NY Manual
SHP Manual

New York Provider Manual
6.2 Primary Care Panels and Member Enrollment Rosters | 7.1 Definition of Services

6.3 Preventive Care Standards

Healthfirst provides its members with access to routine and preventive healthcare services; these services are provided and/or coordinated by the member’s PCP. Direct access to a women’s health specialist is provided within the network for routine and preventive women’s healthcare services. Adult routine physicals and screenings are recommended according to age and risk factors.

Please note: Healthfirst Medicare Plan members do not require a referral to obtain an influenza or pneumococcal vaccine. Additionally, there is no copayment for administering the influenza or pneumonia vaccine.

Providers wishing to file claims for vaccinations under Part D MUST submit these claims through the TransactRx Vaccine Manager at www.TransactRx.com. The TransactRx Vaccine Manager is a website that gives providers the ability to process the Part D vaccine and/or the administrative fee electronically. Member obligation is calculated in a matter of seconds, and assures that you have the member TrOOP (true out-of-pocket cost) at the point of service. There is no cost to providers to process claims through Vaccine Manager.

 

Healthfirst expects participating PCPs to adhere to established preventive care standards and schedules in effect in New York State. These include New York State Vaccines for Children Program (VFC), which supplies selected vaccines to providers caring for Healthfirst PHSP members at no cost. In addition, providers may order vaccines for Medicaid and CHPlus members at no cost through the VFC program.

For additional information on the VFC or Immunization Program or to order vaccines for Healthfirst Medicaid CHPlus members, call:

·     New York State Department of Health Bureau of Immunization: 1-518-473-4437
·     New York City Department of Health and Mental Hygiene Immunization Hotline: 1-347-396-2400
·     New York State Vaccines for Children Program: 1-800-KIDSHOT (1-800-543-7468)

To encourage compliance with timely and appropriate preventive care, Healthfirst has developed The Healthfirst Quality Incentive Program (HQIP) for (Section 16.3) Healthfirst providers. Under this program, eligible PCPs caring for Medicaid, CHP, BHP, QHP, Medicare, Complete Care, and FIDA members can receive additional compensation for their efforts in promoting and documenting the provision of selected preventive care services.

Additionally, Healthfirst provides preventive care screenings and immunization guidelines (Appendix VII) for the pediatric population.

USPSTF Recommendations for Children and Adolescents

The health needs of children and adolescents differ from those of adults. In particular, preventive health care for children must consider the "sensitive" windows during which the course of growth and development may be influenced, and the long span of time over which health outcomes will be affected. The U.S. Preventive Services Task Force (USPSTF) makes evidence-based recommendations for children and adolescents, develops new approaches to assess evidence on child health, and convenes a workgroup dedicated to child health. The USPSTF recommendations about clinical preventive services, including screenings, counseling, and preventive medications for children and adolescents are located at: www.uspreventiveservicestaskforce.org/Page/Name/focus-on-children-and-adolescents#uspstf-recommendations-for-children-and-adolescents

Depression

Prevention is a key in quality clinical care provided to our members. Mental health diagnoses have historically been and continue to be included in the Healthfirst top ten (10) inpatient and outpatient diagnoses. It is extremely important to ensure that our members receive evaluations and get help as soon as possible if they have any symptoms of depression. It is a requirement for Healthfirst providers to include this information in the member’s chart and to refer the member to an appropriate mental health professional, if necessary.

If a member is given a prescription for any antidepressant medication, he/she should be given an appointment to return to their PCP every four (4) weeks for a minimum of three (3) visits within 84 days of receiving the prescription and then return for follow-up visits every three (3) months for at least one (1) year.