NY Manual
SHP Manual

New York Provider Manual
12.3 Authorization of Services | 12.5 Continuity of Care

12.4 Out-of-Network Services

At times, a Healthfirst member may require healthcare services from a nonparticipating provider. These situations may arise for reasons of medical necessity or because a particular service or specialty is not available within the Healthfirst network. When this occurs, our Utilization Management department should be contacted at 1-888-394-4327, Monday through Friday, 8am–5:30pm. Our staff will obtain the clinical information needed to address the member’s specific health condition. A determination will be made regarding whether or not out-of-network care can be supplied by an in-network provider and whether the requested service(s) are medically necessary. Healthfirst will inform you of its decision within three (3) business days of receiving all the information needed to make a decision. Out-of-network care for all plans must be approved by Utilization Management, which evaluates the case in conjunction with the attending practitioner and the member’s PCP.

When a Healthfirst member is referred for out-of-network inpatient hospitalization, the hospital must:

•     Verify the member’s eligibility at the time of admission;

•     Contact Utilization Management to verify that the member’s scheduled admission has been preauthorized and to obtain the authorization number for submission with the claim.

Out-of-network services will not be covered in any Healthfirst plan except for emergency services or services authorized by Healthfirst. Healthfirst members who opt to receive elective out-of-network services without authorization will be held liable for the cost of those services.

Participating providers who knowingly and routinely refer Healthfirst members to nonparticipating providers for non-emergent services may be determined to be in breach of their participation agreement and be subject to termination.

If a Medicare member is referred to an out-of-network provider by an in-network provider, this is considered plan-directed care, and the member will be held harmless except for any copayment responsibility.

Healthfirst members enrolled in Healthfirst’s Medicaid, Child Health Plus, Essential Plan, or Commercial plans who receive unauthorized care or emergency services from a nonparticipating provider and receive a “surprise bill,” as defined in the New York Financial Services Law, may assign their benefits to the nonparticipating provider and be held harmless for any cost in excess of the amount they would have paid for services if they had been provided by a participating provider.