Social Care Networks: Data and IT Fact Sheet for Providers
- Fact Sheet also available in Portable Document Format (PDF)
Introduction
Data exchange is vital to the Social Care Network (SCN) program as it enables SCN operations, service delivery, and payments. Each regional SCN uses a technology platform for health-related social needs (HRSNs) screenings, assessments, referrals to services, fiscal management, and coordination among community-based organizations and other providers.
These platforms exchange SCN data through the Statewide Health Information Network for New York (SHIN-NY) by connecting to regional Qualified Entities (QEs), also known as Regional Health information Organizations (RHIOs).
Additionally, data exchange enables the delivery of needed services to Medicaid members at the right place and right time, and data collection to enable the evaluation of the SCN program's impact on members' health outcomes and health care costs. All stakeholders are required to adhere to state and federal regulations governing data exchange and privacy.
Providers, including physical and behavioral health, are important partners in meeting SCN program and New York Health Equity Reform 1115 Waiver Amendment objectives. This document describes how providers can connect to SCN program data and technology infrastructure. For more information about the SCN program and how providers can get involved, please review the SCN: Introduction for Health Care Providers Guide.
Contents of this document
- Summary: Social Care Networks, Qualified Entities, and tech platforms
- Options for how providers can participate in the SCN program
- Commonly asked questions
- Key points of contact for providers
- Helpful Links
A. Summary: Social Care Networks, Qualified Entities, and tech platforms
| SCN Lead Entity | SCN Region | Qualified Entity | SCN IT Platform |
|---|---|---|---|
| Care Compass Collaborative | Southern Tier | HealtheConnections | Unite Us |
| Health Equity Alliance of Long Island | Long Island | Healthix | Unite Us |
| Healthy Alliance Foundation Inc. | Capital Region | Hixny | Unite Us |
| North Country | Hixny | ||
| Central NY | HealtheConnections | ||
| Hudson Valley Care Coalition, Inc. | Hudson Valley | HealtheConnections | Unite Us |
| Public Health Solutions | Manhattan, Queens, Brooklyn | Healthix | Unite Us |
| Somos Healthcare Providers, Inc. | Bronx | Bronx RHIO | FindHelp |
| Western New York Integrated Care Collaborative Inc. | Western NY | HEALTHeLINK | FindHelp |
| Forward Leading IPA | Finger Lakes | Rochester RHIO | FindHelp |
| TogetherNow1 | |||
| Staten Island Performing Provider System | Staten Island | Healthix | Channels360 |
B. Options for how providers can participate in the SCN program
Providers have multiple options for data exchange with the SCN data / IT infrastructure. The SCN program offers flexibility to accommodate existing technology providers may be using (e.g., EHR systems), and varying levels of provider resources or capacity for technology development. Providers should collaborate with their data / IT teams, their regional SCN Lead Entity, and their qualified entity (QE) to determine which option works best for them. SCNs will accept the options outlined below for providers to participate and be reimbursed for SCN program activities.
Screening
| Option | Reimbursement2 | Key Considerations |
|---|---|---|
| Option 1: Use the SCN IT Platform | ||
| 1a. Use the SCN IT Platform without an EHR API (direct connection) | Reimbursable for providers contracted with an SCN and using the SCN IT Platform |
|
| 1b. Use the SCN IT Platform with an EHR API (direct / native connection, as available) |
|
|
| Option 2: Use an EHR connection to SHIN-NY QE (bypass the SCN IT Platform) | ||
| 2a. Use existing or new connection between EHR and a SHIN-NY QE | Reimbursable for providers contracted with the SCN and share data with the SCN via a QE |
|
| 2b. Use a SMART on FHIR application embedded in EHR |
|
|
| Option 3: Use a QE's Clinical Portal (bypass the SCN IT Platform and EHR) | ||
| 3. Use a QE's Clinical Portal to screen members and send data to SHIN-NY data lake | Reimbursable for providers contracted with the SCN |
|
| Option 4: Submit self-screenings | ||
| 4. Submit self- screenings through Options 1-3 or a mobile app | Reimbursable only when reviewed by a provider in a one- on-one interaction with the member |
|
Navigation, Care Management, and / or Service Delivery
| Option | Reimbursement | Key Considerations |
|---|---|---|
| 1. Use the SCN IT Platform without an EHR API (direct connection) | Reimbursable for providers contracted with an SCN and using the SCN IT Platform |
|
| 2. Use the SCN IT Platform with an EHR API (direct / native connection) |
|
C. Commonly asked questions
Q1. If I am contracted with an SCN Lead Entity, do I need to use the SCN's IT Platform to be reimbursed for screenings?
