NY Manual
SHP Manual

New York Provider Manual
3.1 Description of the Networks | 3.3 Fraud, Waste & Abuse

3.2 Provider Rights and Responsibilities

Provider Rights

Healthfirst will not discriminate against any healthcare professional acting within the scope of his/her license or certification under state law regarding participation in the network, reimbursement, or indemnification, solely on the basis of the practitioner’s license or certification. Nor will Healthfirst discriminate against healthcare professionals who serve high-risk members or who specialize in the treatment of costly conditions. Consistent with this policy, Healthfirst may differentiate among providers based on the following:

  • Healthfirst may refuse to grant participation status to healthcare professionals whom Healthfirst, at its sole discretion, deems not necessary or appropriate for its provider network
  • Healthfirst may use different reimbursement methodologies for different clinical specialties or for different hospital affiliations
  • Healthfirst may implement measures designed to maintain quality and control costs consistent with its responsibilities
  • Healthfirst providers will be given written notice of material changes in participation rules and requirements in this Provider Manual at least 30 days before the changes are implemented. These communications will generally be circulated in newsletters or special mailings.
  • Healthfirst will not prohibit or otherwise restrict a healthcare professional acting within the lawful scope of practice from advising or advocating on behalf of a Healthfirst member regarding the following:
  • The member’s health status, medical care, or treatment options, as well as any alternative treatments that may be self-administered (This includes providing sufficient information to the individual so that there is an opportunity to decide among all relevant treatment options.)
  • The risks, benefits, and consequences of treatment or non-treatment
  • The opportunity for the individual to refuse treatment and to express preferences about future treatment decisions

Provider Responsibilities

Healthfirst maintains provider agreements that incorporate provider and health plan responsibilities consistent with industry standards in compliance with New York State Managed Care Legislation and requirements for individuals and organizations receiving federal funds. The following requirements are applicable to Healthfirst participating providers.


Providers must provide care to all Healthfirst members and must not discriminate on the basis of the following:

•     Age

•     National Origin

•     Race

•     Disability

•     Sex

•     Economic, Social, or Religious Background

•     Sexual Orientation

•     Health Status

•     Claims Experience

•     Source of Payment

•     Legally Defined Handicap

•     Veteran Status

•     Marital Status

In addition, providers are required to be in compliance with Title VI of the Civil Rights Act of 1975, the Age Discrimination Act of 1975, the Americans with Disabilities Act (ADA), and other laws applicable to recipients of federal funds. The New York State Department of Health (NYSDOH) has adopted specific guidelines for ADA compliance by managed care organizations, including their affiliated provider networks. Healthfirst has developed a plan for achieving full compliance with these regulations and may request information from your practice as part of this program. The scope of the guidelines includes ensuring appropriate access to services through physical access to the site of care (wheelchair accessibility), access within the site (exam rooms, tables, and medical equipment), and access to appropriate assessment and communication tools that enable disabled individuals to receive needed services and to understand and participate in their care. For more information on compliance and guidelines of the Americans with Disabilities Act, click here and read through some answers to Commonly Asked Questions on the ADA.

Cultural Competence

Providers must ensure that services and information about treatment are provided in a manner consistent with the member’s ability to understand what is being communicated. Members of different racial, ethnic, and religious backgrounds, as well as individuals with disabilities, should receive information in a comprehensive manner that is responsive to their specific needs. If language barriers exist, a family member, friend, or healthcare professional who speaks the same language as the member may be used (at the member’s discretion) as a translator. In addition, the Healthfirst Member Services and Medical Management departments can provide assistance for members who do not speak English, either through their multilingual staff or by facilitating a connection with a telephone-based language interpretation service. It is essential that all efforts be made to ensure that the member understands diagnostic information and treatment options, and that language, cultural differences, or disabilities do not pose a barrier to communication.

