New Prior Authorization Guidelines for Select Services effective July 1, 2024

Effective July 1, 2024, Healthfirst will change its authorization guidelines for select services on the CMS code list. As of that date, the services requiring prior authorization will include laboratory services (managed through eviCore). See the Provider Alert for a list of codes that will now require prior authorization.

New Effective Date for Acupuncture, Occupational Therapy, Physical Therapy, and Speech Therapy Standard Fee Schedule Rates

The effective date for these changes has been delayed from April 1, 2024, to June 1, 2024.

eviCore Quick Reference Guide

View this eviCore QRG for resources and phone numbers.

Healthfirst Reimbursement Policy Updates - Effective March 1, 2020

Healthfirst Reimbursement Policy Updates

New CMS Modifiers for Distinct Procedural Services (59 Modifier)

Transcranial Dopplers: Coding, Billing, and Medical Requirements

To ensure appropriate payments and maintain billing efficiencies, Healthfirst is committed to informing providers of specific requirements for the usage of any medical device. This alert provides guidance on Healthfirst coding, billing, and medical requirements for Transcranial Dopplers (TCD).

Billing for No-Cost Drugs and Biologicals

Healthfirst requires that providers record all substances administered to patients and that a charge be reported, even for no-cost drugs and biologicals. When this occurs, the provider or qualified healthcare professional should submit a token charge of $0 for the item.

Healthfirst Reimbursement Policy Updates - Effective February 1, 2022

Healthfirst aims to ensure that our reimbursement policy standards are compliant with state and national industry standards. Effective February 1, 2022, several changes will be made to our reimbursement policy to maintain compliance with industry-accepted coding and reimbursement practices, as well as state and national regulatory requirements.

Healthfirst Reimbursement Policy Updates - Effective March 1, 2022

As a part of Healthfirst’s continuing efforts to ensure that our reimbursement policy standards are up to date and compliant with state and national industry standards, our reimbursement policy will undergo several changes effective March 1, 2022. These changes will maintain compliance with industry-accepted coding and reimbursement practices, as well as with state and national regulatory requirements.

Changes to Authorization Guidelines for Selected Medical Services

Effective April 1, 2022, Healthfirst will change its authorization guidelines for selected medical services. These changes are part of Healthfirst’s ongoing responsibility to evaluate its medical policies compared to the latest scientific evidence and specialty society guidance.

Healthfirst Policy for the Authorization of Applied Behavioral Analysis (ABA) Services

Healthfirst’s medical policies are intended to provide guidance in the administration of Healthfirst’s benefit plans and are used by medical directors and other clinical professionals in making medical necessity and other coverage determinations. This policy is applicable to the Commercial Plan, Qualified Health Plan (QHP), Essential Plan (EP) and Child Health Plus (CHP). While this service is not covered by Healthfirst Medicaid Managed Care Plan, ABA services are available to Medicaid beneficiaries through Medicaid Fee-for-Service.