NY Manual
SHP Manual

New York Provider Manual
5.6 Critical/Non-Critical Incident Management and Reporting Procedure | 6.2 Primary Care Panels and Member Enrollment Rosters

​6. Primary Care

6.1 Responsibilities of a Primary Care Provider (PCP)

All members enrolled in Healthfirst select a PCP at the time of enrollment. The PCP is responsible for managing and coordinating healthcare services provided to members, including primary and specialty care, hospital care, diagnostic testing, and therapeutic care. Healthfirst defines the following clinical specialty areas and practitioners as primary care providers. 

Physicians
Nurse Practitioners
<   Adolescent Medicine – GYN
<   Adolescent Medicine
<   Family Practice – GYN
<   Family Practice – OB/GYN
<   Family Practice – OB 
<   General Practice
<   Geriatrics (Medicare and Commercial only)
<   Infectious Disease (HIV Specialist PCP)
<   Internal Medicine
<   Pediatrics
<   Adolescent Medicine
<   Adolescent Medicine – GYN
<   Adult Health
<   College Health
<   Family Health
<   Pediatrics
<   Women’s Health

 

Healthfirst PCP’s are evaluated on an annual basis in areas of quality and satisfaction such as:

·     Wellness and Preventive care
·     Chronic Care Management
·     Enrollee Experience and Satisfaction with Care
·     Medication Adherence and High-Risk Medications

The ratings for each measure are combined to generate an overall quality rating for the provider. More information on this can be found in Section 14.6 of our Provider Manual.

PCPs are the first points of entry into the Healthfirst delivery system. PCPs also play essential clinical and oversight roles in managing the care of Healthfirst members. Healthfirst has identified the following scope of activities and responsibilities as key expectations for participating PCPs.

Access

For participation in the Medicaid or CHP programs, the PCP must practice at least two (2) days per week and maintain a minimum of 16 office hours per week at each primary care office site.

For participation in the Medicare and Commercial programs, the PCP must maintain a minimum of ten (10) office hours per week at each primary care office site.

Maintain 24-hours-a-day, 7-days-a-week access either directly or through arrangements with other Healthfirst providers for back-up coverage. See Section 3 for additional information on access and coverage requirements.

Clinical Care

Provide first-line primary, preventive, inpatient, and urgent care, or arrange for care, as appropriate, to manage conditions outside of the scope of primary care.

Identify Healthfirst members with complex or serious medical conditions—assessing those conditions through appropriate diagnostic procedures—and contact the Healthfirst Care Management staff to collaborate on treatment plans and follow-up.

Provide Healthfirst members with education on the appropriate use of healthcare services, personal health behavior, health risks, preventing STDs, preventing HIV/AIDS, and achieving and maintaining optimal physical and mental health.

Preventive Care

Provide or arrange for all appropriate screenings and preventive care, including immunizations and well-child visits; tuberculosis screening, diagnosis, and treatment; lead screening for children and appropriate dental care; HIV testing and counseling; mammography screening, colorectal cancer screening, cervical cancer screening, and HbA1c testing (Appendix VII).

Maintain compliance with established preventive care standards (Appendix VII-A) and clinical practice guidelines (Appendix XIII) adopted by Healthfirst.

Adhere to the New York State C/THP Guidelines (Appendix VII-B) and Guidelines for Adolescent Preventive Services (GAPS) (Appendix VII-C).

Participate in the Healthfirst Clinical Quality programs designed to improve care for members.

Behavioral Healthcare Screening

Healthfirst promotes the use of the Patient Health Questionnaire (PHQ-9) as a screening tool (Appendix VII-D) to assist its PCPs in identifying Healthfirst members with symptoms of depression who are appropriate candidates for referral to the Healthfirst Behavioral Care Unit or delegated organization. The PHQ-9 should be used at the baseline appointment, at the annual preventive care visit, and at any point where the member's condition indicates that a behavioral health issue may be present. A copy of the questionnaire should be kept in the member’s medical record. This tool is not intended to replace a complete mental health evaluation and assessment.

PCP's must obtain consent from a member before contacting a Healthfirst representative or behavioral health provider requesting that he/she attempt to contact the member to arrange for an evaluation of his/her needs regarding mental health or alcohol/substance abuse services.

Long Term Services and Supports (LTSS)

PCP’s may identify that their members require long-term services and support (LTSS). Some ways to identify this are:

  • If a member is over 21, already receives home care, adult day care or other home care services, and if they already have both Medicaid and Medicare 
  • If a member requests a Home Health Aid, Personal Care Assistant Services, or non-skilled needs with a deficit in their Activities of Daily Living
  • If a member is in need of Adult Day Care services
  • If a SNF member is receiving short term rehab or nursing care and is a candidate of returning to the community with home care
  • If a member has dementia, confusion, Alzheimer’s, psych conditions and/or other cognitive deficits with a deficit in their Activities of Daily Living
  • If a member requests a power wheelchair or a hospital bed with a deficit in their Activities of Daily Living
  • If a member has a fall history with a deficit in their Activities of Daily Living

Any members that meet these needs and are identified as having a need for LTSS, should be referred to the Healthfirst Care Management team or a participating LTSS Provider as classified in the online Healthfirst Provider directory.

Coordination of Care and Services

Coordinate primary and specialty care, ancillary services, and other covered healthcare services and collaborate with Healthfirst case managers and other providers involved in the member's care.

Arrange for behavioral health services through the Healthfirst Behavioral Care Unit or the member’s designated behavioral healthcare management organization.

Arrange for transportation services, as needed, to ensure that members are able to access healthcare services.

PCP’s as well as all members of the Interdisciplinary Team (IDT) of Healthfirst special needs plans, coordinate primary and specialty care, ancillary services, long term services and support (LTSS), and other covered healthcare services.

PCP’s as well as all members of the Interdisciplinary Team (IDT) of Healthfirst special needs plans, arrange for behavioral health services through the Healthfirst Behavioral Care Unit or the member’s designated behavioral healthcare management organization.

PCP’s as well as all members of the Interdisciplinary Team (IDT) of Healthfirst special needs plans, arrange for transportation services, as needed, to ensure that members are able to access healthcare services.

For Healthfirst Leaf Plan and Leaf Premier Plan members, primary care physicians are required to request referrals for most specialist services required by these members. Referral requests will be made through Emdeon on the Healthfirst Provider Portal. Refer to Section 12.3.

Administrative Responsibilities

Verify member eligibility at every visit by logging into the Healthfirst secure Provider Portal at www.healthfirst.org/providerservices or by calling Member Services at 1-866-463-6743 to ensure that members are still active and enrolled in Healthfirst.

Provide comprehensive, accurate, and reliable encounter data with CMS HCFA 1500 or UB-04 claim forms sent to Healthfirst on a timely basis.