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Provider Alerts - Pharmacy Resources & Formularies - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Billing Physician Administered Drugs

Healthfirst Responsibility for Physician Administered Drugs and the NYRx Program

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Medicaid
Reimbursement
Pharmacy
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Prior Authorization No Longer Required for Select EviCore Codes Starting January 1, 2026

Effective January 1, 2026, Healthfirst will remove prior authorization requirements for several CPT codes currently managed by Evicore.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Prior Authorization Requirements for Select Services Starting January 1, 2026

CPT codes, newly released by the Centers for Medicare & Medicaid Services (CMS) and effective January 1, 2026, will include prior authorization requirements.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Prior Authorization Requirements for Select Services Starting April 1, 2026

Effective April 1, 2026, Healthfirst will add prior authorization requirements for select medical services for Medicare Plans only.

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Administration
Healthfirst Plans
Medicare
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Over-the-Counter (OTC) Plus Card Changes for 2026

Starting January 1, 2026, Healthfirst members enrolled in our Life Improvement Plan (HMO D-SNP) and Connection Plan (HMO D-SNP) will need to qualify for Special Supplemental Benefit for the Chronically Ill (SSBCI) to use their OTC Plus Card for healthy food and home utilities.

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Administration
Healthfirst Plans
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Reimbursement Update for Child Abuse Pediatrics Services

Effective December 1, 2025, in alignment with the New York State Department of Health, Healthfirst Medicaid will begin reimbursing physicians certified by the American Board of Pediatrics in Child Abuse Pediatrics a once-per-New York State Medicaid member lifetime fee for services related to the diagnosis, treatment, or supervision of care in cases of suspected child maltreatment.

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Administration
Healthfirst Plans
Medicaid
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Updated Telehealth Modifier Use

Updates to the billing requirements for telehealth services delivered through New York State Office of Mental Health (OMH)

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Reimbursement
Healthfirst Plans
Administration
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Update on NYS Medicaid Coverage for Therapeutic Transcranial Magnetic Stimulation (TMS)

Effective November 1, 2025, Healthfirst will provide coverage for Therapeutic Transcranial Magnetic Stimulation (TMS) for eligible Medicaid, Medicaid Advantage Plus (MAP), and Health and Recovery Plan (HARP) members diagnosed with Treatment-Resistant Major Depressive Disorder (MDD)..

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Administration
Healthfirst Plans
Medicaid
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Important Prior Authorization Changes effective October 1, 2025

Healthfirst will remove prior authorization requirements for selected medical services effective October 1, 2025

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Healthfirst Plans
Administration
Authorization
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Important Prior Authorization Changes effective December 1, 2025

Healthfirst will add prior authorization requirements for selected medical services effective December 1, 2025

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Healthfirst Plans
Administration
Authorization
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Changes To Opioid Treatment Program (OTP) Bundle Rate Billing Requirements Effective November 3, 2025

Updated Billing Requirements to Opioid Treatment Program (OTP)

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Reimbursement
Medicaid
Administration
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Electronic Consultation (eConsult) Reimbursement

Reimbursement Updates for eConsults

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Administration
Reimbursement
Healthfirst Plans
  
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