Non-Contracted Providers

Non-Contracted Providers or Non-Participating Providers –

Why do QHPNY Members need to know which providers are part of our network?

It is important to know which providers are part of our network because, with limited exceptions, while QHPNY Members are a member of our plan, QHPNY Members must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when QHPNY Members are out of the area), out-of-area dialysis services, and cases in which QHPNY authorizes use of out-of-network providers. See Chapter 3 Of the Evidence of Coverage (Using the plan’s coverage for your medical services) for more specific information about emergency, out of-network, and out-of-area coverage.

If you have a QHPNY member that requires services:

How to get care from Non-contracted providers?

If QHPNY Members need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, QHPNY Members can get this care from an prior authorized out-of-network provider. In this situation, QHPNY Members will pay the same as you would pay if they got the care from a network provider.

How to get authorization?

Before seeking care from an non-contracted or out-of-network provider, QHPNY Members should talk to their primary care physician (PCP) regarding the care that they need. He or she will notify us by requesting approval from the plan (“prior authorization”) or the Member themselves may request the prior authorization. As a non-contracted provider, you may contact the Member’s PCP or the Member regarding initiating a prior authorization request.

If a member gets non-emergency care from out-of-network providers without prior authorization, QHPNY Members must pay the entire cost. Limited cases such as emergency care, urgently needed care when our network is not available, or dialysis out of the service area, do not require prior authorization and are always covered at the in-network benefit level, even when you get them from out-of-network providers.

Questions on Members plan or coverage?

QHPNY Evidence of Coverage documents provide detailed information on coverage, benefits, copays or coinsurance and much more. You may find the plan that our member has elected to join on their ID card. A copy of that plan’s Evidence of Coverage is available on this website: https://qhpny.com/2019-evidence-of-coverage/

If you have further questions on coverage and you are a non-contracted provider please contact the Non-contracted Provider Hotline at 1-888-585-5404 or QHPNY Customer Service at 1-877-233-7058 (TTY/TDD 711) Sunday through Saturday, 8:00 a.m. – 8:00 p.m. Eastern Standard Time from October 1 to March 31, and Monday through Friday, 8:00 a.m. – 8:00 p.m. Eastern Standard Time from April 1 to September 30.

How to become a contracted provider with QHPNY:

QHPNY is constantly adding new providers to its network. If you would like to become a contracted provider you may email us at: https://qhpny.com/contact-us/ .

Or you may contact our contracting department at 1-877-233-7058 ext 214

QHPNY reserves the right to contract or not to contract with any provider at any time.

How to submit claims or appeals:

How to submit a claim if you are Non-contracted Provider:

Mail to:
Claims Department
P O Box 340397
Tampa, FL 33694-0397

Claims must be filed no later than 12 months or 1 calendar year after the date of service were furnished.

Quality Health Plans of New York must act promptly to resolve payment disputes with non-contract providers and to ensure that payments are made in accordance with the law.

Many claims are denied due to billing errors therefore, please make sure that your claim is complete at the time of submission. If your claim is denied, as a non-contracted provider you have the right to file an appeal or to correct your claim and resubmit as appropriate.

If your claim is denied as a Non-Contracted Provider you can file an APPEAL:

 How Do I File an Appeal? https://qhpny.com/appeals-and-grievances/

You have the right to file an appeal on denied claim, you must file your request in writing within 60 days of receiving your denial notice.  Under special circumstances, you may ask for more time to request an appeal. QHPNY will waive timely filing requirements due to good faith, so please discuss this with your assigned appeals coordinator. If your denial was processed untimely on QHPNY’s part then you will automatically receive a waiver of the 60 days timely filing requirement.

Your appeals request must include the following information:

  1. The name, telephone number, facsimile number and address of the person requesting the appeal,
  2. The Member’s name and ID
  3. Claim identifying information, including the claim number and date of
  4. The reason for requesting an appeal andsupporting evidence why QHPNY should pay your
  5. A signed Waiver of Liability Statement.

 What is a Waiver of Liability Statement?

When a non-contracted provider request for standard appeal for the purpose of obtaining payment, the Waiver of Liability form must be signed.  By signing this waiver, the non-contracted physician, provider or facility formally agrees to waiver any right to payment from the member for services.  Your appeal request will not be considered without receipt for a signed Waiver of Liability form and will be dismissed if one is not received by QHPNY.

A copy of this Waiver of Liability Form can be obtained at following link on QHPNY website:
https://qhpny.com/appeals-and-grievances/

 You may either Fax or Mail your request for appeal, signed Waiver of Liability and supporting documents to:         

Fax:  877-738-4870
Quality Health Plans of New York
2805 Veterans Memorial Highway, Suite 17
Ronkonkoma, NY 11779
Attention: Appeals

As a Non-contracted Provider if you would like to file a complaint or give us feedback?

 If are a non-contracted provider and are dissatisfied for any reason you may file a complaint with QHPNY. To file a complaint or give QHPNY feedback, please contact QHPNY Non-contracted Provider Hotline at 1-888-585-5404 (TTY/TDD 711) Sunday through Saturday, 8:00 a.m. – 8:00 p.m. Eastern Standard Time from October 1 to March 31, and Monday through Friday, 8:00 a.m. – 8:00 p.m. Eastern Standard Time from April 1 to September 30.

We will respond to your complaint as expeditiously as the issue warrants but no later than 72 hours. QHPNY is committed to assisting you with any issue that you may have.

 Additional Questions – Non-contracted  Provider Hotline –

If you have any questions please contact QHPNY non-contracted Provider Hotline at 1-888-585-5404 (TTY/TDD 711) Sunday through Saturday, 8:00 a.m. – 8:00 p.m. Eastern Standard Time from October 1 to March 31, and Monday through Friday, 8:00 a.m. – 8:00 p.m. Eastern Standard Time from April 1 to September 30.

If you are a contracted provider please contact QHPNY Customer Service at 1-877-233-7058 (TTY/TDD 711) Sunday through Saturday, 8:00 a.m. – 8:00 p.m. Eastern Standard Time from October 1 to March 31, and Monday through Friday, 8:00 a.m. – 8:00 p.m. Eastern Standard Time from April 1 to September 30.

If you are a QHPNY Member please and have any questions please contact QHPNY Customer Service at 1-877-233-7058 (TTY/TDD 711) Sunday through Saturday, 8:00 a.m. – 8:00 p.m. Eastern Standard Time from October 1 to March 31, and Monday through Friday, 8:00 a.m. – 8:00 p.m. Eastern Standard Time from April 1 to September 30