Program Participation and Compliance

Healthfirst has developed Quality Improvement, Medical Management, and other programs to identify opportunities for improving the delivery of health services and their related outcomes. In addition, Healthfirst has operating agreements with Federal, State, and County governments that govern the terms of its participation in the Medicaid managed care, CHP, Healthfirst Leaf Plan, Leaf Premier Plan, and Medicare programs. Regulatory authorities periodically review Healthfirst operations and data reporting (i.e., complaints, enrollment, and financial information). Pursuant to their provider agreements with Healthfirst, participating providers are required to cooperate with Healthfirst to meet its regulatory responsibilities as well as comply with its internal programs to ensure compliance with contractual obligations. This applies to the policies set forth in this Provider Manual as well as to any new programs Healthfirst develops.

Healthfirst invites its providers to participate on committees that address medical management and quality improvement issues. Providers may sit on the Health Care Quality Council and its subcommittees, or they may provide expertise as provider consultants for peer review and specialty utilization management review. You may contact the Clinical Performance Management department to inquire about participation and refer to Section 14 of this Provider Manual for more information.

In addition, Healthfirst providers are responsible for supporting the member care components of the Member Rights and Responsibilities document found in Section 4 of this Provider Manual. It outlines member rights related to access to care, complete treatment information, privacy and confidentiality, non-discrimination, refusal of medical treatment, and other fundamental elements of the member’s relationship with Healthfirst. It is expected that providers will inform members under their care about specific healthcare needs requiring follow-up, and will teach members appropriate self-care and other measures to promote their own health. Further, providers must discuss potential treatment options, side effects, and management of symptoms (without regard to plan coverage).

Please note: The member has the final say in the course of action they will take about their health.

Release of Member Information

Medical information about Healthfirst members must be released to Healthfirst upon request and in compliance with the Confidentiality Policy detailed in Section 5.3 of this Provider Manual. Healthfirst will only release medical information to persons authorized by Healthfirst to receive such information for medical management, claims processing, or quality and regulatory reviews. Providers must also adhere to the appeals and expedited appeals procedures for Medicare members, including gathering and forwarding information on appeals to Healthfirst as necessary.


Providers must submit claims for reimbursement of services provided. These claims also serve as encounter data for services rendered under a capitation arrangement. Claims must be accurate and submitted according to the guidelines described in Section 16. Failure to comply with Healthfirst policies in this regard may result in nonpayment for services or termination from the Healthfirst provider network. See Section 2 for information on non-covered services. Providers should never bill Healthfirst members for covered services, except for any applicable deductible, coinsurance or copayment amount.

Provider Information

Providers are responsible for contacting Healthfirst to report any changes in their practice. It is essential that Healthfirst maintain an accurate provider database in order to ensure proper payment of claims and capitation, to comply with provider information reporting requirements mandated by governmental and regulatory authorities, and to provide the most up-to-date information on provider choices to our members. Any changes and updates to your provider record or participation with Healthfirst, including hospital affiliation, should be submitted at least 30 days before the effective date. Use our electronic Demographic Change Form, found on the Healthfirst Secure Provider Portal, to report to Healthfirst any changes to the list of items below. Changes can also be faxed to Healthfirst at 1-646-313-4634 / Attn: Demographic Update Request. These should be submitted with a fax cover sheet that includes full contact information, and a comprehensive request on the provider or group letterhead that includes the provider’s license number and identifies the practice record for update. Any supporting documentation (such as a W9 form or a Board Certificate) should be faxed with these requests.

•     Update in the provider or group name and Tax ID Number (W9 required)

•     Update in provider/group practice address, zip code, telephone or fax number (full practice information required)

•     Update in provider/group billing address (W9 required)

•     Update in the member age limits for service at the practice (if applicable)

•     Update in NY license, such as a new number, revocation, or suspension (new certificate or information on action required if applicable)

•     Closure of a provider panel (reason for panel closure)

•     Update in hospital affiliation (copy of current and active hospital privileges)

•     Update or addition of specialty (copy of board certificate or appropriate education information)

•     Update in practicing office hours (PCP’s need at least 16 hours)

•     Update in provider’s board eligibility/board certification status

•     Update in participation status

•     Update in NY Medicaid number (if applicable)

•     Update in National Provider Identification Number (if applicable)

•     Update in wheelchair accessibility

•     Update in covering provider

•     Update in languages spoken in the provider’s office