FREQUENTLY ASKED QUESTIONS Healthfirst Leaf Plan Referrals

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1 1. How can referrals be generated for Healthfirst Leaf Plan members? Referrals can be created using the Emdeon system. Here is the website address for Emdeon Emdeon is a leading vendor of electronic real-time connections between healthcare professionals/facilities and health plans such as Healthfirst. Emdeon is already used by many of our providers to confirm member eligibility and submit claims/encounters for payment. Emdeon can now be used for generating referrals to specialist doctors for Healthfirst Leaf Plan members. 2. As a Healthfirst Leaf Plan provider, you may access the Emdeon Referral Request System one of three ways: Go directly to the Emdeon site at On the HF Provider Portal homepage, click on the Authorizations/Referrals link under the Tools section on the right side of the page. After clicking on the hyperlink, you will be directed to a tab where you can Create a New Referral and be directed to the Emdeon log in page. On the HF Provider Portal homepage, scroll over the header link Provider Inquiries and select Referrals from the drop down menu. You will then be directed to the landing page below announcing the partnership between Healthfirst and Emdeon to handle Referral requests. Click on the link indicated below to be re-directed to the Emdeon website for your Referral inquiry. 3. If I am not registered as a user of the Emdeon tools, how do I sign up for the Emdeon Provider Webconnect? At the Log In Screen: 1. Enter your User ID and Password. 2. Click Log In. 3. You will be directed to the Home Page. 4. If you do not yet have a User ID, click on Enroll New User and complete the Pre-Registration process Page 1 of 7

2 4. If I am registered as a current user of Emdeon Office how do I use it for Healthfirst Leaf Plan referrals? You can use Emdeon Office by selecting Healthfirst NY in the health plan drop down under the Service Review Tab and continuing to enter the rest of the information required in this tab. 5. What is the cost of using Emdeon Provider Webconnect? There is no cost to the provider for registering or using the Emdeon Provider Webconnect. This tool is FREE for our Healthfirst providers. Healthfirst also pays the costs of any transaction done on behalf of a Healthfirst member using Provider Webconnect. 6. What is the cost of using Emdeon Office? Emdeon Office is a software tool that can be installed on a provider s computer for a fee. The provider is responsible for the software installation cost and maintenance. Meanwhile Healthfirst pays for any transaction done on behalf of a Healthfirst member using Office. To find out more information on the cost of Emdeon Office you may call Emdeon at If I need assistance with Emdeon Provider Webconnect who can I call for technical help? You may call the Emdeon help desk at If I am locked out of my Emdeon system (Office or Webconnect) how can I get a reset done? You may call the Emdeon help desk at Can I use Emdeon Office or Provider Webconnect to check a member s eligibility? You can use the eligibility function to check a member s eligibility. It will confirm if the member is eligibility as of a certain date. Both the Provider Webconnect and Emdeon Office can be used for the eligibility check. We recommend that you use the Healthfirst Provider Portal for all eligibility verifications. 10. Where else can I get member eligibility and benefit information? A member s eligibility and benefit information can be reviewed by making a Member Eligibility Inquiry in the Payor services section of the Healthfirst Provider Portal at You can also call the Healthfirst Provider Services at , Monday through Friday, 9am-5pm Page 2 of 7

3 11. How do I find a participating Healthfirst Leaf Plan (QHP) specialist? The Emdeon Provider Webconnect has a link in the upper right hand of the screen. (See image below.) This link takes you to the real-time provider online search tool that identifies providers who participate in the Healthfirst Leaf Plan (QHP) network. Provider Directory Healthfirst Documentation The Healthfirst Website as well as the Provider Portal can also be used to find a participating Provider using the Find a Doctor Tool. 12. What Healthfirst Leaf plans require referrals? All Healthfirst Leaf plans (Platinum, Gold, Silver, Bronze and Green) require a referral for non-emergency evaluation and management (E&M) services. All E&M services except for those services rendered in an inpatient setting require a referral. Other treatment and diagnostic procedures and services may require a prior authorization. Refer to the applicable prior authorization list for procedure. Please refer to the Healthfirst Leaf Plan (QHP) Quick Reference Guide, for a listing of services that require prior authorization at What if an out-of-network (OON) provider is asking for a referral for the purposes of continuity of care? A referral cannot be done for an OON provider. Any request for consideration for elective OON services must be approved by Healthfirst. The provider will need to request an authorization for continuity of care. HF will request detailed medical information on the member, and the member needs to be in the midst of an active treatment plan for a specific condition or illness. Members who are not in active treatment at the time of the request will be assisted in finding a network provider for any anticipated care need. Continuity of care is not applicable for basic services which are available in our HF network such as laboratory, DME, supplies and radiology. Continuity of care is for situations where the member needs to complete an already started course of therapy or to obtain services that are not available in our network. 14. If a PCP and a specialist participate under the same tax ID or hospital or group, do they still have to request a referral for the member to see the specialist? 15. How can a specialist check the status of a referral or confirm whether the member has a referral from their PCP for the specialist visit? A specialist can verify if a referral was generated by checking in the Healthfirst Provider Portal, clicking on the Authorizations/Referrals link and entering in the information to search Page 3 of 7

