNY:
  OnTrackNY is an innovative treatment program for adolescents and young adults who have had unusual thoughts and behaviors, or who have started hearing or seeing things that others don’t. OnTrackNY helps people achieve their goals for school, work, and relationships. Programs are located throughout New York State.

Abortion Access

You have the right to safe and legal abortion in New York.
Amida Care covers your abortion care.
If you prefer to remain anonymous to Amida Care when seeking abortion care, you can reach out to the NYC Health Department’s Abortion Access Hub.
Regardless of where you live, the NYC Abortion Access Hub provides confidential help finding an abortion provider, scheduling an appointment, getting financial assistance, and finding transportation and lodging.
Contact the NYC Abortion Access Hub Monday to Saturday, 8 a.m. to 8 p.m., at 877-NYC-AHUB (877-692-2482) or via live chat. After hours you can leave a confidential voicemail at 877-692-2482 and staff will return the call. For more information, visit nyc.gov/abortion.