NY Manual
SHP Manual

New York Provider Manual
4.3 PHSP Enrollment and Disenrollment | 4.5 Member Rights and Responsibilities

4.4 Eligibility Verification 

You may verify a member's eligibility as described below. Note that member eligibility may change from time to time, including retroactively in certain circumstances. Verification of eligibility therefore does not ensure subsequent claims payment. To ensure coverage is renewed, please remind your Healthfirst members to call us 60 days prior to their coverage expiration date so we can assist them with their renewal. Providers must use one of the following steps to verify a member’s eligibility before or at the time of service.

Note that verification of eligibility at the time of service does not guarantee payment by Healthfirst. Claims must still be submitted in a timely manner with all required information. In addition, members may lose eligibility after services are provided and claims are submitted. What’s more, the loss of eligibility may be retroactive to the date of service.

View the Member ID Card

Each Healthfirst member is issued an identification card which includes the member’s PCP, affiliated hospital, and mental health and substance abuse benefits manager, as well as other identification and informational items. If a Healthfirst member is eligible for dental coverage, the dental phone number will be printed on the member ID card. Medicaid members should keep their Healthfirst Medicaid, Managed Care, and Medicaid identification cards together, since some benefits can be accessed only through the Medicaid card. Go to www.healthfirst.org to view a sample of member ID cards for all Healthfirst products.

  

 

Healthfirst Leaf Plan and Leaf Premier Plan member ID cards will indicate the member's plan deductible limit and their cost sharing/copayment responsibilities.  Leaf and Leaf Premier Plan member ID cards will also have the member portal site listed, www.myHFNY.org. Leaf and Leaf Premier Plan members can be referred to the portal to pay their plan premium, find a doctor, access more information on their plan benefits, and more.

 

 
 
2015 Leaf Premier Plans.jpg
 

Verify Online (www.healthfirst.org/providers)

Providers can access eligibility information on our website using the member’s Healthfirst ID number. Providers can verify eligibility for up to ten members at one time or view individual information and demographics.

Call Provider Services (1-888-801-1660) 

Check the Member Enrollment Roster

Members are enrolled monthly into the Healthfirst programs. Members select a PCP at the time of enrollment. Healthfirst provides PCPs a monthly enrollment roster that identifies new members in the provider’s panel as well as those members who have left the practice. The enrollment roster contains demographic information for each member by Healthfirst program. Providers may use these rosters to verify eligibility. However, if a member is not listed on the roster and says that he/she belongs to the provider’s panel, the provider should verify eligibility through the Member Eligibility section of our website or by calling Member Services. Member Enrollment Rosters are available on our the Healthfirst secure provider portal.

Check eMedNY 

Codes:

·     Code SF to verify enrollment in the Healthfirst Medicaid plan
·     Code Y8 to verify enrollment in the Healthfirst Medicare/Medicaid integrated Maximum Care Plan (MAX) Plan
·     Code MH to verify enrollment in the Healthfirst Medicare/Medicaid with Long Term Care benefits for CompleteCare (CC) Plan       

In some cases, a member may be added to a provider’s panel after the monthly enrollment roster is created. If there is a discrepancy between the roster, the member’s identification card, and the eMedNY system, or if there are questions about a member’s eligibility, please call Member Services for the most current information.

Commercial Plans

Members in Healthfirst Leaf  and Leaf Premier Plans or HMO A-D plans may have monthly premium responsibilities. Members with premium obligations will have to pay their premiums on time in order to maintain their insurance coverage. Members who receive no federal subsidies will have a 30-day grace period in which to pay their premiums. Members who receive federal subsidies will have a 90-day grace period to pay their premium. If members fail to pay their premium at the end of their grace period, they will be disenrolled. Claims incurred by members in the first 30 days of a 90-day grace period will be paid; those incurred in days 31–90 will not be paid, unless the member pays their premium before the end of their grace period. To verify a members eligibility in the commercial plan, providers can:
·     Call Provider Services at 1-888-801-1660
·     Log on to the provider portal, www.healthfirst.org/providers
​​​