NY Manual
SHP Manual

New York Provider Manual
3.6 Credentialing, Recredentialing Requirements & Provisional Credentialing | 3.8 Termination of Provider Agreements

3.7 Provider Profiling

Healthfirst monitors the performance of its provider network to ensure the quality and appropriate use of healthcare services and to identify opportunities for provider improvement and the management of medical costs. Healthfirst has developed criteria and methodologies to collect and analyze profiling data to evaluate a provider’s practice patterns and performance. Areas evaluated include but are not limited to billing and coding patterns; inpatient, outpatient, ancillary, and pharmacy utilization trends; and specialty costs.

All providers are measured against an appropriate group of healthcare providers using similar treatment modalities and servicing a comparable member population. On a periodic basis and upon the request of a provider, Healthfirst will provide a copy of the provider profile, data, and analysis used to evaluate the requesting provider’s performance. Providers shall be afforded the opportunity to meet with Healthfirst to discuss the information reported in the provider profile and the unique nature of the provider’s member population, which may have a bearing on the provider’s profile. Providers will also be afforded the opportunity to work cooperatively with Healthfirst to improve performance.

All provider profiling evaluations comply with Section 4406 D(4) of the New York State Public Health Law.