A. No, a provider contracted with an SCN does not need to use the SCN's IT Platform to be reimbursed for screenings. As outlined in Options 2 and 3 in the Screening table above, providers contracted with an SCN can use an EHR connection to the SHIN-NY QE to send screening data or use a QE clinical portal if your QE offers this functionality. Reimbursement to providers under Options 2 and 3 is limited to screenings, and those screening must include the New York State (NYS) Accountable Health Communities (AHC) screening question-and- answer pairings and SHIN-NY Consent Question.4
Q2. If I am not contracted with an SCN Lead Entity, can I still screen members for HRSNs using my EHR?
A. Yes, providers that do not have a contract established with an SCN Lead Entity are still encouraged to screen members and can send screenings to their QE in an acceptable format, which are then shared with SCNs for Navigation and Service Delivery as long as the provider collects and sends SHIN-NY member consent (i.e., NYS-specific “Question 0”) along with the screening data. However, providers not contracted with an SCN Lead Entity cannot be reimbursed for screenings.
Q3. Can an Independent Physician Association (IPA) submit screenings through its regional QE on behalf of its provider network?
A. An IPA can submit screenings and receive payment for the submitted screenings on behalf of its networked providers if it is contracted with an SCN Lead Entity. IPAs not contracted with an SCN Lead Entity can submit screenings, however those screenings will not be reimbursed.
Q4. Can I use a screening tool other than Accountable Health Communities (AHC) if it is already embedded in my EHR, and will those screenings be reimbursed?
A. OHIP strongly recommends using the AHC screening tool for the SCN program (which includes a consent to screen question). Providers can use a custom screening form (i.e., other than the AHC) if it includes all of the exact question-and-answer pairings in the AHC tool outlined in “Table 5-3: Select required data elements for screenings conducted outside the SCN IT Platform” of the SCN Operations Manual. Any custom screening form must include the exact question prompts and answer choices from the AHC, and the EHR must be capable of sending the required LOINC codes (see here for guidelines on LOINC coding). The screening tool used must include NYS-specific "Question 0" to obtain consent for screening. If providers use a screening tool that does not satisfy these requirements, those screenings will not be reimbursed.
Q5. How can I be reimbursed if a member completes a self-screening?
A. Providers can complete screenings interactively with a member, or screenings may be completed by the member prior to the visit (e.g., during registration) and then reviewed with the provider during the face-to-face visit. Per the SCN Operations Manual, providers will not receive payment if a member self-screens without a subsequent one-on-one interaction with a provider, including screenings in which the member only uses an online self-screening tool or other digital screening with no one-on-one human interaction (e.g., online form, AI chatbot).
Q6. Why do I need to collect consent data and how often does consent need to be renewed?
A. It is important that members understand how their HRSN Data may be shared upon consent. Any member must be allowed to decline screening in any setting where screening is offered. If a member consents, their screening data will be shared with a regional QE, and SHIN-NY will share the screening data with the SCN Lead Entity. Providers are required to collect member consent before conducting screening. If a member declines, the screening should not take place. For more information, refer to the SCN Operations Manual, Section 5: Care Delivery Approach, sub-sections k: Member Consent, i-iii. Member Consent for Screening, Eligibility Assessment and Referral / Navigation.
Q7. Does a provider need to work with the QE located in its own region, or can a provider work with another QE to share screening data?
A. Providers are encouraged to collaborate with their regional QE. However, a provider may contribute screening data via any QE. Providers with existing connections to a QE for other services are not required to use that same QE to share screening data.
Q8. Does the QE charge providers for getting connected and will the QE charge providers who are already connected to send their screening data?
A. No, there is no cost to providers in getting connected to a QE and no additional costs for providers that are connected to a QE to share screening data.
Q9. Will I be able to see whether a member has been seen elsewhere by another entity (e.g., a community-based organization)?
A. Yes, all six regional QEs have expanded their QE Clinical Query Portals to include a section for HRSN information. Providers with the member's SHIN-NY consent can see whether a member has been screened, assessed and/or referred for services.
Q10. Will I be reimbursed for all screenings that I conduct?
A. Providers will only be reimbursed for screening members that are eligible Medicaid members, have not been screened in the last 12 months, unless a major life event warranted a re-screening, and the screening involved a one-on-one interaction between the provider and member. Providers should refer to “Table 5-1: Frequency of HRSN Screening” for a list of possible major life events and “Table 5-4: Excluded Populations” in the SCN Operations Manual for a list of ineligible populations. For an individual member, providers can receive up to one additional reimbursed re-screen per year following a member's annual screening by submitting the re-screening Healthcare Common Procedure Coding System (HCPCS) code and supporting modifier in the invoice to the SCN Lead Entity.
Q11. How will I be reimbursed for the time I spend with a member for HRSN screenings done in my EHR?
A. By default, a screening submitted by providers will be reimbursed for one 15-minute service unit if the provider spends at least 8 minutes interacting with the member. Providers should work with their SCN Lead Entity to understand options for reimbursement of multiple service units and required documentation. For example, providers may configure their EHRs to capture the time spent on screening and share that data with the QE. The data will then be routed to the SCN Lead Entity.
