NY Manual
SHP Manual

SHP Provider Manual
4.3 Provider Credentialing and Recredentialing | 4.5 Provider Non-Disclosure and Confidentiality

4.4 Provider Rights and Responsibilities and Dual Eligible Members

Provider Rights

Senior Health Partners’ participating providers can act within the lawful scope of their license to advise or advocate for members, and possess external appeal rights as follows: 

  1. Health Status or Plan of Care options (including sufficient information to enable the member to decide among various care plan options);
  2. Filing a complaint or making a report or comment to an appropriate governmental body regarding Senior Health Partners’ policies if the provider believes that the policies  negatively impact the quality of care or access to care; and
  3. Effective January 1, 2010, Public Health Law 4914 was amended to extend external appeal rights to providers in connection with concurrent adverse determinations (See Manual Section 5-7.)  

Provider Responsibilities 

Senior Health Partners’ participating providers’ responsibilities include, but not limited to:

a)      Provide quality care

  1. Provide care within scope of practice (as defined by Senior Health Partners) and in accordance with Senior Health Partners access, quality and participation standards.

  2. Adhere to Senior Health Partners’ clinical guidelines (see section 1.3 Provider Agreement).

  3. Provide optimal care to members without regard to age, race, sex, religious background, national origin, and disability, and sexual orientation, source of payment,  veteran status, claims experience, social status, health status, or marital status.

  4. Comply with the Americans with Disabilities Act (ADA) guidelines set forth by the New York Department of Health, e.g., Wheelchair access.  

Dual Eligible Members

If a service is Medicare qualified, it is the provider’s responsibility to determine if the member is Medicare eligible. If the member is Medicare eligible and the service is Medicare qualified, the Provider must bill Medicare and Senior Health Partners will be responsible for the co-pay of covered service.  

Senior Health Partners’ Responsibilities to Providers

Senior Health Partners recognizes its obligation to assure participating providers the following:

a)            Comprehensive plan training and orientation programs

b)            Timely and ongoing communication from knowledgeable staff

c)            Timely payment for covered services rendered to members

d)            Timely responses to questions or concerns

e)            Assistance with complex member issues

f)             Timely resolution of grievances and appeals

g)           Constructive feedback on performance and utilization