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.

Provider Alert - Cost Sharing for Medicare Part B Drugs

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

Healthfirst to Manage Some Outpatient Authorization Requests Formerly Handled by OrthoNet

Effective Jan. 1, 2024, Healthfirst will resume responsibility for management of prior authorization (PA) requests for all Physical, Occupational, and Speech Therapies; Podiatry Services, and Vascular Surgery. This Provider Alert will help you understand how this change might affect you...

Medical Nutrition Therapy Added to the Article 29-I VFCA Health Facilities

In accordance with the approved Medicaid State Plan Amendment: Medical Nutrition Therapy (MNT) has been added to the Article 29-I VFCA Health Facilities (29-I) Other Limited Health Related Services (OLHRS) Fee Schedule. View for more details.

Pharmacist-Administered Human Papillomavirus (HPV) Vaccine Now Available to Healthfirst Patients Aged 18+

New York law has expanded the types of immunizations licensed pharmacists can administer to patients 18 years or older, including the HPV vaccine.

Reimbursement Policy: Anesthesia Start and Stop Times

Healthfirst requires that providers include the start time, stop time, and duration of anesthesia in the note segment of the 5010 claim form.

Online Authorization Tool – Requesting Prior Authorization for Medical Benefit Specialty Drugs