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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Required for Select Services Starting October 1, 2026

CPT/HCPCS Level II codes newly released by the American Medical Association (AMA) and The Centers for Medicaid and Medicare Services - effective October 1, 2026 - will require prior authorization and will be managed by Healthfirst’s delegated vendor(s) EviCore, under the EviCore Lab Program and Integra.

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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Requirements for Select Codes Starting December 30, 2026

Effective December 30, 2026, Healthfirst will require prior authorization for select codes. These changes are part of Healthfirst’s ongoing responsibility to evaluate its medical policies compared to the latest scientific evidence and specialty society guidance.

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Provider Alerts - Claims & Billing - Practice Guidelines and Tips - 2026
Prior Authorization Requirements for Select Codes Starting November 30, 2026

Effective November 30, 2026, Healthfirst will require prior authorization requirements for several CPT codes.

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Healthfirst Plans
Authorization
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Important Update to Electronic Remittance Advice (ERA) Distribution Logic

Healthfirst is updating the logic used to route ERA transactions.

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Administration
Reimbursement
  
Provider Alerts - Claims & Billing - Coronavirus (COVID-19) - Policy, Billing, or Coverage Update - 2021
COVID-19 Testing — Billing Guidance

Healthfirst will cover medically appropriate COVID-19 testing at no cost share during the public health emergency when such testing is ordered by a physician or licensed healthcare professional for the purpose of diagnosis or treatment of COVID-19.

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COVID-19
  
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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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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Administration
Healthfirst Plans
Authorization
Reimbursement
  
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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Administration
Healthfirst Plans
Medicaid
Medicare
  
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
Reimbursement
  
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 - 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
  
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