NY Manual
SHP Manual

New York Provider Manual
12.2 PCP-Directed Care | 12.4 Authorization of Services

12.3 Referrals for Leaf Plans

When a Healthfirst Leaf Plan 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 is required for the member to be evaluated by a contracted specialist provider in our commercial network. 

Referrals from the health plan are not required for the following services: 

·     Emergency services
·     Contracted urgent care centers
·     Obstetric and gynecologic services (OB/GYN) including preventive care, acute gynecologic care, and pregnancy care
·     Mental health and substance abuse practitioners
·     Delegated vendor authorization and referral rules apply for the following services:
·     Chiropractic (ASHN)
·     Dental (DentaQuest)
·     Vision, including Optometrists and Opticians (Davis)

Please refer to Section 10 — Ancillary and Other Special Services for additional information on our ancillary service providers.

The member’s assigned PCP is responsible for generating any referrals for the member. If the PCP is not available, the PCP’s designated covering physician should generate a referral for the member.

If the member has a specialist provider acting as the member’s PCP, then that specialist physician can generate a referral for the member. Please see the Healthfirst Provider Manual for how a specialist physician can request designation as a PCP.

All evaluation and management services by the specialist provider, except for those services rendered in an inpatient setting, require a referral. Other treatment and diagnostic procedures and services may require a prior authorization. The service will be reviewed for medical necessity. Once the review is completed, the provider and the member will be notified of a decision.  Please refer to Appendix XI for the preauthorization guidelines for Leaf Plans.

Any eligible service under the Commercial benefits are subject to the member’s eligibility on the date(s) of the service and any conditions, terms, and/or limitations under their Summary of Benefits.  Any referrals will be subjected to copay, coinsurance, deductible, etc.

Before receiving a referral, it is recommended that the member see their PCP. We encourage our PCPs and other providers to make sure they have all the necessary information they need about the current clinical status of a member, as well as any needed past medical history, to make sure the referral is appropriate and medically necessary for the member. This may require examination of the member and other diagnostic procedures prior to making a referral. At the provider’s discretion, they can generate a referral without seeing the member while using appropriate medical judgment on the situation.

Referrals should be generated prior to the service being rendered. In case of an urgent situation or business administrative emergency that does not allow for prior processing of a referral action, a referral can be generated for up to three (3) business days after the service was rendered. Healthfirst reserves the right to question the referring provider about the reason for any retroactive referrals. Referred providers are subject to their scope of reimbursement under their current contract with Healthfirst. Provider and member self-referrals are not allowed.

Referrals cannot be issued by the PCP or OBGYN for out-of-network or out-of-area providers. Requests for elective services from out-of-network/out-of-area providers will require review and authorization from Healthfirst Medical Management.