NY Manual
SHP Manual

New York Provider Manual
2.4 Benefits-Covered Services | 3.2 Provider Rights and Responsibilities

3. Healthfirst Provider Networks

3.1 Description of the Networks

Healthfirst serves the healthcare needs of its members through comprehensive provider networks for each of its various programs (Healthfirst Medicaid, Child Health Plus, Medicare, Healthfirst Leaf Plans, and Healthy New York). While each network is separate and unique, most Healthfirst providers participate in one or more of these networks. Each network includes the clinical practitioners necessary to offer the full spectrum of covered healthcare services.

The networks are organized around each Healthfirst hospital or designated group of hospitals. This includes all inpatient and outpatient facilities, primary care and specialty care providers, and other healthcare personnel affiliated with the hospital’s delivery system, so that providers can refer members and coordinate treatment according to their normal practices and referral patterns. Medical services are generally rendered by hospital and community-based providers within each hospital system. Additional services such as behavioral health, home care, dental, and other ancillary services are provided and managed by either Healthfirst, selected hospitals, or other organizations specializing in these areas.

While our network is organized around the Healthfirst hospitals so that existing referral and practice patterns among providers are maintained, members may see any participating provider within the network for a given Healthfirst program.

Hospital Responsibilities

Healthfirst was started by its member hospitals seeking to provide high quality, comprehensive, managed healthcare services to members covered under government- sponsored and other health benefit programs. Healthfirst has contracted with these and other hospitals to provide inpatient care, outpatient services, and diagnostic testing to its member population. The hospitals and their associated delivery system of  providers, allied and ancillary health personnel, therapists and other affiliated providers, comprise the core of the Healthfirst provider network. A listing of participating Healthfirst hospitals can be found in the Provider Directories.

The following is an overview of responsibilities for hospitals participating with Healthfirst:

·     Provide all contracted services within the scope of the hospital’s operating certificate
·     Verify member eligibility for all services
·     Obtain prior authorization for all elective admissions from the Healthfirst Medical Management Department
·     Report all obstetrical admissions for delivery to Healthfirst at the time of the delivery or on the next business day
·     Provide Healthfirst with Client Identification Numbers (CIN) for all newborns delivered to Healthfirst members
·     Refer members back to their primary care providers (PCPs) for coordination of specialty care following an emergency room visit
·     Refer all Healthfirst Leaf Plan Members to In-Network specialists prior to the specialist service being rendered using the appropriate referral request form
·     Ensure continuity of care by coordinating discharge arrangements with the member’s PCP, specialty care provider (as appropriate), and other post-discharge providers, such as certified home health agencies and the Healthfirst Medical Management department
·     Ascertain whether the member has executed an Advance Directive, include an executed Advance Directive in the member’s medical record, and honor the member’s wishes as documented in the Advance Directive
·     Notify Healthfirst Medicare members receiving inpatient hospital care (or their representative) when services will be discontinued and/or their original Medicare or Medicare Advantage Plan will no longer pay for their benefits. (See Section 15 for more information)
·     Adhere to provider Appointment Availability and 24-Hour Access Standards as specified by the New York State Department of Health
·     Implement operating procedures required to comply with the Healthfirst policies and procedures

Primary Care

Healthfirst primary and specialty care providers practice in a variety of settings including hospital outpatient departments, hospital-sponsored independent community- based practices, and private provider offices located either on member hospital campuses or within the community.

Primary Care Providers (PCPs) are providers or Nurse Practitioners who specialize in Family Practice, Internal Medicine, Geriatrics or Pediatrics. All members enrolling in Healthfirst select a participating PCP. Generally, members choose geographically convenient providers and hospitals. Members may change their PCP at any time and select a new provider from the Healthfirst network.

PCPs are responsible for coordinating all of the care a member receives and are expected to refer members to specialists in the Healthfirst network for care that is outside of the scope of primary care. Written referrals are not required for most Healthfirst members to receive care from in-network specialists. However, PCPs are responsible for monitoring all member care and promoting the return of the member for services and management. PCPs are also responsible for requesting authorizations from Medical Management. Referrals or authorizations, when required, are essential for prompt claims payment. Please refer to Section 12 for more details on referral and authorization processes.

Because the PCP is the member’s first contact with Healthfirst, the PCP is responsible for identifying members with complex or serious medical conditions, assessing those conditions using appropriate diagnostic procedures and recommending them to Care Management for intensive review and follow-up. If the case meets Care Management selection criteria, the PCP, along with Care Management, formulates and implements a time-specific treatment plan, taking into consideration the member’s input. The PCP should also make referrals for an adequate number of visits to specialists to accommodate the treatment plan, and update treatment plans periodically. Please refer to Section 13 of this manual for more information.

Primary Care for Leaf Plan and Leaf Premier Plan Members

Primary Care Providers for Leaf Plan members will be required to generate referrals for Leaf Plan members for most specialist services. Referrals should be generated by the PCP prior to the specialist service being rendered, and can be submitted online through the Healthfirst Provider Portal. 

Primary Care for HIV Positive Members

All HIV Specialist PCPs must meet additional credentialing requirements to serve this population. (See Appendix II-A) These multi-disciplinary providers coordinate care throughout the service delivery system.

Treatment Adherence

At every visit, the HIV Specialist PCP should discuss and document in the medical record the member’s adherence to their treatment plan. For members who do not adhere to their treatment plan, the provider should either provide directly or ensure access to additional treatment adherence support services. To arrange for community-based treatment adherence support services, contact the Healthfirst Care Management Department at 1-888-394-4327.

