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About

Gym Benefit

Plan Benefits

Gym Benefit

As a Partners Health Plan (PHP) member, you are eligible to be reimbursed for gym or fitness classes!

About Your Gym Benefit:

PHP members who attend gym or fitness classes (online or in person) a minimum of 26 times during the calendar year are eligible to receive reimbursement for gym expenses up to an annual maximum of $400 upon receipt of payment and confirmation of attendance under PHP’s Gym Benefit.

Girl holding OTC Benefit Card

How does the
fitness benefit work?

Attend a gym or exercise class (in person or online) for a minimum of 26 times in a calendar year. Examples of qualifying fitness facilities and classes that you can be reimbursed for include:

  • Membership fees for
    standard or adaptive
    gyms, including YMCAs
    and community centers
    where fitness services
    are offered
  • Aerobics classes
  • Boot camps
  • Boxing/Kickboxing
  • CrossFit
  • Indoor rock climbing
  • Martial arts
  • Pilates
  • Swimming
  • Tennis/Racquetball
  • Circuit Training
  • Weight/Resistance
  • Yoga
  • Zumba
  • Dance classes

Submitting Documentation & Receiving Reimbursements

  • How do I receive my reimbursement?

    • Submit your completed and signed Gym Reimbursement Form.

    • Include proof of attendance (e.g. print-out from fitness facility, signed letter from facility or class instructor, certificate of attendance for applicable dates, etc.).

    • Include proof of your payment (e.g., receipt, automatic bank withdrawal statement) for the gym fee, as well as any money you paid for fitness classes.
  • Where do I submit all my documents?

    Mail your documents to:
    Partners Health Plan
    Attn: Gym Reimbursement
    8 Southwoods Blvd Ste 110
    Albany, NY 12211

    or email these documents to
    This email address is being protected from spambots. You need JavaScript enabled to view it.

    The required documents (signed form, receipts, and proof of attendance) must be received by Partners Health Plan no later than the end of the calendar year.

Gym Benefit
Reminders & Frequently Asked Questions

PHP members who attend gym or fitness classes (online or in person) a minimum of 26 times during the calendar year are eligible to receive reimbursement for gym expenses up to an annual maximum of $400.

This calendar-year benefit expires at the end of the year, e.g., December 31st, 2024. Reimbursement requests can be submitted once the minimum number of visits is completed.  To receive reimbursement, PHP members must pay upfront for these services, meet the minimum visit requirements of 26 visits within a calendar year, and submit the required documentation.

  • Am I eligible for this benefit?

    Yes, if you are an active member of Partners Health Plan for a continuous enrollment period during the calendar year.

  • What do I have to do?

    Attend a gym or exercise class in person or online for a minimum of 26 times in a calendar year.

  • What gyms can I go to?

    To receive this benefit, you can attend any gym or fitness facility (online or in person) within the PHP service area as long they can provide proof of attendance such as a print-out from the fitness facility, a signed letter from the facility, or class instructor noting the dates in which you attended or, certificate of attendance from each visit or class attended.

  • Can I use PHP’s transportation benefit to get to the gym?

    No. Transportation will not be provided to any gym, fitness facility, or fitness classes.

  • Can I go to multiple gyms or fitness facilities to meet the minimum visit requirement of 26 visits within a calendar year?

    Yes, you can attend a combination of any gym or classes online or in person as long as you can obtain proof of attendance from each gym or fitness facility attended. Please feel free to submit more than one completed Gym Reimbursement Form if needed.

  • Does this benefit include all services offered by the gym or fitness facility?

    You can be reimbursed for group fitness classes at a fitness facility if there is a separate class fee in addition to membership fees. However, you will not be reimbursed and will be personally responsible for the cost of any amenity items such as sauna, massages, tanning, personal training, or locker fees.

  • Is there a limit on the number of times I can request reimbursement?

    No, you can submit reimbursement requests once the visit minimum has been reached as many times as needed as long as you have not exceeded the annual maximum of $400 per year. However, a completed Gym Reimbursement Form is required for each submission.

  • Can I attend a paid group class and work out at the same gym on the same day?

    Yes, however, the paid class will count as 1 visit toward the minimum visit requirement. Multiple visits per day will only count as one visit.

  • Do unused allowance amounts roll over?

    No, unused allowance amounts do not roll over to the next calendar year.

  • What types of purchases or services do not qualify for reimbursement?

