NY Manual
SHP Manual

SHP Provider Manual
Section 1 About Senior Health Partners
1.1 Welcome Network Provider Letter
1.2 Introduction to Senior Health Partners
Section 2 Members
2.1 How to Identify a Senior Health Partners Member
2.2 Member Rights and Responsibilities
2.3 Member Co-Payments
2.4 Non-English Speaking Members
2.5 Impaired Members
Section 3 Care Management Teams
3.1 Care Management
3.2 Coordination of Services
3.2a Sample Service Plan Letter (Page 1)
3.2a Sample Service Plan Letter (Page 2)
3.2b Sample Service Plan Update Letter (Page 1)
3.2b Sample Service Plan Update Letter (Page 2)
3.3 Covered and Non-Covered Services
3.4 Assessments of Members
Section 4 Providers
4.1 Network and Provider Relations
4.2 Provider e-Newsletter and Notices
4.3 Provider Credentialing and Recredentialing
4.4 Provider Rights and Responsibilities and Dual Eligible Members
4.5 Provider Non-Disclosure and Confidentiality
4.5a Notice of Privacy Practices
4.6 Termination of Provider Agreement
4.7 Provider Participation in Senior Health Partners’ Operations
4.8 Network Evaluation
Section 5 Billing Reimbursement Procedures
5.1 Billing Reimbursement Procedures
5.1a Claims Submission Procedures
5.1b Requests for Review and Reconsideration of a Claim
5.2 Provider Information
5.3 Fraud Waste and Abuse
5.4 Claims Appeals/Review and Reconciliation Process
5.5 Overpayment Recovery Appeals Process
5.6 Adverse Reimbursement Change
5.7 Provider External Appeals – Effective January 1, 2010
Section 6 Grievances Appeals and Compliments
6 Grievances, Appeals and Compliments
6.1 Complaints and Grievances
6.2 Appeals
6.3 Compliments
6.4 Quality Review and Oversight
Section 7 Quality Assurance Performance Improvement and Compliance
7.1 Quality Assurance, Performance Improvement (QAPI) Plan and Compliance
7.2 Quality Assurance Performance Improvement (QAPI)
7.3 Provider Quality Report Cards
Section 8 How Providers Can Refer Members to Senior Health Partners
8.1 Senior Health Partners /Provider Partnership
8.2 Instructions for Providers to Make Referrals