NY Manual
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New York Provider Manual
XIV-B Reimbursable Services | XV New York State Communicable Disease Reporting Requirements

Appendix XIV-C — Glossary of EOP Code Messages

Use the following glossary as a guide to understanding the most common payment determination messages found in the EOP. 

EOP Message
Explanation of Message
Authorization Required, not Found 
Prior authorization for service was not obtained or referral form not submitted. This includes authorizations that do not match the services billed.
Require Medical Record 
Healthfirst requires the complete medical record for claim review.
Service Included in Case Rate
Payment for this service is included in the reimbursement for another service.
Service Capitated to Hospital 
Monthly payment was made to the hospital for this service.
Denied: Medical Chart not Received Within 45 Days
Service denied: provider did not submit records within 45 days of date of request.
Denied: Information (INF) not Received Within 60 Days of Request
Service denied: requested information (INF) was not received within 60 days of original request.
Denied-INF/Appeal not Received Within 60 Days
Service denied: request for appeal/review or submission of additional information was not received within 60 days of original EOP denial.
Failure to Comply with Healthfirst Notification Policy
Healthfirst requires notification of emergency room care within 48 hours and notification of inpatient admission by the next business day. Notification was not received.
Provider Not Eligible for Service
Service rendered is not covered under the provider’s contract/specialty. Usually applies when PCP performs nonprimary care service.
Exact Duplicate of Closed Claim    
Healthfirst has already received and processed a claim for these services.
Denied: Failure to Preauthorize 
Service denied: required authorization from Medical Management department was not obtained.
Emergency Room Record Required
Healthfirst requires submission of complete emergency room medical record to process claim.
Failure to Provide Clinical Information/Review
Medical Management department did not receive clinical information during inpatient stay.
Admission Not Medically Necessary
Services denied: based on information provided, Healthfirst determined that services were not medically necessary.
Member Not Enrolled on Date of Service
Service denied: patient not a Healthfirst member on the date service was provided.
Claim Exceeds Filing Date 
Service denied: claim was not received within 180 days of date of service.
Intranetwork provider – not member’s PCP