NY Manual
SHP Manual

New York Provider Manual
14.1 Overview and Philosophy | 14.3 Clinical Practice Guidelines

14.2 Reporting Requirements and Quality Programs

Healthfirst is required to report to federal, New York State, and New York City regulatory authorities on a variety of data elements, including clinical studies 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 also 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, procedure consents (e.g., sterilization/hysterectomy), child abuse and domestic violence, and any other required data sets. 

This section of the Provider Manual describes the range of regulatory reporting requirements and provider data requirements mandated by CMS, the NYSDOH, the NYC DOHMH, and Healthfirst. It also describes the Quality Program’s tools, support, and educational initiatives that Healthfirst has implemented to help providers meet and satisfy these regulatory requirements.

Risk Adjustment: Member Diagnosis Information and Coding Requirements

Medicare, NYS-Medicaid, and Health Exchange Programs utilize ICD-9-CM as the official diagnosis code set for each respective risk-adjustment model. Accordingly, ICD-9 diagnosis codes are required in the determination of risk-adjustment factors. Accurate and appropriate ICD-9 codes must be submitted for each beneficiary. As of 10/1/2015, ICD-9 codes will no longer be accepted by Healthfirst and will be replaced with the ICD-10 code set.

Coding and Medical Record Documentation:

·     As a standard policy, Medicare, Health Exchange, and NYS-Medicaid programs require accuracy and specificity in diagnostic coding
·     Use current ICD-9-CM diagnostic coding conventions through 9/30/2015 and ICD-10 coding conventions beginning 10/1/2015
·     Ensure office staff is up to date on the basics of ICD-9-CM and ICD-10 coding
·     Code in the highest level of specificity known
·     Clinical specificity of a disease/condition can be expressed through the fourth (4th) and/or fifth (5th) digit of some ICD-9CM diagnostic codes (ending 9/30/2015)

·    Clinical specificity of a disease/condition can be expressed through the fourth (4th), fifth (5th), sixth (6th), and/or 7th (seventh) digit of some ICD-10CM diagnostic codes(beginning 10/1/2015)

·    Specificity of coding is based on the accuracy of information written in the medical records
·     Medical records are the source of all codes
·     Verify that codes are supported by the medical record
·     All claims submitted that do not have the appropriate fourth (4th) and/or fifth (5th) digit in the ICD-9CM diagnostic codes will be denied by Healthfirst

 Guidelines when managing medical records:

·     As per provider and member agreement with Healthfirst, access to medical records must be available for verification of diagnosis (please refer to your agreement)
·     Include the member’s identification on each page of the medical record and date of service.  Include the signature of the person(s) doing the treatment, reason for the visit, care rendered, conclusion and diagnosis, and follow-up care plan in all medical records
·     Documentation in the medical record of encounters with members must include all conditions and comorbidities being treated and managed
·     Include the provider’s credentials on the medical record, either next to his/her signature or preprinted with the provider’s name on the practice’s letterhead
·     Report and submit all diagnoses that impact the member’s evaluation, care and treatment; reason for the visit; co-existing acute conditions; chronic conditions or relevant past conditions
·     Medical records must reflect the codes submitted
·     For more information on Medicare program: www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/
·     For more information on Medicaid program: www.health.state.ny.us
·     For more information on the Health Exchange program:  www.hhs.gov/
·     For more information on ICD-9-CM: www.cdc.gov/nchs/icd.htm 
·     For more information on ICD-10-CM:  www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10

Quality Assurance Reporting Requirements (QARR)

QARR are a series of measures designed to examine managed care plan performance in several key areas. These measures are largely adopted from the NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®), with additional New York State–specific measures added to address public health issues of particular significance in New York. 

HEDIS consists of eighty-three (83) measures and QARR has three (3) NYS-specific measures across five (5) domains of care. Highlights of the four (4) domains from HEDIS/QARR that are greatly impacted by the performance of a Plan’s participating providers are presented here.

