NY Manual
SHP Manual

New York Provider Manual
7.4 Family Planning and Reproductive Health | 9.1 Description of the Network

​8. Specialty Care

8.1 Definition of Specialty Care

Healthfirst has contracted with specialist providers and other specialty care professionals to provide healthcare services beyond the scope of primary care. Healthfirst Medicaid, CHP, and Medicare members can access these services in accordance with Healthfirst's prior authorization policies. Healthfirst commercial members can access these services in accordance with Healthfirst's commercial referral and prior authorization policies.

Specialty care practitioners provide medically necessary care within the scope of their practice. They are responsible for the following four (4) activities:

Identifying individuals with complex or serious medical conditions, assessing and diagnosing those conditions, and working with the member, as well as the PCP and Medical Management team, to provide effective, coordinated medical care

Collaborating with PCPs to provide coordinated clinical care and to enhance continuity of care for Healthfirst members. Specialists are responsible for contacting the PCP to request information where needed

Following up with PCPs in writing to apprise them of consultation results, diagnostic testing results, and treatment plans

Assisting members in accessing required services such as diagnostic tests, acute rehabilitation, home care, DME, and transportation

A complete listing of participating specialty providers can be found at www.hfdocfinder.org. A directory can also be created and printed or emailed, based on the search criteria entered, such as zip code and provider specialty.

Specialists as PCPs

Under certain circumstances, Healthfirst may authorize a specialist to serve​​ as a member’s PCP. This may occur when a member has a life-threatening, degenerative or disabling condition, or a disease that requires prolonged specialized medical care through a specialty provider or at a specialty care center. In these situations, Healthfirst arranges for the specialist to take on primary care responsibilities in caring for the member. The member’s PCP must be part of this decision process, and the Healthfirst Medical Management department must authorize the transfer of primary care responsibilities to the specialist. The specialist will then be accountable for coordinating care, referring the member to sub-specialty providers as appropriate, managing health education and preventive care activities, and complying with all guidelines, reporting requirements, and medical and Care Management policies.

For HIV members: If the PCP does not meet the qualifications of an HIV specialist, an HIV specialist will be assigned to assist the PCP in an ongoing consultative relationship as part of the member’s routine care.

The following situations illustrate examples of cases when it would be acceptable and beneficial for a specialty care provider or specialty care center to take on the primary management of care for a Healthfirst member:

·     HIV-positive members may select an HIV specialist to serve as their PCP
·     Members with multiple traumas who require prolonged complex rehabilitative management
·     Members with cancer who require a complex, ongoing course of treatment

The following procedures are applicable under these circumstances. Additional information on this subject also appears in Sections 3 and 12 of this Provider Manual.

If the PCP or specialist believes that it is in the member’s best interest to assign primary care responsibilities to the specialist, or if the member requests this arrangement, the PCP will discuss this option with the member.

The PCP or specialist will contact Medical Management with information about the member’s condition, course of treatment, and the name of the treating specialist. If all parties agree, the PCP, the specialist, and Medical Management will coordinate a plan to transfer care.

If a member has requested the transfer and the PCP or the specialist disagrees with the request, the member may contact Medical Management directly. In these cases, the Medical Director will make a final determination.

Specialty Care Centers

In some situations, a member may be best served by receiving care for a complex condition through a team of providers affiliated with an accredited or designated Specialty Care Center with experience in treating their life-threatening or degenerative and disabling disease or condition. For example, an HIV-infected mother with an HIV-infected and/or HIV-exposed child may be appropriately served by a Maternal/Pediatric HIV Specialized Care Center. The member, his/her PCP, or a specialty provider may initiate a request for this service. When a member makes the request, the PCP and Medical Management will evaluate the situation, and the following procedures will be followed:

The member, or the PCP on behalf of a member, should contact Medical Management to request care at a Specialty Care Center if he or she believes that this is the most appropriate resource.

If there is a Specialty Care Center in the Healthfirst network that provides the same or substantially similar services to those requested, the member will be directed for in-network care.

If it is determined that an out-of-network Specialty Care Center is the most appropriate provider of care for an individual member, Ancillary Services will contact the out-of-network Specialty Care Center to negotiate an arrangement. (Healthfirst is financially responsible for all authorized out-of-network medical expenses.)