NY Manual
SHP Manual

New York Provider Manual
16.8 Healthfirst Payment in Full/Member Hold Harmless | 17.2 General Billing and Claim Submission Requirements

17. Billing & Claims Processing 

Billing and reimbursement policies serve as a supplement to the Provider Compensation section of the Provider Manual. Please refer to Appendix XIV for a complete list of coding requirements.

17.1 Member Eligibility

Payment for services rendered is subject to verification that the member was enrolled in Healthfirst at the time the service was provided and to the provider’s compliance with the Healthfirst Medical Management and prior authorization policies at the time of service.

Providers must verify member eligibility at the time of service to ensure the member is enrolled in Healthfirst. Failure to do so may affect claims payment. Note, however, that members may retroactively lose their eligibility with Healthfirst after the date of service. Therefore, verification of eligibility is not a guarantee of payment by Healthfirst. Please contact Overpayment Recovery at 1-866-635-1520 in cases where members retroactively lose coverage so that you can obtain further information, including any other payor that may be billed.

Claims submitted for services rendered without proper authorization will be denied for “failure to obtain authorization.” No payment will be made.

In certain cases, a managed care plan member, including Healthfirst members, may change health plans during the course of a hospital stay. When this occurs, providers should bill the health plan to which the member belonged at the time of admission to the hospital.