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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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Administration
Healthfirst Plans
Authorization
Reimbursement
  
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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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Practice Guidelines and Tips - 2026
Somatus Care Management Program for Patients with Chronic Kidney Disease or End Stage Renal Disease

As part of our continued effort to provide members with the best possible quality care, Healthfirst has partnered with Somatus Inc. (Somatus) to support members diagnosed with Chronic Kidney Disease (CKD) or End Stage Renal Disease (ESRD).

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Administration
  
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Effective January 1, 2026, several drug manufacturers have voluntarily withdrawn from participation in the Medicaid Drug Rebate Program (MDRP).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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Administration
Healthfirst Plans
Authorization
Reimbursement
  
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
  
Provider Alerts - Pharmacy Resources & Formularies - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Billing Physician Administered Drugs

Healthfirst Responsibility for Physician Administered Drugs and the NYRx Program

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Medicaid
Reimbursement
Pharmacy
  
Provider Alerts - Practice Guidelines and Tips - 2025
NYS Medicaid APG Weight Adjustment for Dialysis Clinics

Effective January 1, 2026, the New York State (NYS) Medicaid program, including both Fee-for-Service (FFS) and Medicaid Managed Care (MMC) plans, will incorporate the costs of phosphate binders provided during dialysis sessions into the Ambulatory Patient Group (APG) payment.

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Administration
Medicaid
  
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