Q12. Am I qualified for 2025 NYS Patient-Centered Medical Home (PCMH) Managed Care incentives if I submit an HRSN screening through one of the options outlined in the Screening table above?
A. Yes, the submission of HRSN screenings satisfies the NYS PCMH Managed Care Incentive requirement for PCMH providers to develop a workflow to refer members to SCNs. PCMH providers are also required to submit an attestation by March 31, 2025, confirming their participation in the SCN program. Please see here for more details on the 2025 PCMH incentives.
Q13. Is there funding to support providers in connecting to the SCN data/IT infrastructure?
A. SCN Lead Entities can fund contracted providers to connect and onboard to their SCN IT Platform. However, SCN program funds cannot be used to pay for IT infrastructure outside of the SCN IT Platform, including EHR integrations such as APIs or changes to EHR workflows or other systems (e.g., care management software).
Q14. What data security / compliance requirements should providers be aware of?
A. Providers should adhere to SHIN-NY data privacy and security policies, as well as federal and New York State requirements, and New York State's guidance (e.g., HIPAA compliance, 1115 SHIN-NY interoperability). Please see the Privacy and Security Guidance for Qualified Entities and Their Participants for additional details on data privacy and security requirements.
D. Key points of contact for providers
SCN Lead Entities
| SCN Lead Entity | Point of contact |
|---|---|
| Care Compass Collaborative | Mark Ropiecki - mropiecki@carecompassnetwork.org |
| Health Equity Alliance of Long Island | Lori Andrade - landrade@hwcli.com |
| Healthy Alliance Foundation Inc. | Erica Coletti - erica.coletti@healthyalliance.org |
| Hudson Valley Care Coalition, Inc. | Amie Parikh - aparikh@hvcare.net |
| Public Health Solutions | Zachariah Hennessey - zhennessey@healthsolutions.org |
| Somos Healthcare Providers, Inc. | Lidia Virgil - lvirgil@somoscommunitycare.org |
| Western New York Integrated Care Collaborative Inc. | Support inbox - info@wnyicc.org |
| Forward Leading IPA | Patricia McMahon - pmcmahon@forwardleadingipa.org |
| Staten Island Performing Provider System | Joseph Conte - jconte@statenislandpps.org |
For general questions about the SCN program and how to participate, please contact SDH@health.ny.gov.
Qualified Entities
| Qualified Entity | Points of contact |
|---|---|
| Hixny | Bryan Cudmore - Bcudmore@hixny.org |
| HealtheConnections | Bernard Bush - bbush@healtheconnections.org
Rachel Kramer - rkramer@healtheconnections.org |
| Healthix | Harold Del Pino - hdelpino@healthix.org
Nick VanDuyne - nvanduyne@healthix.org |
| Bronx RHIO | Sujatha Thalappillil - Sujatha@shatzkinsystems.com
Keela Shatzkin - Keela@Shatzkinsystems.com Kathryn Miller - KMILLER@bronxrhio.org |
| HEALTHeLINK | Stacy Goyette - SGoyette@wnyhealthelink.com
Charles McCarthy - CMcCarthy2@wnyhealthelink.com |
| Rochester RHIO | Michael Frey - michael.frey@grrhio.org
Marlene Bessette - marlene.bessette@grrhio.org Teraisa Mullaney - teraisa.mullaney@grrhio.org Murali Krishnan - murali.krishnan@grrhio.org Lisa Frerichs - lisa.frerichs@grrhio.org |
For general questions about SHIN-NY, Qualified Entities and how to get connected, please contact 1115-waiver@nyehealth.org.
E. Helpful Links
| SCN Information for Health Care Providers website | The NYS DOH website with information for providers about participating in the Social Care Networks |
| SCN: Program, Billing, and Data Governance Operations Manual | Guidance on requirements governing the delivery of HRSNs services, as well as instructions related to data management, security and sharing |
| NYeC 1115 Waiver website | Links to criteria and specifications for submitting screening data to the QE via CSV (flat file), CCDA, or through the FHIR IG |
| LOINC Coding Specifications | Guidelines on the LOINC coding specifications for the AHC screening tool |
| NYS PCMH Managed Care Incentive | NYS website with additional details on the NYS PCMH Managed Care incentives |
| SHIN-NY Privacy and Security Policies | Privacy and security guidelines for Qualified Entities and providers participating in the New York's Statewide Health Information Network |
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1 TogetherNow is not submitting data in production at this time. 1
2 A comprehensive list of criteria for reimbursement is available in the SCN Operations Manual. 2
3 Please see the Helpful Links at the end of this document for NYeC resources for submitting data to the QE via CSV, CCDA, or FHIR. 3
4 Please refer to the SCN Operations Manual, "Table 5-2: AHC HRSN Screening Tool" in Section 5: Care Delivery Approach, Subsections B. Screening, v. AHC Screening Tool." 4
