Health Data

On November 12, 2020, the United States Departments of Health and Human Services, Labor and Treasury issued a Final Rule entitled Transparency in Coverage (the Rule) aimed at increasing the availability and transparency that consumers have to access health care pricing information through their health plans. Most non-grandfathered group health plans or health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets are required to make available to the public, including consumers, researchers, employers, and third-party developers, machine-readable files that include detailed pricing information. The Rule also applies to Qualified Health Plans (QHP) and commercial issuers, but does not apply to Medicare Advantage, Medicare Supplement, Medicaid Managed Care, Child Health Plus or Essential Plan coverage, or vision- or dental-only plans.

To comply with the Rule, Healthfirst has made the required machine-readable files available using the Table of Contents links below. The data files are presented in the standardized formatting required by CMS and updated as required by the Rule. Please note that the formatting of these files is not meant for individual consumer use. Individual consumers are encouraged to use the Cost Estimator tool accessible from the Healthfirst Customer Center using their Member Login.

Disclaimer: The machine-readable files contain information generated from our systems and from our vendors. While we believe the information to be accurate, we cannot guarantee that the information is error-free, complete, or will operate without interruption. The machine-readable files do not guarantee coverage of or payment for any item or service, nor a guarantee of the reimbursement rate that will be applied for any item or service. The claims reimbursement process is subject to a variety of factors that are not addressed in this file, including eligibility, prior authorization, prerequisites, and other plan terms.

The MRFs are split into three parts. The first two parts include in-network providers. The third part includes the allowed amounts for out-of-network providers with a minimum of twenty claims. Additional files are available for Vision, Dental, and Chiropractic plans. Click each link to download the corresponding file:

Part 1 - Professional In-Network Providers Table of Contents
Part 2 - Institutional In-Network Providers Table of Contents
Part 3 - Out-Of-Network Providers Table of Contents

Machine-readable file for Vision plans
Machine-readable file for Dental plans
Machine-readable file for Chiropractic plans

There are many ways you can receive your medical information from Healthfirst. If you have a smartphone, you can request your records through third-party apps.

Healthfirst is required to deliver the following information through third-party apps:

• Adjudicated (paid) claims data;
• Encounters with capitated providers;
• Clinical data that Healthfirst maintains in our systems; and
• Drug benefit data (if applicable).

For a copy of the health records that Healthfirst maintains about you, send a request specifying the records you’re seeking to:

Healthfirst Member Services
P.O. Box 5165, New York, NY 10274-5165
Fax: 1-212-801-3250

You can also make a request over the phone by calling Member Services at 1-844-347-5816, Monday to Friday, 8am–8pm, or sending an email to
Forms@healthfirst.org.

To ask Healthfirst to share a copy of your electronic health records with an entity or another individual, complete the authorization form located here.

Send the completed authorization form and all relevant documentation to:

Healthfirst Member Services
P.O. Box 5165, New York, NY 10274-5165
Fax: 1-212-801-3250
Phone: 1-844-347-5816

You can also make a request over the phone by calling Member Services at 1-844-347-5816, Monday to Friday, 8am–8pm, or sending an email to
Forms@healthfirst.org.

For additional information about the health records that Healthfirst maintains about you, please see the Notice of Privacy.

Claims data is required to be sent within 1 business day after a claim it is adjudicated.

Encounter and clinical data are required to be sent within 1 business day after Healthfirst receives the data.

Drug benefit data are required to be sent within 1 business day after the effective date of the information or any updates.

We are only required to send you data which we maintain from January 1, 2016 forward.

• There may be many apps from which to choose. You should consider the ones that will keep your data private and secure and that explain how they will handle and protect your data. Although Healthfirst recommends choosing an app with a transparent and robust privacy policy, the decision is ultimately yours.
• Look for an easy-to-read privacy policy that includes:
  • How health data will be collected;
  • How non-health data will be collected (for example, location data);
  • If your health data will be stored, and for how long;
  • If your data is stored, will it be de-identified or made anonymous;
  • The data that might be shared and/or sold, to whom, and why;
  • How you can limit the app’s use and disclosure of your data;
  • If/How you can correct inaccurate data;
  • A process for collecting and responding to user complaints;
  • How users will be informed about changes to the privacy policy;
  • Information on the methods used to keep your health data secure;
  • An explanation of how to stop using the app to access your health data and how any data stored in the app will be deleted; and
  • Documentation stating that the app developer will follow the Carin Code of Conduct, which is a set of principles for how healthcare organizations can share data with consumer applications.

• Healthfirst is a “covered entity” under the HIPAA Privacy and Security rules, which means we must comply with all of the HIPAA rules regarding the use and disclosure of your health information, as well your right to access, amend, or correct your data.
• For details on how Healthfirst protects your data, or to report a privacy issue, please see our privacy notices.
• You can also email the Privacy Office at hipaaprivacy@healthfirst.org, call the Privacy Office at 1-877-464-4365, or write to the Privacy Office at Healthfirst Privacy Office, P.O. Box 5183, New York, NY 10274-5183.

Note: Once your data is shared with your selected app, in most cases the data is no longer protected by HIPAA.

• If you believe that we have violated your privacy rights, you have the right to file a complaint with us. You may file a complaint with us by emailing, calling or writing the Privacy Office:
  • Email Healthfirst at HIPAAPrivacy@healthfirst.org
  • Write to the Healthfirst Privacy Office, P.O. Box 5183, New York, NY 10274
  • Call us at 1-212-801-6299

• The Office for Civil Rights (“OCR”) is responsible for the enforcement of the HIPAA rules and is the agency to contact with a complaint that cannot be resolved directly with Healthfirst. To file a complaint you can:
  • Visit the online portal at hhs.gov/ocr/smartscreen/main.jsf;
  • Write to the Office for Civil Rights, US Department of Health and Human Services, Jacob Javits Federal Building, Suite 3312, New York, NY 10278;
  • Call the OCR Hotline at 1-800-368-1019; or email OCR at ocrmail@hhs.gov
  • Email OCR at ocrmail@hhs.gov

• Third-party apps are not subject to the HIPAA rules, but to the Federal Trade Commission (“FTC”) under the FTC Act. The FTC Act protects against “unfair or deceptive acts or practices” in or affecting commerce. Examples of these include:
• An app sharing personal data without permission even if its privacy policy says it would not do so.
• An app’s website containing statements in its marketing materials, FAQs, etc. that are untrue.
• Complaints to the FTC can be made online at https://reportfraud.ftc.gov/ or by calling the FTC’s Consumer Response Center at 1-877-382-4357.
• The Federal Trade Commission (FTC) provides information about mobile app privacy and security for consumers here: https://www.consumer.ftc.gov/articles/0018-understanding-mobile-apps