Provider Toolkit

Use our provider portal to submit authorization requests and to check the status of existing authorizations.
Login to Provider Portal
How to Obtain Authorizations on the Portal
Medicare Prior Authorization Requirements

Welcome From Provider Relations

Orientation Training 

• Medicare
• Managed Long Term Care (MLTC) 

The Provider Orientation Training presentations contain an introductory overview of all our health plans. The presentations feature a brief overview of benefits, eligibility, and goals for each plan. They also feature documents that will help you with the onboarding process. Please reach out to your assigned account manager with any further questions.

About Our Plans
Find out more about our long-term care and special needs plans.

Access and Availability Standards for Medicare Patients
According to the Centers for Medicare & Medicaid Services, all health plans are required to maintain and monitor a network of appropriate providers, supported by written arrangements, that is sufficient to provide adequate access to covered services to meet the needs of the population served. This is a regulatory requirement that involves standards that must ensure that the hours of operation of the plan’s providers are convenient to, and do not discriminate against, enrollees. The plan must also ensure that, when medically necessary, services are available 24 hours a day, seven days a week. This includes requiring primary care physicians to have appropriate backup for absences. The standards should consider the enrollee’s need and common waiting times for comparable services in the community. Please download this PDF for more information.

Provider Reference Guide (All Plans)
This guide is a convenient resource when you have questions about claims, member services, medical management, utilization, compliance, pharmacy, or participating labs.

Annual Wellness Visit Coding Guidance (New Document Coming Soon)
To be used when coding for comprehensive health visits with VNS Health Health Plan members.   

Clinical Practice and Preventive Health Guidelines (All Plans)

HEDIS QARR Provider Reference Guide 

CAHPS and Health Outcomes Survey Checklist
Tracks annual HEDIS quality measures and recommends how to discuss them with patients.

HOS Survey Questions Talking Points   
Suggests talking points your practice may leverage to address the health topics included in the survey.

Comfort Care Options
Medicare Hospice Care FAQs for Hospice Providers
The Hospice Care Benefit program is designed to increase patient access to hospice services and improve coordination between hospice providers and other clinicians at the patient’s end of life.

References for SelectHealth Providers
SelectHealth Provider Reference Guide
Quickly find out who to contact for specific plan information.

SelectHealth Plan Overview for Providers
Learn more about SelectHealth, including special initiatives and program offerings.

Drug Reference Guide for Transgender Care
This guide provides a summary of recommended medication therapies along with their SelectHealth formulary coverage status.

Prescriber Billing Codes

Practitioner Dispensing Policy Clarification Billing Codes (Effective 10/4/2022)

Sarepta Prescriber Billing Codes 

• Amondys 45 (Casimersen) Prescriber Billing
• Exondys 51 (Eteplirsen) Prescriber Billing
• Vyondys 53 (Golodirsen) Prescriber Billing

Genentech Prescriber Billing Codes

• Avastin (Bevacizumab) Prescriber Billing
• Herceptin (Trastuzumab) Prescriber Billing
• Perjeta (Pertuzumab) Prescriber Billing
• Xolair (Omalizumab) Prescriber Billing

For assistance with billing questions, please call 1-866-783-0222.

PrEP Prescribers Directory
Please use this online directory from the AIDS Institute to find providers offering the services listed below:

• HIV
• HCV
• PrEP
• PEP
• Buprenorphine
• STI services
• Opioid Overdose Prevention Program

If you’d like to register to be featured in the directory, visit https://providerdirectory.aidsinstituteny.org/Register/RegisterCreate.

Diagnosing and Treating Opioid Use Disorder (OUD) During COVID-19

Pharmacy Vaccine Coverage and Billing Effective 4/1/23

Effective April 1, Immunizations administered at the pharmacy will be covered under NYRx. The pharmacy must be enrolled in the NYS Medicaid program, and enrolled pharmacies are eligible for reimbursement of covered vaccination services. For billing guidance, please review the Pharmacists as Immunizers Fact Sheet.

Authorization used to be required for all DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies) items. After 03/15/24, only certain items will continue to need health plan authorization.

For those items that no longer require authorization:

• Claims will no longer be held or denied due to lack of authorization.
• Clinical documents will no longer need to be forwarded to the health plan for clinical review.

Usual rules outside of a prior authorization process will still apply:

• All federal and state requirements for DMEPOS providers to obtain and maintain specified documents.
• Benefit exclusions will continue to apply. i.e., because authorization is not required does not mean that the item is covered under the health plan’s benefit.
• Benefit limits will continue to apply. If claims are received in excess of a benefit limit, an appeal will be required.
• Coordination of benefits will remain the same.

