NY Manual
SHP Manual

New York Provider Manual
Section 1 Introduction
1.1 Introduction to the Provider Manual
1.2 About Healthfirst, Inc.
1.3 Network Management and Provider Services
Section 2 Healthfirst Programs and Benefits
2.1 Healthfirst PHSP Programs
2.2 Healthfirst Medicare Plans
2.3 Healthfirst Commercial Programs
2.4 Benefits-Covered Services
Section 3 Healthfirst Provider Networks
3.1 Description of the Networks
3.2 Provider Rights and Responsibilities
3.3 Fraud, Waste & Abuse
3.4 Appointment Availability and 24-Hour Access Standards
3.5 Provider Application Process
3.6 Credentialing, Recredentialing Requirements & Provisional Credentialing
3.7 Provider Profiling
3.8 Termination of Provider Agreements
Section 4 Eligibility and Membership
4.1 Introduction
4.2 Marketing, Advertising, Outreach and Enrollment
4.3 PHSP Enrollment and Disenrollment
4.4 Eligibility Verification
4.5 Member Rights and Responsibilities
4.6 Member Services and Education
Section 5 Regulatory and Reporting Requirements
5.1 Reporting Requirements
5.2 Medical Record Reviews and Documentation Standards
5.3 Confidentiality
5.4 Advance Directives/Healthcare Proxy
5.5 Disclosure Restrictions for Services Paid Out-of-Pocket
5.6 Critical/Non-Critical Incident Management and Reporting Procedure
Section 6 Primary Care
6.1 Responsibilities of a Primary Care Provider (PCP)
6.2 Primary Care Panels and Member Enrollment Rosters
6.3 Preventive Care Standards
Section 7 Obstetrics and Gynecology
7.1 Definition of Services
7.2 Diagnostic Testing
7.3 Consent Requirements for Hysterectomy - Medicaid, CHPlus and FHPlus
7.4 Family Planning and Reproductive Health
Section 8 Specialty Care
8.1 Definition of Specialty Care
Section 9 Behavioral Healthcare and Chemical Dependency
9.1 Description of the Network
9.2 Benefits and Access to Care
9.3 Program Overview
9.4 Utilization and Medical Management Guidelines
Section 10 Ancillary and Other Special Services
10.1 Overview of Services and the Provider Network
10.2 Laboratory
10.3 Pharmacy
10.4 Durable Medical Equipment (DME), Orthotics & Prosthetics
10.5 Home Healthcare
10.6 Dental
10.7 Routine Vision
10.8 Hospice - Medicaid CHPlus FHPlus Medicare and Commercial
10.9 Transportation
10.10 Custodial-Long-Term-Care-Placement
Section 11 Emergency and Urgent Care
11.1 Emergent Care
11.2 Urgent Care
Section 12 Medical Management
12.1 Program Overview
12.2 PCP-Directed Care
12.3 Authorization of Services
12.4 Out-of-Network Services
12.5 Continuity of Care
12.6 Concurrent Review
12.7 Retrospective Review
Section 13 Care Management
13.1 Overview
Section 14 Clinical Performance Management
14.1 Overview and Philosophy
14.2 Reporting Requirements and Quality Programs
14.3 Clinical Practice Guidelines
14.4 Focused Studies, Surveys and Investigations
14.5 Quality Improvement – Medicare
14.6 Quality Evaluation of Providers
Section 15 Appeals and Grievances
15.1 Provider Notice Requirements – Medicare
15.2 SNF/HHA/CORF Provider Service Terminations – Medicare
15.3 Notification to Members of Non-Coverage of Inpatient Hospital Care – Medicare
15.5 Organization Determinations and Reconsiderations – Medicare
15.6 Expedited Organization Determinations and Appeals – Medicare
15.7 Coverage Determinations for Part D Prescription Drugs – Medicare
15.8 Coverage Determinations for Prescription Drugs – Medicaid, FHPlus, CHPlus
15.9 Action Denial Notice – Medicaid, FHPlus and CHPlus
15.10 Action Appeals – Medicaid, FHPlus
15.11 Expedited Appeals – Medicaid, FHPlus
15.12 Member Rights to a Fair Hearing – Medicaid, FHPlus
15.13 External Review – Medicaid, FHPlus
15.14 Member Complaints – Medicaid, FHPlus
15.15 Standard Appeals – Commercial, CHPlus
15.16 Appealing the Grievance – Commercial, CHPlus
15.17 Expedited Appeals – Commercial, CHPlus