    • Fitness Supplies (e.g., weights, jump ropes, yoga mats, foam rollers, exercise bikes or peddlers, kettlebells, resistance bands, swimming goggles, bowling balls and fishing rods, etc.).
    • Social and country club membership fees or dues
    • Athletic clothing (e.g., knee pads, sneakers, and helmets)
    • Food items and services (e.g., Protein shakes, liquid supplements, etc.,)
    • Electronic music devices or subscriptions to digital music services
    • Weight management programs (online or in-person)
    • Smart fitness devices (like Fitbit, Apple, and Google watches)
    • Licenses/certifications for hunting, fishing, firearms, etc.
    • Organized sports fees (e.g., Basketball, Tennis, Football, Golf, Bowling, Pickleball, Softball, Baseball etc.)
    • Walking, running, or fundraising clubs.
    • Classes or rehab sessions that are already part of your benefit do not count as a gym/fitness class visit.
  • What if I complete more than 26 visits/sessions/classes in a calendar year?

    The amount reimbursed shall not exceed the cost of $400 even if more than 26 visits/classes were completed in a calendar year.

  • When can I expect my reimbursement?

    You can expect reimbursement within 60 calendar days of approval. All gym reimbursements will be made by check payable to you and will be mailed to your residence. If there is any reason why your reimbursement cannot be processed, you will be notified in writing.

  • Who should I call if I have questions about reimbursement?

    If you have any questions about your gym reimbursement benefit, please contact your Care Manager or call PHP Participant Services at 1-855-747-5483.

For more information about enrolling in the
PHP Care Complete FIDA-IDD Plan:

Contact us!

Complete the form below to connect with a Partners Health Plan Outreach Associate to learn more about PHP FIDA-IDD Plan benefits and enrollment procedures or to request informational materials. 


Connect with our outreach team!

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You can reach out to one of our NYS licensed Outreach Associates to schedule a one on one education session at your convenience.

Meet the PHP Outreach Team

Are you ready to enroll in PHP Care Complete FIDA-IDD Plan?

To enroll, visit or call NY Medicaid Choice at 1-844-343-2433 (TTY: 1-888-329-1541), Monday through Friday, 8:30 AM to 8:00 PM, and Saturday, 10:00 AM to 6:00 PM.

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Prior Authorization Requirements

Your Benefits

Prior Authorization Requirements

Some services need Prior Authorization through Partners Health Plan Utilization management.  See below to learn more. 

What services need Prior Authorization through PHP's Utilization Management?

The services below need Prior Authorization. 

* Service requires authorization during Participant's 90-day continuity of care period.

  • Ambulatory Surgery Procedures*

    • Abdominoplasty
    • Blepharoplasty
    • Mastoplexy
    • Otoplasty
    • Keloid & Scar Revisions
    • Mammoplasty, Reduction or Augmentation
    • Surgical Treatment of Gynecomastia
    • ENT Procedures (Rhinoplasty, Septoplasty,
      Uvoluplasty, LAUP)
    • Varicose Veins Treatment
    • Ventral Hernias
    • Bariatric Surgery
  • Home Health Care Services

    • Does not includes CDPAS & PCA as IDT team will approve
    • Initial Assessment – Nursing, OT, PT, Speech, Nutritional Counseling and Pulmonary Therapies no auth required.
  • Home Infusion Services

  • Inpatient Admissions*

    • Acute Care Facilities, including Inpatient OBGYN
    • Skilled Nursing Facilities / Nursing Home
    • Behavioral Health Care Facilities
      • Elective Admissions
      • Urgent / Emergent Admissions
      • Substance Abuse and Rehabilitation
    • Inpatient Rehabilitation Facilities
  • Medical Social Services*

  • Nerve Block / Epidurals*

  • Organ Transplant Evaluation & Services*

  • Rehabilitation Services – Outpatient

    • Physical Therapy
    • Occupational Therapy
    • Speech Therapy
    • Pulmonary & Cardiac Rehabilitative Therapy
    • Nutritional Counseling
  • Radiology *

    • MRI
    • Functional MRI
    • MRA
    • PET
  • Private Duty Nursing

  • Outpatient Services *

    (below services only)

    • Chiropractic Services
      • No PA required for subluxation of spine.
      • Any other services require prior auth
    • Podiatry – 4 Annual Visits
      • 4 routine visits covered per year without UM review.
      • All other podiatry visits will require UM approval
  • Other Services*

    • Hyperbaric Oxygen Treatment
    • Investigation & Experimental Treatment

How does a provider obtain Prior Authorization for these services?

