NY Manual
SHP Manual

New York Provider Manual
12.4 Authorization of Services | 12.6 Continuity of Care

12.5 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 Medical Management department should be contacted at 1-888-394-4327, Monday through Friday, between 8:00am and 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 Medical 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 Medical 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 coverage is not available in any Healthfirst plan except for emergency services or by referral by Healthfirst. Healthfirst members who opt to receive out-of-network services without authorization will be held liable for the cost of those services.

In the case of a Medicare member who was 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. 

Please refer to Appendix XI-A for a complete list of prior authorization guidelines for Healthfirst Medicaid, CHP, and Healthfirst Medicare Plans. Please refer to Appendix XI-B for a complete list of prior authorization guidelines for Healthfirst Leaf Plans.