of Care
<   Adult BMI Assessment
<   Weight Assessment & Counseling for Nutrition & Physical Activity for Children /Adolescents
<   Childhood Immunization Status
<   Immunizations for Adolescents
<   Human Papilloma Vaccine for Female Adolescents
<   Lead Screening in Children
<   Adolescent Preventive Care
<   Breast Cancer Screening
<   Cervical Cancer Screening
<   Non-Recommended Cervical Cancer Screening in Adolescent Females
<   Chlamydia Screening in Women
<   Colorectal Cancer Screening
<   Non-Recommended PSA-Based Screening in Older Men
<   Care for Older Adults
<   Appropriate Testing for Children with Pharyngitis
<   Appropriate Testing for Children with Upper Respiratory Infection
<   Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
<   Use of Spirometry Testing in the Assessment & Diagnosis of COPD
<   Pharmacotherapy Management of COPD Exacerbation
<   Use of Appropriate Medications for People with Asthma
<   Medication Management for People with Asthma
<   Asthma Medication Ratio
<   Cholesterol Management for Members with Cardiovascular Conditions
<   Controlling High Blood Pressure
<   Persistence of Beta-Blocker Treatment After a Heart Attack
<   Comprehensive Diabetes Care
<   HIV/AIDS Comprehensive Care
<   Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
<   Osteoporosis Management in Women who had a Fracture
<   Use of Imaging Studies for Low Back Pain
<   Antidepressant Medication Management
<   Follow-up Care for Children Prescribed ADHD Medication
<   Follow-Up After Hospitalization for Mental Illness
<   Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are using 
      Antipsychotic Medications
<   Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia
<   Use of Multiple Concurrent Antipsychotics in Children and Adolescents
<   Metabolic Monitoring for Children and Adolescents on Antipsychotics
<   Medication Reconciliation Post-Discharge
<   Potentially Harmful Drug-Disease Interactions in the Elderly
<   Use of High-Risk Medications in the Elderly
Access &
of Care
<   Adults’ Access to Preventive/Ambulatory Health Services
<   Children and Adolescents’ Access to Primary Care Practitioners
<   Prenatal and Postpartum Care
<   Annual Dental Visit
<   Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
<   Call Answer Timeliness
<   Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
of Care
<   CAHPS Health Plan Survey 5.0H, Adult Version
<   CAHPS Health Plan Survey 5.0H, Child Version
<   Children with Chronic Conditions
Utilization & Relative Resource Use
<   Frequency of Ongoing Prenatal Care
<   Well-Child Visits in the First 15 Months of Life
<   Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life
<   Adolescent Well-Care Visits
<   Frequency of Selected Procedures
<   Ambulatory Care
<   Inpatient Utilization – General Hospital/Acute Care
<   Identification of Alcohol and Other Drug Services
<   Mental Health Utilization
<   Plan All-Cause Readmissions
<   Antibiotic Utilization
<   Relative Resource Use for People with Diabetes
<   Relative Resource Use for People with Cardiovascular Conditions
<   Relative Resource Use for People with Hypertension
<   Relative Resource Use for People with COPD
<   Relative Resource Use for People with Asthma

Performance in the HEDIS/QARR data sets is one (1) of the core indicators on which Healthfirst plan-wide quality improvement efforts have been focused. It is extremely important to note the following:

HEDIS/QARR measures are primarily based on preventive health standards and clinical practice guidelines issued by expert panels and community respected organizations such as the American Academy of Pediatrics (AAP), U.S. Preventive Services Task Force (USPSTF), National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), American Diabetes Association (ADA), American College of Obstetrics and Gynecology (ACOG), and the American College of Cardiology (ACC).

HEDIS/QARR requires specific technical specifications on how data is reported for each measure (see Appendix XVI).

Documentation is key – starting from the medical records (members’ charts) to the business office submission of encounter and claims data. There are measures such as well-child visits in the Medicaid product that can only be reported through claims and encounter data, but only if the appropriate coding and timing of service was submitted to the plan.

To assist providers, the Clinical Performance Management department will periodically prepare and forward listings of members to the appropriate providers indicating services that were not reflected on the encounter and claims data submitted. Providers are asked to review their records to see whether these services were rendered but not reported to Healthfirst. If the services were rendered, providers are asked to submit the claims/encounter data to Healthfirst as soon as they are identified. If they were not but would be beneficial to the member, the provider is asked to reach out to the member to offer the service. Staff from the Clinical Performance Management department will work with providers closely to monitor provider specific initiatives and performance rates.


Provider Network Reports

On a quarterly basis, Healthfirst submits its Health Provider Network (HPN) report to the State, listing all participating providers. This submission includes provider license numbers, Medicaid provider numbers, office locations and hours, provider types and specialties, etc. Healthfirst must attest to the accuracy of this provider information with a notarized affidavit. It is imperative that the information you give us about your practice— such as office address and office hours, your credentials and license/provider numbers—be accurate at the time and be updated promptly whenever there is a change. To submit any change in your information, fill out the Demographic Change Form on our website at www.healthfirst.org or call Provider Services at 1-888-801-1660.