4 16. Will a member have access to the confirmed referrals requested by their PCP? Yes, referrals will be visible in the Healthfirst member portal. A copy of the referral can be also be printed and handed to the member. 17. When is a referral needed for a member enrolled in a Healthfirst Leaf Plan? If a member needs to have an elective evaluation by a participating Healthfirst Leaf Plan specialist provider then a referral is needed. The referral is for the evaluation and management services during an office visit to the provider. The referral covers up to 6 visits for a six month period. Referrals are not required for the following: Urgent Care Emergency services Primary and preventive obstetric and gynecologic services (OB/GYN) including annual examinations Care resulting from such annual examinations Treatment of acute gynecologic conditions, or for any care related to a pregnancy from a qualified contracted Provider of such services Mental health and substance abuse practitioners Visits to any participating PCP or OB/GYN within the Member's network Emergency care Vision care services except when rendered by an ophthalmologist Ambulance services in medical emergencies Mammograms Medically necessary vaccines administered in any setting Radiology provider or radiology facility within the Member's network Covering providers, as long as they identify themselves as covering on the claim or have the same Federal Tax Identification Number or Provider ID Certain diabetic supplies (Note: All DME will require authorization.) Blood transfusions and Blood products Laboratory and pathology services performed at a participating Quest network lab or other participating laboratory provider. A lab slip or Doctor's order can be used to order the testing Services rendered by a Physician Extender who is employed by or works under supervision of the Member's PCP and/or OBGYN Delegated vendor authorization and referral rules apply for the following services: (Please refer to the delegated vendor policy for further guidance) Chiropractors (ASHN) Dentists (Dentaquest) Opticians (Davis) Page 4 of 7

5 18. Is the PCP giving out referral to Chiropractors, Dentists, and Opticians? Referrals for delegated vendors must be made through the delegated vendors following their referral policies. 19. If a member wishes to see a gynecologist for a regular or annual check-up is a referral required? No. 20. If a pregnant woman is receiving services from their Obstetrician, does it require a referral for every visit or one referral to cover all visits? A referral is not required for pregnancies. 21. What if a member s specialist needs to request that their patient visit another specialist? In instances, when the specialist is not the acting PCP, the PCP will have to refer the member. Specialists must coordinate with the PCP to generate a referral to the next specialist. 22. If a member is seeing a specialist for more than 6 visits, does this member require another referral from their PCP beyond the 6 visits for the same specialist? 23. If the referral has passed the 180 days, does the member require a new referral from their PCP beyond 180 days to the same specialist? 24. What if a specialist needs to do a procedure that does not require authorization, and is not an evaluation and management service, will the referral cover it? The provider can do diagnostic, surgical or treatment procedures in the office or clinic as long as it does not require an authorization. Referrals are for evaluation and management services. 25. Can a referral to one specific specialist provider in a practice be used by a member to see another provider in the same practice? A referral to see a specialist provider in a practice can be used by the member to see another provider in the same practice as long as they bill with the same TIN. For example a member who is referred to a cardiologist can see another cardiologist in the same practice (with the same TIN) using the same referral Page 5 of 7

6 26. Is a referral (or authorization) a guarantee of payment? Authorizations or referrals are not a guarantee of payment and any claim is subject to the deductible, copays and coinsurance under the terms of the member s Healthfirst Leaf Plan. The member must be eligible as of the date of service for a claim to be considered payable by Healthfirst. Please call Provider Services at for any questions about the status of a member s enrollment or about grace periods. 27. Does the PCP need to print out the referral and give it to the member to take as confirmation for their specialist visit? Can a specialist require a paper confirmation of the referral? A PCP can print a referral for a member and give it to the member. A Specialist can verify if a referral was issued by checking the Healthfirst Provider Portal. 28. Who can providers contact with general questions about referrals? Providers can contact their Healthfirst Network Management Representative or call Provider Services at telephone number for any questions. 29. Are referrals, service code/diagnosis code specific like authorizations? Yes, referrals do require a diagnosis code to be entered, and referrals are specific to the diagnoses listed in the request. If there is more than one diagnosis code then the primary diagnosis should be added. 30. Will specialists have access to the Emdeon system? No, the specialist will have access to the Healthfirst Provider Portal where they can verify referral status. 31. If there is a referral already submitted electronically, however the member no longer needs to see the specialist. Does the member or provider need to take any action? No, the referral will expire after 180 days. 32. If there is information on a referral needs to be corrected, can the provider update information via Emdeon system or does the provider need to submit a new referral? Once submitted, information on a referral cannot be corrected. The provider will need to submit a new referral. 33. What provider ID do I use for a referral transaction? Your Healthfirst provider ID# Page 6 of 7

7 34. Why do I need to use a Healthfirst Provider ID for a referral transaction? The Healthfirst Provider ID is a required field. When you do a search on the Healthfirst provider listing you will select providers who participate in our Leaf products and their Healthfirst ID# will specifically identify the specialty provider. 35. What member ID do I use for a referral transaction? The member ID# located on the member s Healthfirst insurance card. 36. How do I save the transaction information on a referral to my computer? See Emdeon Referral Tutorial that is posted in the Provider Portal. 37. What is a trace number? A trace number is a number generated by the Emdeon Webconnect system. It is considered as the Emdeon referral number. 38. Is a referral needed from a PCP to a Specialist practicing at the same site with the same TIN? 39. Can specialists enter referrals to other specialists? No. 40. Is there a limit to how many people can enroll as a new user on Emdeon for a specific TIN? No. 41. Is the Emdeon username/login for Healthfirst the same as the one a Provider uses for other plans using the Emdeon systems? Page 7 of 7