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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 - 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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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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Healthfirst Plans
Authorization
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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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Healthfirst Plans
Authorization
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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Manufacturers Withdrawing from the Medicaid Drug Rebate Program (MDRP)

Effective January 1, 2026, several drug manufacturers have voluntarily withdrawn from participation in the Medicaid Drug Rebate Program (MDRP). In accordance with federal requirements, NYRx will no longer provide Medicaid coverage for drugs manufactured by the companies listed in this provider alert.

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Administration
Healthfirst Plans
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Changes to Prior Authorization Submissions for Back Pain Management and Spinal Surgery Services

Starting June 1, 2026, Healthfirst providers will need to submit prior authorizations via Optum’s Spine, Pain, and Joint portal as the OrthoNet portal will be discontinued.

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Reimbursement
Healthfirst Plans
Administration
Authorization
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Integra Partners to Manage Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Prior Authorization Requests Effective June 1, 2026

Effective June 1, 2026, Integra Partners will manage prior authorization (Utilization Management) for all Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) on behalf of Healthfirst for all plans.

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

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

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Healthfirst Plans
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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization No Longer Required for Select Codes Starting April 1, 2026

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

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Essential Plan: What Providers Must Know about Newborn Enrollment

Healthfirst is reinforcing New York State Department of Health (NYSDOH) requirements regarding newborn coverage rules. This alert highlights the importance of timely newborn reporting, billing, and enrollment.

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Administration
Medicaid
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
CMS Cell and Gene Therapy (CGT) Access Model for Casgevy™ (exagamglogene autotemcel) and Lyfgenia® (lovotibeglogene)

Medicaid Practitioner Administered Drugs Update

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Administration
Healthfirst Plans
Medicaid
  
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