NY Manual
SHP Manual

New York Provider Manual
16.7 Healthfirst Consultation Payment Policy | 17.1 Member Eligibility

16.8 Healthfirst Payment in Full/Member Hold Harmless

Pursuant to their provider contract, participating providers are prohibited from seeking payment, from billing, or from accepting payment from any member for fees that are the legal obligation of Healthfirst, even if Healthfirst becomes insolvent or denies payment on a claim, regardless of the reason. Participating providers must refund all amounts incorrectly collected from Healthfirst members or from others on behalf of the member. As permitted by a provider’s contract with Healthfirst and by applicable law, Healthfirst will recoup payments inappropriately made by a member from a provider’s future claims payments and will remit the amount to the member.

Healthfirst is not financially responsible for reimbursing non-covered services provided to members. Please see Section 2 for additional information on the procedure to be followed in order to bill and collect from members for non-covered services.

With the exceptions of deductibles, copayments, or coinsurance, all payments for services provided to Healthfirst members constitute payment in full, and providers may not balance-bill members for the difference between their actual charges and the reimbursed amounts. Any such billing is a violation of the provider’s contract with Healthfirst and of applicable New York State law. Where appropriate, Healthfirst will refer providers who willfully or repeatedly bill members to the relevant regulatory agency for further action.

Additionally, per requirements set forth by the Centers for Medicare & Medicaid Services (CMS), dual-eligible members will not be held responsible for any cost-sharing for Medicare services when the state is responsible for paying those amounts. Providers must accept Healthfirst’s payment as payment in full or bill the appropriate state source (i.e., Medicaid FFS). This requirement applies to all dual-eligible individuals and not just to those members enrolled in a Medicare Advantage Dual Eligible Special Needs Plan (SNP) or Medicare-Medicaid Plan (MMP).