NY Manual
SHP Manual

New York Provider Manual
4.6 Member Services and Education | 5.2 Medical Record Reviews and Documentation Standards

5. Regulatory and Reporting Requirements

5.1 Reporting Requirements

Healthfirst is required to report to federal, New York City, and New York State regulatory authorities on a variety of data elements, including financial, clinical, and quality-related indicators. In order to maintain compliance with these requirements, Healthfirst relies upon its provider network to supply it with comprehensive, accurate, and timely information. Healthfirst expects its participating providers to follow all public health and regulatory guidelines related to the reporting of communicable diseases, the delivery of preventive care services, lead screening, procedure consents (e.g., sterilization/hysterectomy), child abuse and domestic violence, and any other required data sets. Please refer to Section 14 for more information.

Fraud, Waste & Abuse Hotline

If you suspect fraud, waste, or abuse by a Healthfirst member, by another provider, or by Healthfirst itself, please call our Compliance Hotline at 1-877-879-9137, which allows anonymous reporting and is staffed 24/7, or visit www.hfcompliance.ethicspoint.com. Fraud is broadly defined as intentional deception, or misrepresentation an individual knows to be false or does not believe to be true and makes regardless, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person.

Examples of fraud, waste, and abuse include:

·     Submitting inaccurate claims
·     Billing for services that were not provided
·     Accepting inducements to utilize or refrain from utilizing a service
·     Using another person’s Healthfirst Identification Card
·     Failing to comply with Healthfirst policies