NY Manual
SHP Manual

New York Provider Manual
12.1 Program Overview | 12.3 Authorization of Services

12.2 PCP-Directed Care

For Medicaid, Medicare, and CHP members, providers do not need to submit referrals to Healthfirst for approval when referring to participating providers in the Healthfirst network.

For members enrolled under the Healthfirst Leaf Plans, the PCP or OB/GYN provider must submit electronic referrals for all specialist visits. There are some exceptions to the referral requirements for Leaf Plan members. See subsection 12.3 for a list of referral requirements and exceptions.

However, there are no non-emergent, out-of-network benefits for any plan, and the provider must obtain approval from Healthfirst's Medical Management department if the provider wishes to refer a member to a nonparticipating provider. See subsection 12.5 on how to refer members out of network.

General Guidelines

The following guidelines may assist in ensuring referrals are appropriately managed:

Members should be referred to specialists who can best communicate with the member in accordance with the principles of cultural competence. This is to ensure optimal communication between providers and members of various racial, ethnic, and religious backgrounds, as well as disabled individuals. For example, members should be referred to specialists who speak the member’s language when the member does not speak or understand English. The Provider Directories provide data on languages spoken by the provider, as well as other relevant information. Or you may contact Medical Management for assistance.

Specialists may assume primary care responsibility for members with life-threatening, degenerative, or disabling conditions requiring prolonged specialty care services. In certain cases, it is more effective for a specialist or specialty care center to manage the full spectrum of care for a particular member. Under these circumstances, the member’s PCP should contact Medical Management to arrange for the member’s primary and specialty care services to be coordinated and managed by a designated specialty care provider with expertise in the member’s condition.

If possible, the PCP, OB/GYN, or the office staff should assist the member in making appointments with specialists and should provide directions to the specialist’s office. This is important for ensuring member compliance with specialty referrals and for obtaining prompt access to specialty services for members requiring urgent care. Medicaid members and certain Medicare members are entitled to transportation assistance. Please see Section 10 for additional details.

Ancillary Services

The PCP or specialty care provider may refer a member for ancillary services, such as laboratory or routine x-ray services, by filling out a prescription to order these services.

Prior authorization from Healthfirst-delegated entities including, but not limited to, radiology, dental, vision care is required. Refer to Section 10 and Appendix XI for additional information on this process. Please refer to Appendix XI-B for Leaf Plan provider authorization requirements.

Behavioral Health and Chemical Dependency Services

Members may self-refer to a participating Behavioral Health Specialist  for assessment or treatment of a mental health or substance use disorder. Healthfirst members may obtain assistance regarding behavioral health services by contacting the Behavioral Health Unit at 1-888-394-4327.

Authorization for routine in-network outpatient behavioral health services is not required. Please note that admissions and the following outpatient services: ECT, neuropsychological testing, partial hospital program, intensive outpatient treatment, and day treatment, are subject to utilization and medical-necessity review to ensure that the most appropriate treatment and level of care is being provided. Authorization from the Healthfirst Behavioral Health Unit or the delegated behavioral care management organization is required.

Obstetrical Services

Healthfirst does not require female members to obtain referrals before accessing routine gynecological care. In accordance with NYS prenatal care regulations (10 NYCRR Part 85.40), Healthfirst provides comprehensive prenatal care services to its members, including but not limited to prenatal risk assessment, health education, mental health and related social services, labor and delivery, and post-partum care.

During pregnancy, the obstetrician assumes the responsibility for coordinating and managing the member’s care. The OB/GYN may treat and/or make specialty referrals for any medical conditions arising during pregnancy without referring the member back to her PCP; however, if illness or injury occurs that is unrelated to the pregnancy, the OB/GYN should refer the member to her PCP for further evaluation and treatment. In addition, when caring for a high-risk pregnant member, the provider should register the member in the Obstetric Care Management Program by calling the Obstetric Care Manager at 1-888-394-4327.