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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Required for Newly Released Codes Starting July 1, 2026

Codes newly released by the American Medical Association will include prior authorization requirements starting July 1, 2026.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Required for Select Codes Starting October 1, 2026

Effective October 1, 2026, Healthfirst will require prior authorization for select medical services.

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Healthfirst Plans
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Provider Alerts - Claims & Billing - Practice Guidelines and Tips - 2026
Interoperability and Prior Authorization Final Rule Requirements

Healthfirst is updating prior authorization and concurrent review decision timeframes to comply with the CMS Interoperability and Prior Authorization Final Rule. Effective January 1, 2026, standard authorization decisions for applicable Medicaid and Medicare lines of businesses.

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Healthfirst Plans
Medicaid
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Provider Alerts - Behavioral Health and Foster Care - Practice Guidelines and Tips - 2026
Clinical Document Submission for Healthfirst Personal Wellness Plan

Frequently asked questions related to the submission of clinical documents by Behavioral Health providers for HARP/PWP members.

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Administration
Healthfirst Plans
Authorization
  
Provider Alerts - Claims & Billing - Practice Guidelines and Tips - 2026
Request a Continuous Glucose Monitoring Device for Healthfirst Medicare, Essential Plan, and Qualified Health Plan Members

Healthfirst members with Type 1 or Type 2 diabetes may qualify for a Continuous Glucose Monitoring (CGM) device if eligible. Available to Medicare, Essential Plan, and QHP members through an in-network DMEPOS provider, not a pharmacy.

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Administration
Healthfirst Plans
Authorization
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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Introducing Genetic and Molecular Coding Validation from Concert Genetics

Effective May 1, 2026, Healthfirst is updating reimbursement policies for genetic and molecular lab testing for all Healthfirst Plans with respect to our new partnership with Concert Genetics

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Administration
Healthfirst Plans
Authorization
Reimbursement Policy
  
Provider Alerts - Plans & Benefits - Policy, Billing, or Coverage Update - 2026
New York State Essential Plan 200-250 Coverage to End Effective 7/1/2026

The New York State Essential Plan coverage for individuals with incomes between 200% and 250% of the Federal Poverty Level (FPL) will end effective July 1, 2026.

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Healthfirst Plans
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Introducing Claim Pattern Review Program from Cotiviti

Effective August 1, 2026, Healthfirst will implement Cotiviti’s Claim Pattern Review Program to conduct ongoing reviews of specific professional claims.

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Administration
Healthfirst Plans
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Required for Select Codes Starting July 1, 2026

Effective July 1, 2026, Healthfirst will require prior authorization requirements for several CPT codes.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Required for Select Codes Starting June 1, 2026

The following codes newly released by the Centers for Medicare and Medicaid Services (CMS) on April 1, 2026, will include prior authorization requirements starting June 1, 2026.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Physical Therapy Authorization and Approval Guidance Effective January 31, 2026

A provider questionnaire will now accompany initial prior authorization requests for Adult Physical Therapy across all Healthfirst plans to support efficient reviews and appropriate care decisions.

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Administration
Healthfirst Plans
Authorization
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Provider Alerts - Practice Guidelines and Tips - 2026
Somatus Care Management Program for Patients with Chronic Kidney Disease or End Stage Renal Disease

As part of our continued effort to provide members with the best possible quality care, Healthfirst has partnered with Somatus Inc. (Somatus) to support members diagnosed with Chronic Kidney Disease (CKD) or End Stage Renal Disease (ESRD).

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Administration
  
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