Co-Management with an HIV Specialist

If a member has a life-threatening or degenerative and disabling condition or disease (other than HIV), either of which requires specialized medical care, the member may request a standing referral to a specialist to act as the PCP. A co-management model will be used in this circumstance. In these situations, an HIV specialist assists the PCP in an ongoing consultative relationship as part of routine care and continues with primary responsibility for decisions related to HIV-specific clinical management in coordinating with the other specialist. Providers are expected to cooperate in the process.

Harm Reduction Services

Providers must ensure harm reduction services are provided to HIV positive members. These services include:

·     Education and counseling regarding reduction of perinatal transmission
·     Individual and group HIV prevention and risk reduction education and counseling
·     Harm reduction education
·     Counseling and supportive services for partner/spousal notification

If you are not sure where to refer a member, the Healthfirst Care Management Department can assist you in securing these services. Call 1-888-394-4327 for more information.

Specialist Providers (excluding Behavioral Health Providers)

Healthfirst has contracted with specialist providers and other specialty healthcare professionals to provide care and services to its members whose treatment falls outside the scope of the PCP’s training. For most Healthfirst products such as Medicaid, CHP, and FHP, members are able to access these specialty services without a referral from their PCP or authorization by Healthfirst. Healthfirst Leaf Plan and Leaf Premier Plan members require a referral for most specialty services as outlined in Section 12 of the Provider manual.

Specialist providers also have the responsibility of identifying individuals with complex or serious medical conditions. Once identified, the condition should be assessed and monitored using appropriate diagnostic procedures. These cases should be referred to Care Management for intensive review and follow-up. The specialist, along with Care Management, should establish and implement a time-specific treatment plan taking into consideration the member’s input and coordinating with the PCP.

Specialty care services are provided by clinicians practicing within the Healthfirst Network. Healthfirst may make special arrangements to accommodate referrals to specialists affiliated with non-network institutions when appropriate.

Tertiary Care

Healthfirst negotiates system-wide arrangements for the provision of selected tertiary care services.

Behavioral Healthcare

Healthfirst has contracted with providers, community agencies and other licensed professionals to provide Behavioral Healthcare services, including mental health and chemical dependency (addiction) treatment, outside the scope of the PCP’s training. Special delegated arrangements for management of behavioral health services apply to members affiliated with certain hospitals. See Section 9 for more information.

Ancillary Services

Healthfirst has established both network-wide and hospital-specific arrangements to provide ancillary services such as vision care, home healthcare, and dental services, as well as other services to its members. Healthfirst provides specialized healthcare services, diagnostic testing, therapies and medical items, supplies, devices, DME, and chiropractic services through contracted ancillary providers. Members can access ancillary services via a written prescription or a direct call from the PCP or Specialist provider. Please refer to Section 10 for a detailed description of all Ancillary Services policies and procedures.

Levels of Participation

The relationship between Healthfirst and its participating providers is characterized by three levels (e.g., employed, community-based, etc.). In some cases, the participation level of the provider determines which ancillary service vendors may be used. The levels are as follows:

·     Level I providers are employees of participating hospitals. They are credentialed by the hospital with delegated oversight by Healthfirst, and are bound by the terms of the agreement executed by the participating hospital which employs that provider. Payment for services rendered by these providers is made to the hospital, not to the individual provider.
·     Level II providers are contracted with Healthfirst directly on an individual basis or as members of a professional corporation or diagnostic and treatment center. These providers are credentialed by the Healthfirst hospital(s) with which they are affiliated, with delegated oversight by Healthfirst. Payment for services is made directly to the provider or designated contracting entity.
·     Level III providers are PCPs based in the community who do not have admitting privileges at a Healthfirst participating hospital. These providers hold individual contracts with Healthfirst and are credentialed by Healthfirst. Providers are compensated directly for services rendered.

Partnering with Healthfirst - Mutual Expectations

Healthfirst is committed to working with its participating providers to ensure that high-quality services are provided in an atmosphere of collaboration and respect. Mutual expectations are as follows:

From Healthfirst

·     Open, respectful, and receptive communication
·     Knowledgeable and helpful staff
·     Timely response to questions and concerns
·     Timely communication of policy changes
·     Timely, comprehensive orientation, training and educational programs
·     Timely processing of provider applications
·     Timely payment for covered services rendered
·     Responsive appeals and grievance processes
·     Assistance with complex member issues
·     Feedback on performance and utilization

From Participating Providers

·     Professional, respectful and responsible healthcare for members
·     Timely response to inquiries
·     Assistance with problem-solving and other issues
·     Maintenance of all contractual credentialing standards and licensing obligations
·     Adherence to access and scheduling standards
·     Compliance with medical management protocols
·     Timely and accurate claims submission
·     Compliance with quality improvement protocols and requests
·     Cooperative office and administrative staff

Quality Improvement and Commitment to Providers

Healthfirst has implemented a uniform Integrated Quality Plan and Quality Improvement Program throughout the network with oversight maintained by the Healthfirst Chief Medical Officer and Healthfirst Clinical Performance Management staff. This program supports processes designed to improve the quality and safety of clinical care and the quality of service provided to members to ensure members receive the highest quality of care. This includes clinical and service quality indicators, public health reporting, quality investigations, focused clinical studies, quality programs, and member satisfaction surveys. All Healthfirst providers are required to participate in quality improvement efforts.

In addition, any Quality Improvement plans developed by participating providers must adhere to the Healthfirst program standards. Healthfirst offers provider education and training programs regarding quality improvement initiatives conducted by the Clinical Performance Management and Network Management departments. Healthfirst works closely with participating facilities to build consensus and support for critical network policies and procedures and to find solutions to operational issues.