Obtain the Prior Authorization Request Form

Prior Authorization Request Form

Complete the form and fax, along with all pertinent clinical information, to Utilization Management at 855-769-2509

 Call Utilization Management if you have any questions at 855-769-2508

What services require Prior Authorization through Partners Health Plan Care Coordination Team?

  • Adult Day Health Care

  • Assertive Community Treatment

  • Continuing Day Treatment

  • Consumer Direction Personal Assistance Services (CDPAS)

  • DME / Prosthetics / Orthotics

  • Enteral / Parenteral Nutrition

  • Personalized Recovery Oriented Services

  • Personal Care Services

  • Personal Emergency Response Services

  • Office for People with Developmental Disabilities (OPWDD) Home and Community-Based (HCBS) Waiver Services

Provider FAQ & Quick Reference Guide

Provider Resources

FAQ & Reference Guide

For additional questions or assistance from the Network Development and Provider Relations team, please visit the Provider Assistance page and complete a Provider Ticket Submission Form.

Provider Quick Reference Guide

Frequently Asked Questions

  • Who is HealthSmart?

    HealthSmartis PHP’s Third-Party Administrator (TPA). HealthSmart provides various management services for Partners Health Plan (PHP) including, but not limited to, claims processing.

  • What are my options for submitting claims to PHP:

    See our Billing and Claims page for claims submission information and guidelines.

    Billing and Claims

  • What is PHP’s EDI submitter number? Is it the same for both clearinghouse options?

    14966 - Yes, it isthe same submitter ID value regardless ofsubmission to the Change HealthCare (formerly Emdeon) or HealthSmart Clearinghouse

  • Can I submit claims through the provider portal?

    Yes.

    • Web-based Claims Submission:

      Providers can now easily create and upload a professional or institutional single claim as a pdf file via the provider portal (php.healthsmart.com). 

      • Web-based claims are considered paper claims and will follow all existing claim submission protocols.
      • Please note that only valid claim forms (CMS 1500 or UB 04) may be uploaded using this method.

    See our Billing and Claims page for other claims submission options, information, and guidelines.

    Billing and Claims

  • Is there a charge for submitting claims directly to the HealthSmart Clearinghouse?

    No, there is no charge to PHP providers to submit PHP claims directly to the HealthSmart Clearinghouse.

  • Who should I contact if I am interested in submitting EDI claims to the HealthSmart Clearinghouse?

    Contact HealthSmart EDI Support at 1-888-744-6638. You will have to complete an EDI enrollment form, as well as, a User License Agreement to begin the submission process.

    EDI Enrollment Packet

  • Who should I contact if I am interested in submitting EDI claimsthrough the Change Healthcare Clearinghouse?

    Call 1-877-363-3666

  • How often are PHP’s check runs?

    PHP typically generates two check runs per week.

  • What forms of payments are offered?

    See the ECHO Payment & Remits FAQ.

    ECHO Payment & Remits FAQ

  • I received a virtual card payment and no longer wish to receive payments in this form. How do I opt out of this form of payment?

    See the ECHO Payment & Remits FAQ.

    ECHO Payment & Remits FAQ

  • I would like to obtain my PHP payment via Electronic Funds Transfer, how can I go about doing so?

    See the ECHO Payment & Remits FAQ.

    ECHO Payment & Remits FAQ

  • Why would I receive a PHP payment via virtual card payment if I did not specifically request this method for receipt of PHP payments?

    See the ECHO Payment & Remits FAQ.

    ECHO Payment & Remits FAQ

  • I submit my claims via the HealthSmart Clearinghouse. What do I need to do to receive electronic remittances (835)?

    See the ECHO Payment & Remits FAQ.

    ECHO Payment & Remits FAQ

  • Do I have to be receiving EFT/ACH payments from Zelis Payments to be able to obtain an electronic 835 remittance transaction?

    See the ECHO Payment & Remits FAQ.

    ECHO Payment & Remits FAQ

  • How soon after check payments are generated should I expect to retrieve my 835 electronic transmission via the HealthSmart Clearinghouse?

    See the ECHO Payment & Remits FAQ.

    ECHO Payment & Remits FAQ

  • Who should I contact if I am having difficulty with receiving my 835 electronic remittances ?

    See the ECHO Payment & Remits FAQ

    ECHO Payment & Remits FAQ

  • Why is my claim denying with a Remark Code ‘PA’?

    This code identifies that you have submitted a procedure code which requires the NDC Code, Qualifier, and Units for which you did notsubmit any or all these data elements on your claim submission.

  • Why did I receive a Claim Adjustment Reason Code 252 (an attachment/other documentation is required to adjudicate this claim/service) and Remittance Advice Remark Code M119 on my 835 Claim Payment/Advice?

