NY Manual
SHP Manual

New York Provider Manual
14.2 Reporting Requirements and Quality Programs | 14.4 Focused Studies, Surveys and Investigations

14.3 Clinical Practice Guidelines

Clinical practice guidelines (Appendix XII) are systematically developed standards that help practitioners and members make decisions about appropriate healthcare for specific clinical circumstances. The use of clinical practice guidelines gives Healthfirst the ability to measure the impact of guidelines on outcomes of care and may reduce practice variations in diagnosis and treatment. In addition to guidelines and recommendations required by CMS, the NYSDOH, and the local departments of health, participating providers are expected to comply with the guidelines adopted by Healthfirst.

Healthfirst has adopted preventive care and practice guidelines that are based on nationally accepted guidelines that are reviewed and updated every two (2) years unless otherwise specified. Healthfirst adopts guidelines upon the recommendation and approval of the Healthfirst Quality Improvement Committee (QIC). They are communicated to providers—including performance indicators chosen by the clinical members of the Committee—through the Provider Manual, annual mailings, newsletters, and the Healthfirst website. Performance against chosen indicators is measured annually—preventive guidelines are measured utilizing HEDIS/QARR measurement tools and clinical guidelines are measured using focused studies methodologies.

Please note: Healthfirst disclaims any endorsement or approval of these guidelines for use as substitutes for the individualized clinical judgment and decision making that is required in the treatment and management of our members. These guidelines provide a tool for objective comparison of clinical practices among network providers and ensure appropriateness of care to our members. These guidelines are readily available by virtue of their already broad publication and distribution.

To obtain a copy of the list of guidelines required by the NYSDOH and the list of guidelines adopted by Healthfirst, visit http://healthfirst.org/providers/provider-resources/