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 Healthfirst members 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, Child Health Plus, HARP, and Essential Plan 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, Qualified Health Plan and Commercial programs, the PCP must maintain a minimum of 10 (ten) office hours per week at each primary care office site.

Maintain access 24 hours a day, 7 days a week 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 Health 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 Health (BH) Care Management 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.

Before asking a Healthfirst representative or a behavioral health provider to try contacting a member to arrange for an evaluation of the member’s needs regarding mental health or alcohol/substance abuse services, a PCP must get the permission of the member in question to do so.

Healthfirst makes every effort to partner with providers to promote the integration of Behavioral Health and medical-service delivery to adults and children. To this end, primary care and other medical providers will be routinely engaged in dialogue with Healthfirst clinical management teams and are invited to participate in ongoing education, trainings and seminars, access to rapid consultation from child and adolescent psychiatrists, and referral and linkage to appropriate Behavioral Health providers for our most at-risk child, adolescent, and adult members.

Long-Term Services and Supports (LTSS)

• PCPs may identify that their members require long-term services and support (LTSS). Some ways to identify this are:If a member 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 Aide, 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 Health Care (ADHC) services

• If a SNF member is receiving short-term rehab or nursing care and is qualified to  return 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, with someone to direct their care in the community

• 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 history of falling and a deficit in their Activities of Daily Living

• Please note some programs require members to be over age 21

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 Health Care Management Unit or the member’s designated behavioral health care management organization.

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

PCPs, 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.

PCPs, as well as all members of the care planning team (some Healthfirst plans call this the Interdisciplinary Team (IDT)), arrange for behavioral health services through the Healthfirst Behavioral Care Management Unit or the member’s designated behavioral health care management organization.

PCPs, as well as all members of the care planning team (some Healthfirst plans call this the Interdisciplinary Team (IDT)), arrange for transportation services, as needed, to ensure that members are able to access healthcare services.

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.