If not requesting authorization, DMEPOS providers will need to carefully determine:

• whether the member is covered by the health plan
• whether the item is covered under the specific health plan’s benefits

Please remember: DMEPOS providers can always request predeterminations (voluntary authorization requests) before dispensing items even when health plan authorization is no longer required.

Health Information Exchange Fact Sheets and Forms

Information in Spanish and English explaining how the Health Information Exchange works. Includes a list of frequently asked questions to share with patients who are members of our health plans (English, Spanish).

Authorization for Access to Patient/Member Information Through Health Information Exchanges (English, Spanish).

Advanced Care Planning Form
Health care organizations such as ours are required by New York State Department of Health regulations to provide information about advanced directives to all of our members.
The New York Health Care Proxy Law allows patients to appoint someone they trust, for example, a family member or close friend, to make health care decisions for them if they lose the ability to make decisions for themselves.
As sensitive as it can be, a proactive discussion of end-of-life issues with patients is extremely important to avoid confusion and potential discord regarding their preferences for care. We have developed this downloadable one-page overview of advance care planning that contains helpful suggestions and information about various forms of advance directives. We also provide a basic advance care planning checklist to make it easier for you and your patients to assess needs.

Additional forms include the following:
Health Care Proxy (English, Spanish)
New York Advance Directive Planning for Important Healthcare Decisions

What Is Medicaid?
We offer helpful information about this important government program that may be useful for both you and your patients or clients. Visit How to Apply for Medicaid.

Provider EMR Data Sharing – Provider Information Packet
The Provider Information Packet is a comprehensive guide to all aspects of our EMR flat file sharing initiative. In addition to the links below, it contains high-level summaries, timelines, initial and ongoing workflows, file format information, and FAQs. Providers and staff are encouraged to review this guide when sharing data with us via EMR flat file, as it contains important information to ensure successful submission.

Provider EMR Data Sharing – Measure Definitions
This guide lists the measures providers may be asked to document details for in a member medical record. Definitions, applicable lines of business, and sample procedure codes are also included.

Provider EMR Data Sharing – Measure Dictionary
The EMR data sharing measure dictionary details the approaches providers may use to achieve measure compliance and close gaps. By utilizing these guidelines, providers will be able to assist us in achieving and reporting total quality of care for our members. Specifications, key elements, and timelines are also presented for reference.

We know the importance of medication adherence. This medication adherence tip sheet makes it easy for providers to help our members take the right meds at the right time — no matter how complex their medication regimens. In addition, the tip sheet will help empower members and caregivers to easily see what medications to take and when to take them.

Here are some resources that may be helpful to those living with HIV/AIDS, and their families.

SelectHealth supports the Let’s Stop HIV Together campaign sponsored by the Centers for Disease Control and Prevention. The campaign features information on Testing, Prevention, Treatment and Stigma and includes videos of people sharing their experiences of living with HIV.

Visit the Let’s Stop HIV Together website for information on:

• • HIV Testing
  • HIV Prevention
  • HIV Treatment
  • HIV Stigma

HIV Tobacco Cessation Improvement Campaign

The New York State Department of Health AIDS Institute is excited to announce the launch of the HIV Tobacco Cessation Improvement Campaign. Antiretroviral therapy is extending the lives of people living with HIV (PLWH); yet in the United States, PLWH who smoke lose over 6 years of life expectancy compared with PLWH who do not smoke.

Please let your patients know about the NYSDOH campaign to help improve the health of PLWH across New York State. Have them visit hivtobaccofreeny.org to enroll and learn more about the campaign.

New York State Policies and Guidelines

• New York State Department of Health HIV Testing Policies and Procedures
• New York State Department of Health Updates and Changes to HIV Treatment Guidelines
• New York State HIV Testing Law – FAQs

Additional Resources

• New York State Department of Health
• New York City Department of Health and Mental Hygiene
• Signs and Symptoms of Acute/Early HIV
• AIDS Info (A Service of the U.S. Department of Health and Human Services)
• The AIDS InfoNet
• Centers for Disease Control and Prevention
• National Women’s Health Information Center

As of 1/1/2025, some medically administered drugs like injectables may require utilization management such as a prior authorization to determine appropriateness of care, while ensuring safe and effective use. Milliman Criteria is used as a guideline to support clinical decisions. Members on the effected monoclonal antibodies and antineoplastics in 2024 that are requiring a PA in 2025, will be grandfathered in 2025.

View prior authorization list. 

If you believe that these options are not right for your patient, please send us (Medical Management team) documentation by fax (866) 791-2214 indicating why your patient cannot use the preferred alternative(s). This documentation can include a summary of the patient’s medical history and treatment rationale, as well as recent medical records such as office visit notes.