NY Manual
SHP Manual

New York Provider Manual
17.7 Overpayments | 18 Glossary of Terms
17.8 Member Financial Responsibility
 
Members in certain Healthfirst plans are financially responsible for some Covered Services.  These members' cost sharing amounts may include co-payments, coinsurance, and/or deductibles ("Member Expenses").
Member co-payments, which are a specific dollar amount for Covered Services, may be collected at the time of service.   Refer to the Provider Portal to determine any co-payments which may apply. 
Providers may not collect any other Member Expenses (coinsurance or deductible) until we have received and adjudicated a claim and determined the Member’s Expense based on their co-insurance or remaining deductible.  We will advise you of the Member Expense in the EOB for the adjudicated claim.  Providers must wait until they receive an EOB showing the amount due from the Member due before billing and collecting the Member Expense. 
At times we may recalculate Member Expense based on additional claims information receive from your and other providers.  If this result in additional payment to you for amounts previously identified as a Member Expense, you must reimburse the member directly in a timely manner. This is not contingent on the Member requesting a refund.
In addition, if a member pays you more than the amount indicated on the EOB for any reason, you must also refund the Member the amount the member overpaid as soon as possible after learning of the Member’s overpayment.