Reporting Requirements for the New York State Cancer Registry (NYSCR)

The Cancer Research Improvement Act of 1997 amended section 2401 of the Public Health Law. Under this law, all managed care organizations certified pursuant to Article 44 are required to report cancer cases to the NYSCR. A prescribed list of data elements to track cancer incidence has been developed. Data is collected from the encounter forms submitted to Healthfirst by providers. Healthfirst providers must submit encounter forms to document services rendered and may be requested to forward additional information to support the reporting requirements of the NYSCR.

Public Health and Communicable Disease Reporting

Public health law requires that confirmed diagnoses of specific communicable diseases must be reported to the NYSDOH. Diseases relating to the potential for bioterrorism attacks are included on the mandatory reporting list. For a copy of the complete set of mandatory reporting lists, please refer to Appendix XV, check the NYSDOH website at www.health.ny.gov/professionals/diseases/reporting/communicable, or call the NYSDOH at 1-518-474-0548.

In addition to providers, all laboratories must submit a report to the NYSDOH when a communicable disease is identified. However, even though a laboratory may report the disease, providers are also required to submit a report once the diagnosis is confirmed.

Reports may be submitted by mail, fax, or telephone, and specific forms must be used in certain cases. If you file a report by telephone, please remember to document this in the member’s medical record, being sure to include the date reported, the telephone number, and the name of the person taking the report. The following telephone list contains important numbers for you to have available to report communicable and other reportable diseases. 

Telephone Guide for Communicable and Reportable Diseases
New York City
NYC AIDS Reporting
NYC Communicable Disease Bureau
Lead Poisoning
Sexually Transmitted Diseases
Nassau County
Communicable Disease Control
Suffolk County          
Bureau of Epidemiology & Disease Control

Additional Information Regarding Public Health Reporting

Providers must cooperate with local department of health efforts to address and identify community health problems and gaps in service.


HIV/AIDS Comprehensive Care

Report new cases of HIV infection and HIV illnesses, along with AIDS cases, to the NYC DOHMH on a timely basis. Cases of HIV infection, HIV-related illness, and AIDS are reportable by telephone to

Please ensure that HIV-positive Healthfirst members receive necessary preventive care services and that appropriate documentation is found in the member’s medical records

Encounter data/claims should contain the following appropriate coding:


Two outpatient visits for primary care or HIV related care - 1 in the first 6 months of the year; 1 in the second 6 months of the year (ages 2 years and older)

CPT-4: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429 ICD-9 Diagnosis: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Two viral load tests - 1 in the first 6 months of the year; 1 in the second 6 months of the year  (ages 2 years and older)
CPT-4: 87534-87536, 87537-87539
One syphilis test (age 19 and older only)
CPT-4: 86592-86593, 86780

If your patient does not have private health insurance or Medicaid, he/she can get HIV care and medication from the AIDS Drug Assistance Program (ADAP) at no cost. For more information, call 1-800-542-2437

The HIV/AIDS practice guidelines are downloadable at www.hivguidelines.org/clinical-guidelines/. For additional information, visit www.health.state.ny.us/diseases/aids/index.htm

Encourage members to get tested for HIV infection, especially populations at risk, such as drug users, homosexual males, bisexual males/females, sexually active teenagers, etc. 

Provide members with the toll-free numbers 1-800-541-AIDS (1-800-541-2437) and 1-800-233-SIDA (Spanish) for HIV testing and counseling 

Today’s test technologies afford individuals the ability to receive an HIV test result in a single visit. If your office or organization offers HIV counseling and testing and has not yet adopted rapid testing, you should consider doing so.

Detailed guidance for implementing rapid testing for HIV is available at www.health.ny.gov/diseases/aids/testing/#rapid. 

Sexually Transmitted Diseases (STDs)

Disease surveillance indicates that over fifty (50) percent of all infections reported on a national level are sexually transmitted. STDs represent the most commonly reported infectious diseases among sexually active adolescents. It is extremely important that both the healthcare provider and the health plan from which a young person may seek help and advice regarding these diseases are sensitive to the issues and challenges that face this population. Suggestions to improve performance:

·     Be sure encounter data/claims contain appropriate coding
·     Encourage members to get tested for STDs, especially members of high-risk populations and populations at risk, such as drug users, homosexual males, bisexual males/females, sexually active teenagers, etc. For additional information, visit www.health.state.ny.us/diseases/communicable/std/index.htm
·     Provide members with the following STD hotlines for information and testing sites:   

o     CDC National STD Hotline: 1-800-227-8922

o     NYS Department of Health STD Education Office: 1-212-427-5120

o     NYS HIV/AIDS Hotline: 1-800-541-AIDS (1-800-541-2437) 