    Thisidentifies that you have submitted a procedure code which requires the NDC Code, Qualifier, and Units for which you did not submit any or all these data elements on your claim submission.

  • Why did I receive a Claim Adjustment Reason Code 252 (an attachment/other documentation is required to adjudicate this claim/service) and Remittance Advice Remark Code M119 on my 835 Claim Payment/Advice?

    This identifies that you have submitted a procedure code which requires the NDC Code, Qualifier, and Units for which you did not submit any or all these data elements on your claim submission.

  • Why is a National Drug Code (NDC) required?

    New York State Department of Health (NYSDOH) mandates that all Managed Care Plans must report National Drug Codes (NDCs) for all physician-administered drugs.

  • Which procedure codes require NDC information be reported?

    All physician-administered drugs, by all provider types, require a valid 11-digit NDC number and the applicable quantity and measurement. This includes all J-codes and all other applicable drug codes (i.e., chemotherapeutics, therapeutics, etc.).

  • How do I submit the required NDC information on an 837 electronic claim submission?

    In either the 837I or 837P format providers must report the 11-digit NDC and its corresponding information, in addition to the procedure code, in the LIN segment of Loop ID 2410 to specify the physician-administered drug that is part of the service described in SV1 forthe 837 format. Providers must also report the quantity and unit of measure of the NDC as outlined in the table below:

  • Where do I enter the required NDC information if I am submitting a paper claim?

    • CMS-1500 Box 24A example: NDC qualifier (N4) + NDC (11-digits) + unit of measurement qualifier (UN) + unit quantity (1)
    • UB04 FL 43 example: NDC qualifier (N4) + NDC (11-digits) + unit of measurement qualifier UN) + unit quantity (1)

    *The following are the only acceptable values forsubmission as a Unit of Measurement Qualifier: • GR (gram) • ML (milliliter) • ME (milligram) • UN (unit) • F2 (international unit)

  • How do I resubmit my claim if I received a denial for missing/invalid NDC information?

    On an Institutional UB-04 claim you should submit as a corrected claim, which is identified by utilizing the applicable Bill Type ending in ‘7’ to designate as corrected (i.e., XX7, 137, 737, etc.)

    On a Professional CMS-1500 claim you should mark the claim as corrected and include the original claim number in Box 22 ‘Original Reference No.’.

    All resubmissions/corrected claimsshould include all original claim lines, not just the correction to the physician-administered drug claim lin

Quick Reference Guide

Need Provider Assistance?

The Partners Health Plan Network Development and Provider Relations team is here to assist you with your billing, claims, authorization, education, and any other general inquiry. Use the Contact Us button below to complete a Provider Ticket Submission Form.

Contact Us

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DD Provider FAQ & Quick Reference Guide

Provider Resources

DD Provider FAQ
& Reference Guide

For additional questions or assistance from the Network Development and Provider Relations team, please visit the Provider Assistance page and complete a Provider Ticket Submission Form.

Provider Quick Reference Guide

Frequently Asked Questions

  • How does a provider know when a member enrolls with PHP or disenrolls from PHP?

    PHP will notify all DD providers that are associated with an enrolling or disenrolling member based on the member’s TABS report. An email will be sent to your agency before the first of the month in which the member is enrolling or disenrolling.

    This notification will also provide helpful information about the members’ PHP plan and billing information for your agency. If you believe your organization is not receiving these notices, please contact Provider Relations for assistance here.

  • What should I do if a Care Manager is not responsive to my requests?

    Please allow Care Managers reasonable time to respond to requests. For routine, non-urgent issues, expectations are that you should receive a response within 2 business days. If you do not receive a response within the expected time frame, please use the Care Management chain of command.

    All Care Managers have their supervisor’s name and contact information listed in their email signature for ease of knowing who to contact.

  • I do not know who a person’s Care Manager is, how can I figure this out?

    You can call PHP’s Provider Services line at 855-747-5483 for this information.

  • How does my organization know when a person we support changes Care Managers?

    PHP has a warm handoff process which includes the new Care Manager reaching out to providers to introduce themselves and connect with the team supporting the person supported. If you are unsure if a Care Manager change has occurred, please contact PHP's Provider Services line for assistance in identifying the current Care Manager.

  • Am I able to reach Care Management for support after typical business hours?

    PHP Care Managers are not available after business hours. Please wait for the following business day or call PHP's Nursing Advice Line at 1-855-769-2507 regarding any behavioral or medical concerns. The nursing advice line is available 24 hours a day, 365 days a year.