15.18 External Review – Commercial, CHPlus
Section 16 Provider Compensation
16.1 Payees
16.2 Primary Care Services/Primary Care Providers
16.3 Healthfirst Quality Incentive Program
16.4 Specialty Care and Specialists
16.5 Obstetrical Care
16.6 Family Planning Services
16.7 Healthfirst Consultation Payment Policy
16.8 Healthfirst Payment in Full/Member Hold Harmless
Section 17 Billing and Claims Processing
17.1 Member Eligibility
17.2 General Billing and Claim Submission Requirements
17.3 Time Frames for Claim Submission, Adjudication and Payment
17.4 Coordination of Benefits (COB)
17.5 Explanation of Payment (EOP) / Electronic Funds Transfer (EFT) / Electronic Remittance Advice (ERA)
17.6 Claim Inquiries, Claim Reconsideration and Appeal Process
17.7 Overpayments
17.8 Avoidable Readmission Reimbursement Policy
Section 18 Glossary of Terms
18 Glossary of Terms
Appendix I Appointment Availability and 24-Hour Access Standards
I Appointment Availability and 24-Hour Access Standards
Appendix II Credentialing
II-A Credentialing Requirements
II-B Healthfirst Office Site Evaluation Form
II-C Interpretative Guidelines for the Office Site Evaluation Form
Appendix III Medicaid Managed Care Exclusions and Exemptions
III Medicaid Managed Care Exclusions and Exemptions
Appendix IV Marketing Guidelines
IV-A Medicaid Marketing Guidelines for Medical Service Providers
IV-B Medicare Marketing Guideline
Appendix V Medical Record Standards
V Medical Record Standards
V-A Medical Record Standards Tool (Medicaid / CHPlus)
V-B Medical Record Standards Tool (Medicare)
Appendix VI Healthcare Proxy
VI Healthcare Proxy
Appendix VII Preventive Care
VII-A Preventive Care Standards and Required Documentation
VII-B Child/Teen Health Plan (C/THP) Guidelines and Immunization Schedule
VII-C Guidelines for Adolescent Preventive Services (GAPS)
VII-D Primary Care Provider Behavioral Health Screening Tool
VII-E Healthfirst Wellness Reward Card - PHSP
VII-F Healthfirst Wellness Reward Card - Medicare
Appendix VIII Description of Skilled Nursing Service
VIII Description of Skilled Nursing Service
Appendix IX-A Healthfirst Transportation - Provider Approval Form
IX-A Healthfirst Transportation - Provider Approval Form
IX-B Member Transportation Reimbursement Form
IX-C Non-emergent Transportation Services Policy Livery and Ambulette
Appendix X Medicare Member Reimbursement Form
X Medicare Member Reimbursement Form
Appendix XI Pre-Authorization Guidelines
XI Pre-Authorization Guidelines
XI-B Pre-authorization Guidelines - Leaf Plans
Appendix XII Clinical Practice Guidelines
XII Clinical Practice Guidelines
Appendix XIII-A Notice Of Medicare Non-Coverage
XIII-A Notice Of Medicare Non-Coverage
XIII-B Important Information for Healthfirst Medicare Plan Members Appeal Rights
XIII-C Standard Description and Instructions for Healthcare Consumers to Request an External Appeal
XIII-D Attending Physician’s Attestation for a Patient’s External Appeal
XIII-E Appointment of Representative Statement and Form
XIII-F Detailed Notice of Discharge
XIII-G Important Message from Medicare About Your Rights
Appendix XIV Codes Claims and Reimbursable Services
XIV-A Appropriate Codes for Claims/Encounter Data
XIV-B Reimbursable Services
XIV-C Glossary of EOP Code Messages
Appendix XV New York State Communicable Disease Reporting Requirements
XV New York State Communicable Disease Reporting Requirements
Appendix XVI HEDIS QARR Quick Reference Guide
XVI HEDIS/QARR Quick Reference Guide
Appendix XVII Quality Rating Measures
XVII Quality Rating Measures
Appendix XVIII Behavioral Health Addendum
XVIII Behavioral Health Addendum
Appendix XIX Health and Recovery Plan (HARP)
XIX Health and Recovery Plan (HARP)
Appendix XX Provisions from the 2007 Managed Care Reform Bill
XX Provisions from the 2007 Managed Care Reform Bill