·     Remind Healthfirst members that confidential STD services are available at the NYCDOH clinics for non-Healthfirst sexual and needle sharing partners for no charge
·     Document all care and services rendered in the member’s chart and submit claims and encounter forms using the above appropriate codes

Tuberculosis (TB) Control

Healthfirst has adopted the clinical practice guidelines for the diagnosis and treatment of tuberculosis from the Clinical Policies and Protocols Manual, Bureau of Tuberculosis Control, New York City Department of Health, Third Edition, June 1999; Updated Fall, 2006. All Healthfirst providers should use these guidelines in the care and treatment of Healthfirst members with TB. These guidelines contain important information about counseling TB members and their families and about household precautions that are necessary to avoid spreading the disease.

A copy of these guidelines can be ordered from the NYC DOHMH Bureau of Tuberculosis Control by calling 1-212-788-4162. Directly Observed Treatment (DOT) programs are available at various locations throughout New York City, and referrals can be made for members who are not compliant with their medication regimen or do not keep follow-up visits. To enroll/refer a Healthfirst member to the DOT program, call 311.

The New York City health code mandates the reporting of children aged younger than five (5) years with a positive tuberculin skin test (TST) to the Department of Health and Mental Hygiene. Medical providers and infection control practitioners are now required to report on these children, in accordance with Article 11. Treatment for latent TB infection is recommended in all children as soon as active TB is ruled out. For all DOH-reported cases, children younger than five (5) years are assigned a Case Manager to follow up on their evaluation and treatment. 

Child Abuse and Domestic Violence

It is important that providers and their staff be alert to potential cases of child abuse, domestic violence, and adult and elder abuse. An assessment screening is recommended for all new members during annual follow-ups and when child abuse/domestic violence is suspected (including in same-sex relationships). Reporting of child abuse or maltreatment is mandatory for all healthcare professionals. The Injury Prevention Program (TIPP) can be used as a reference guide to help prevent/minimize injury and violence. Your local department of health is also a resource for additional information and referral resources for domestic violence and abuse. The telephone numbers listed below provide resources for information and reporting of child abuse and domestic violence:

·     New York State Child Abuse or Maltreatment Registry: 1-800-635-1522
·     General Information on Child Abuse: 1-877-543-7692
·     General Information on Domestic Violence: 1-800-942-6906
·     General Information on Social Services: 1-800-342-3009

Hepatitis B Screening

All pregnant women must be screened for Hepatitis B, with a follow-up vaccination when indicated. If applicable, infants and close contacts of the women must also be tested. Members with positive Hepatitis B findings must be reported to the local department of health.

Smoking Cessation

Tobacco has been linked to lung cancer and other deadly chronic diseases. We urge providers to help your members fight tobacco addiction as part of your standard of care rendered to your members. For every member at every clinic visit, the healthcare provider should:

·     Identify whether a member is a smoker
·     Document smoker status in the member’s chart as a vital sign 
·     Provide smoking cessation resources, such as:
o     NY State Smoker’s Quitline – 1-866-NY-QUITS or 1-866-697-8487
o     Smoking Cessation Centers – for a list of smoking cessation centers in NYC and Long Island, visit www.healthfirst.org, www.nysmokefree.com, https://a816-nycquits.nyc.gov/pages/homepage.aspx, and www.cdc.gov/tobacco/how2quit.htm
·     Treat by introducing pharmacological counseling therapies 

Healthfirst Medicaid programs provide smoking cessation counseling coverage for eligible members. Nonprescription medications must have “over the counter” written on the order. Healthcare providers can call the NY State Quitline to obtain concise, up-to-date information on stop-smoking techniques and medications, or to order office materials that can be shared with their members


Member Incentive Program

Through Healthfirst’s Health Promotion Programs, members may be entitled to the following incentives:

  • The Healthfirst Wellness Reward Card Program is a way for Healthfirst members to earn rewards for taking care of themselves:
    The program is available to Healthfirst Medicaid, Child Health Plus and Medicare members.  Members can qualify for reward cards by completing selected preventive screenings and  health initiatives, such as well child visits, completion of health risk assessments, mammograms, medication adherence and colorectal screenings. Reward card forms can be found on  the Provider Portal, at http://healthfirst.org/providers/.  Members can fill out a form and mail or fax the form back to Healthfirst. Providers must submit the correct claims in order for the  members to be approved for a reward card.

    Free car service – Available to qualified Medicaid members who need prenatal and/or post-partum visits, well-child visits, and immunizations within the required time frames. Members should contact Member Services at 1-866-463-6743 to arrange for their free transportation