  • How do I contact PHP’s Regional Leadership team?

    Partners Health Plan has 3 Regional Care Manager Directors:

    Renata Goldman (Westchester, Rockland, and Bronx)
    This email address is being protected from spambots. You need JavaScript enabled to view it.

    Giselle Peter (Brooklyn, Manhattan, Staten Island, and Queens)
    This email address is being protected from spambots. You need JavaScript enabled to view it.

    Jennifer Rechner (Nassau and Suffolk)
    This email address is being protected from spambots. You need JavaScript enabled to view it.

  • How often should a Care Manager be in contact with a person I support?

    PHP Care Managers will contact the member and/or their advocate monthly.

  • Where can I access PHP Life Plans?

    We encourage all providers to request Medisked portal access to view and approve plans. To request access please email This email address is being protected from spambots. You need JavaScript enabled to view it.

  • How do I assist a person in finding a healthcare provider that is in-network with PHP?

    PHP’s Provider Search Tool is available on the PHP website. This search tool allows a person to search for healthcare providers, dentists, pharmacies and more. If further assistance is needed in finding the right provider, please contact Provider Relations here.

  • If I cannot find a document in Choices, who should I contact?

    Please contact the member’s Care Manager.

  • There is a discrepancy between a member’s current program compared to what is reflected in Choices. What should I do?

    Please contact the member’s Care Manager.

  • Why do I need to share preventative health and appointment information with Care Managers?

    PHP Care Managers are responsible for comprehensive person-centered planning, including coordinating services and support for individuals they support. Knowing what preventive healthcare a person has received is a critical component of understanding supports that may be needed. Additionally, Care Managers receiving the appropriate documentation assures care has been rendered and allows the Care Manager to assist with any needed follow-up.

  • I am unfamiliar with submitting claims to PHP. Where can I find more information on this?

    For more information on billing and claims submissions, please use this link to learn about your organization's claim submission options and general guidelines. PHP’s FAQ and Reference Guide also has helpful information specific to claims submissions. Lastly, Provider Relations can assist you with any questions. Reach out to Provider Relations here if needed.

  • How do I contact PHP’s Provider Relations Department?

    For assistance with any provider-related questions or concerns, please complete the Provider Relations Help form on our website linked here. Once the form has been submitted, a Provider Relations team member will get back to you shortly. Please include as much detail on the ticket submission request as possible so our team can provide you with the most timely and thorough feedback.

  • My organization has program vacancies and other opportunities we’d like Care Managers to be aware of. How can we share this information?

    PHP’s Provider Relations team is happy to share any program opportunities, workshops, or other relevant information with our Care Management teams. Please reach out to Provider Relations using this link to share any information you feel will be beneficial for PHP’s Care Management team and members. The Provider Relations team can also discuss any further information-sharing opportunities with your organization as needed. 

Quick Reference Guide

Need Provider Assistance?

The Partners Health Plan Network Development and Provider Relations team is here to assist you with your billing, claims, authorization, education, and any other general inquiry. Use the Contact Us button below to complete a Provider Ticket Submission Form.

Contact Us

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Compliance

Compliance

The purpose of Partners Health Plan’s (PHP) Compliance Program is to assure corporate compliance and promote corporate integrity. It is PHP’s commitment to ensure an environment that promotes the highest ethical conduct and compliance with applicable laws, regulations, policies, and procedures.

PHP has a Compliance Program aimed at establishing a culture that promotes prevention, detection, and resolution for any misconduct or violation of the Compliance Program. 

Compliance Officer

The Compliance Program includes communication lines to the Compliance Officer that are accessible to all employees, persons associated with PHP, including individuals served and their families and advocates, executives and Board of Manager members, to allow compliance issues to be reported. These communication lines include a method for anonymous reporting. Any compliance issue reported to the Compliance Officer will be taken seriously and investigated. 

Who Can File A Report?

Anyone, may report a suspected violation of the Code of Conduct, Compliance Guidelines, operational policies, any law or regulation, or any other concern to the Compliance Officer.

FILE A REPORT

Compliance Hotline

PHONE: 1.855.252.7606

ONLINE: Compliance Resource Center
Note: Enter "Partners Health Plan" in Organization Name field when filing a report online.

  • Telephone and online reporting
  • Report anonymously and confidentially
  • Toll-free, available 24/7
  • Multilingual specialists available
  • Staffed by a third party vendor

By Mail:

Partners Health Plan
C/O Compliance Officer
2500 Halsey Street
Bronx, NY 10461

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