NY Manual
SHP Manual

SHP Provider Manual
3.5 Sample Service Plan Update Letter (Page 1) | 3.7 Covered, Coordinated and Non-Covered Services

3.6 Sample Service Plan Update Letter (Page 2)

You can file a complaint about your managed care at any time with the New York State Department of Health by calling 1-866-712-7197.
Clinical Services Department
cc:                   Requesting Provider
{Insert as applicable}[At your request, a copy of this notice has been sent to:
                        [Enrollee Representative(s)]
Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”). Coverage for Senior Health Partners, Managed Long-Term Care Plan, is provided by Healthfirst PHSP, Inc.

© 2018 HF Management Services, LLC   


<<SHP_29 01/2011>>

Home Health Care Determinations

Effective January 1, 2010, subdivision 3 of PHL 4903 was amended to change the timeframe for utilization review determinations of home health care following an inpatient hospital admission. Typically, the request for these home health care services following an inpatient stay is for skilled services and is reimbursable by Medicare.  

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 services. 

Senior Health Partners will furnish utilization review determinations of home health care services following a Medicare denial or exhaustion of a Medicare benefit following an inpatient hospital admission: i.e., in a general hospital that provides inpatient care or inpatient services in an Article 28 rehabilitation facility, as follows: 

     •   Within one business day of receipt of the necessary information OR

     •   Within 72 hours of receipt of the necessary information if the day after the request for services falls on a weekend or holiday 

If a request for home health care services and all necessary information is provided to Senior Health Partners prior to a member’s inpatient hospital discharge, Senior Health Partners will make arrangements to coordinate benefits with the Medicare plan. If no Medicare insurance plan is in place, Senior Health Partners shall not deny the home care coverage request on the basis of a lack of medical necessity or a lack of prior authorization while the determination is pending. 

An appeal of a denial for home healthcare services following a discharge from a hospital admission will be treated as an expedited appeal. 

Reports of Services Rendered

Providers are required to provide written reports to care managers following authorizations for service evaluations and after services provided to members. Payments may be deferred due to delays in receipt of required reports.