NY Manual
SHP Manual

New York Provider Manual
16.1 Payees | 16.3 Healthfirst Quality Incentive Program

16.2 Primary Care Services/Primary Care Providers

Healthfirst has established a set of healthcare services which Healthfirst considers to be Primary Care Services and which are to be rendered by Primary Care Providers (PCPs) within the Healthfirst provider network. These services support the member’s primary care needs in both an ambulatory (office or clinic) and an inpatient setting and include the following:

·     Early and periodic screening, diagnostic and treatment (EPSDT) services, including preventive office visits and immunizations
·     Primary care office visits for urgent conditions
·     Primary care inpatient visits
·     Basic hearing and vision screenings
·     Urgent laboratory services for diagnosis and/or treatment of members with acute conditions
·     Dual-energy X-ray absorptiometry, chest X-rays, and ultrasounds for the diagnosis and/or treatment of members with acute conditions
·     Other basic diagnostic tests and simple treatments of urgent and chronic conditions

A complete list of reimbursable services for primary care physicians is detailed in  Appendix XIV-B  and listed by CPT code.

Given the important role that PCPs play in the Healthfirst network and in providing primary care services to members, PCPs are not expected to provide specialty or other healthcare services which are not primary care services as described in this Provider Manual. As explained more fully in Section 3.1, PCPs are responsible for coordinating all of the care a member receives and are expected to refer members to in-network specialists for care that is outside the scope of primary care.

With regard to Healthfirst commercial ​Leaf Plan products and Leaf Premier Plan products, when a member needs elective care that a PCP or OB/GYN (women can choose either an OB/GYN or PCP) cannot generally provide within the scope of his/her practice, a referral to an in-network Leaf Plan or Leaf Premier Plan provider who can perform these services will be required. Consistent with this requirement, Healthfirst will not reimburse PCPs for services other than the listed primary care services unless the PCP is also credentialed and designated by Healthfirst as a specialist. Note, however, that family practice providers who provide minor surgery, obstetrical, or gynecological care for members will also be reimbursed for those services. 

Referrals are not required for the following services, among others: 

·     Emergency services
·     Primary and preventive obstetric and gynecological services (OB/GYN), including annual examinations
·     Care resulting from such annual examinations
·     Treatment of acute gynecological conditions, or for any care related to a pregnancy from a qualified contracted provider of such services

If you are not yet credentialed as a specialist and wish to be credentialed by Healthfirst as a Specialist in addition to being a PCP, please speak to your Network Representative or contact Healthfirst Provider Services at 1-888-801-1660 for assistance in the application process.

To also ensure that PCPs are able to coordinate member care, Healthfirst members seeking primary care from your clinic or practice that are not assigned to your member panel must be directed back to their assigned PCP for care or referred within their PCP’s own network, as appropriate. Claims submitted for primary care services rendered by a provider other than the member’s assigned PCP will be denied. These claims will be denied for “Intra-Network Primary Care – Not Member’s PCP.” Members, however, are free to change their PCP. If the member is in need of an appointment immediately and wishes to switch to your panel, Member Services can make the appropriate changes right away. Members should call Member Services at 1-866-463-6743 for assistance in switching PCPs.

PCPs may be reimbursed either through monthly capitation or on a fee-for-service basis, depending on the terms and conditions of their provider agreement with Healthfirst.

Regardless of whether reimbursement is via capitation or fee-for-service, all PCPs must submit claims for all services, including capitated services, in order to provide encounter data. Healthfirst uses encounter data to verify the types and level of services provided and for mandatory reporting to federal and state regulatory agencies. See Section 14 for reporting requirements.

For more information on payments to providers who receive a monthly capitation for each member on their panel, see Appendix XIV-B.