Frequently Asked Questions: Healthfirst Laboratory Benefit Management Program

Effective June 1, 2023, Healthfirst will apply updated billing and reimbursement policies to claims reporting laboratory services performed in office, hospital outpatient, and independent laboratory locations. Review these answers to frequently asked questions.

Transition of the Pharmacy Benefit from Managed Care to Fee-for-Service

Effective April 1, 2023, Medicaid members enrolled in Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will receive their pharmacy benefits through the NYRx Pharmacy program, formerly known as the NYS Fee-for-Service (FFS) Pharmacy program.

Coverage Update: Monoclonal Antibody Therapies

As of December 1, 2022, bebtelovimab is not FDA-approved and will not be covered by Healthfirst. View details.

Authorization Requirement Update for Vision Services

Effective May 1, 2023, Healthfirst no longer requires authorization for selected vision services.

Introducing Coding Validation from Cotiviti

Effective Sept. 1, 2023, consistent with the recommendations of the Office of Inspector General and the Centers for Medicare & Medicaid Services, Healthfirst will implement Cotiviti’s Coding Validation, an enhanced program based on nationally sourced guidelines regarding modifier usage.

New Prior Authorization Guidelines for Select Services

Effective Nov. 1, 2023, Healthfirst will change its authorization guidelines for select services due to newly created codes on the CMS code list. As of that date, the services requiring prior authorization will include spinal surgery services managed through OrthoNet™, as well as radiation therapy and laboratory services managed through eviCore.

Coronavirus: Telehealth Policies FAQ

Did you know that providers need to be approved by Healthfirst to continue qualifying for reimbursement of telehealth services? Access our FAQs to learn more.

Drug Testing Policy

Healthfirst aims to ensure that our policy standards are up to date and are compliant with state and national industry standards. Effective February 1, 2021, Healthfirst has limited the reimbursement of drug testing as outlined in this document.

Waiver of Liability Form 2020

Medicare Coverage Billing Guidance for Intensive Outpatient Programs

As of Jan. 1, 2024, Medicare now covers Intensive Outpatient Services. Learn more about the program and billing requirements here.

Provider Alert - Cost Sharing for Medicare Part B Drugs

Details regarding cost sharing policy changes due to the Inflation Reduction Act.