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Have questions about
claims or our network?


Our automated phone system is available:
24 hours a day 7 days a week

Live Phone Representatives are available:
Monday-Friday,
9:00 am to 5:00 pm
1-888-801-1660

New York Claims Submission Address:
P.O Box 958438
Lake Mary, FL 32795

New York Request for Review and Reconsideration:
P.O Box 958438
Lake Mary, FL 32795

Electronic Payor ID: 80141

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ATTENTION PROVIDERS

The Affordable Care Act, signed into law in 2010, requires that Medicaid payments be consistent with efficiency, economy, and quality of care, and that a minimum  amount is reimbursed for certain primary care services delivered by designated primary care physicians.  The specific primary care services defined in the Act include certain procedure codes for evaluation and management (E&M) services and certain vaccine administration codes.  Under this provision, effective January 1, 2013, managed care organizations are required to reimburse eligible Medicaid PCPs at least as much as the Medicare physician fee schedule (MPFS) rate in CYs 2013 and 2014.  The directive for payment at the Medicare rate extends to primary care services paid on a fee-for-service (FFS) basis, as well as to those paid on a capitated or other basis by Medicaid managed care plans.  In New York State, all providers who qualify for the increased payment amount in CYs 2013 and 2014, are maintained on a list located at http://www.health.ny.gov/health_care/medicaid/fees/.

As you are already aware, New York State and all Medicaid Managed Care plans throughout the state have been working together to develop and implement the methodology to pay eligible providers retroactive to January 1, 2013, and then process payments going forward until the expiration of the provision.  All plans are required to submit payment reports to New York State by October 25, 2013, and issue payments to providers in accordance with the State schedule, by January 31, 2014.

Healthfirst is currently in the process of identifying the claims eligible for the Medicaid Primary Care Rate Increase (PCRI) based on the New York State provider list and eligible procedure codes.  Our reimbursement methodology is outlined below:

Fee-for-Service Payments:

  • Healthfirst will identify all procedure codes submitted by eligible providers from dates of service rendered on January 1, 2013 through June 30, 2013. 
  • The Healthfirst contractual amount paid to the eligible provider will be compared to the greater of the 2013 Medicare Physician Fee Schedule or the 2009 Medicare CF.
  • The positive difference resulting from the above calculation will be the amount due to the provider.  Any negative values will be set to zero and will have no impact on the final total.
  • Reports will be submitted to New York State by October 25, 2013, and payments will be issued to providers in accordance with the State schedule, by January 31, 2014.                                                                                                                                                                                                                                                     

Capitated Payments:

  • Similar to FFS payments, Healthfirst will identify all procedure codes submitted by eligible providers from dates of service rendered on January 1, 2013 through June 30, 2013. 
  • Healthfirst will allocate a portion of primary care capitation to each eligible procedure code.
  • The portion of primary care capitation allocated to each eligible procedure code will be compared to the greater of the 2013 Medicare Physician Fee Schedule or the 2009 Medicare CF.
  • The positive difference resulting from the above calculation will be the amount due to the provider.  Any negative values will be set to zero and will have no impact on the enhanced payment.
  • Reports will be submitted to New York State by October 25, 2013, and payments will be issued to providers in accordance with the State schedule, by January 31, 2014.

If you have any questions about the Healthfirst payment methodology or our timeframe for implementation, please contact the Provider Services hotline at (888)801-1660.