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Provider Alerts (Policy, Billing, or Coverage Update) - 2021
Pharmacy Billing Guidance for COVID-19 Vaccine Under Healthfirst’s Medicaid Managed Care Plan (MMC) and Personal Wellness Plan

Per New York Governor Cuomo’s Executive Order #202, during the declared disaster emergency, pharmacies may bill for COVID-19 vaccines that have been authorized by the FDA under Emergency Use Authorization (EUA) under Healthfirst’s Medicaid Managed Care Plan and Personal Wellness Plan. As additional COVID-19 vaccines become available under an EUA, or are otherwise approved by the FDA, this billing guidance will be updated as needed.
Personal Wellness Plan
  
  
Pharmacy Billing Guidance for COVID-19 Vaccine Under Healthfirst’s Medicaid Managed Care Plan (MMC) and Personal Wellness Plan
Provider Alerts (Policy, Billing, or Coverage Update) - 2021
Transition of the Pharmacy Benefit from Managed Care to Fee-for-Service

Effective May 1, 2021, at the direction of the New York State Department of Health (NYSDOH), Medicaid Managed Care (MMC) plans will move the pharmacy benefit into the NYS Fee-for-Service (FFS) program. To prepare for this change, on March 1, 2021, Healthfirst will transition select physician-administered drugs paid under the pharmacy benefit to the Healthfirst medical benefit.
  
Transition of the Pharmacy Benefit from Managed Care to Fee-for-Service
Provider Alerts (Policy, Billing, or Coverage Update) - 2021
Anesthesia Services Maximum Daily Units

Anesthesia services (00100–01999) are limited to a specific number of units per member, per provider group, per day. These limits are considered “typical” but may not reflect the actual services provided.

If units are billed beyond our established limits, the total units allowed will be adjusted to the assigned maximum allowed; all other units will be denied. However, additional units can be considered for payment with supporting documentation upon appeal.
Reimbursement
  
  
0077 21 Provider Alert Anesthesia Unit Policy v3 1 FINAL
Provider Alerts (Policy, Billing, or Coverage Update) - 2021
Ambulance Diagnosis Policy

Per CMS LCD L35162 (Jurisdiction H and L), emergency ambulance services (A0425–A0434) are a covered benefit when the services meet the medical necessity requirements as outlined in the CMS manuals and Federal Register sections listed in the CMS National Coverage Policy section indicated in this document.

Providers should report the most appropriate ICD-10 code that adequately describes the patient’s medical condition at the time of transport as the primary diagnosis. 40TIn addition, a secondary diagnosis must be reported to indicate that transportation by any other means is medically contraindicated.
Reimbursement
  
  
0078 21 Provider Alert Ambulance Diagnosis Policy v3 1 FINAL
Provider Alerts (Practice Guidelines and Tips) - 2021
Healthfirst Utilization Management

On December 23, 2020, the New York Department of Financial Services (DFS) issued Insurance Circular Letter No. 17, Coronavirus and the Suspension of Certain Utilization Review and Notification Requirements under the “Surge and Flex” Protocol. Access this document to learn about what Healthfirst is doing in response to this protocol and for more information.
Utilization Review
  
Skilled Nursing Facility
  
  
Healthfirst Utilization Management

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