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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Required for Select Services Starting October 1, 2026

CPT/HCPCS Level II codes newly released by the American Medical Association (AMA) and The Centers for Medicaid and Medicare Services - effective October 1, 2026 - will require prior authorization and will be managed by Healthfirst’s delegated vendor(s) EviCore, under the EviCore Lab Program and Integra.

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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Requirements for Select Codes Starting December 30, 2026

Effective December 30, 2026, Healthfirst will require prior authorization for select codes. These changes are part of Healthfirst’s ongoing responsibility to evaluate its medical policies compared to the latest scientific evidence and specialty society guidance.

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Provider Alerts - Policy, Billing, or Coverage Update - 2026
Public Charge Regulation Update

USCIS updated Public Charge guidance, expanding case-by-case consideration of individual circumstances. Healthfirst encourages members to seek guidance before making changes to their or their children’s health coverage.

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Administration
Healthfirst Plans
Reimbursement
  
Provider Alerts - Claims & Billing - Practice Guidelines and Tips - 2026
Prior Authorization Requirements for Select Codes Starting November 30, 2026

Effective November 30, 2026, Healthfirst will require prior authorization requirements for several CPT codes.

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Administration
Healthfirst Plans
Authorization
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Important Update to Electronic Remittance Advice (ERA) Distribution Logic

Healthfirst is updating the logic used to route ERA transactions.

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Administration
Reimbursement
  
Provider Alerts - Practice Guidelines and Tips - 2026
Managing Member Concerns and Grievances

These FAQs serve as a resource to help practices identify and address member concerns and dissatisfaction. Along with enhancing the quality of care and service delivery to foster a positive member experience and reduce the occurrence of complaints and grievances.

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Provider Alerts - Practice Guidelines and Tips - 2026
Cotiviti Claim Pattern Review Program

Starting August 1, 2026, Healthfirst will implement Cotiviti’s Claim Pattern Review (CPR) Program to conduct ongoing reviews of specific professional claims.

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Healthfirst Plans
Reimbursement
  
Provider Alerts - Practice Guidelines and Tips - 2026
Managing Shared Services in Households with Multiple Members

Effective April 6, 2026, Healthfirst may designate a portion of authorized Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS) hours as shared services when two or more members live in the same household.

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Administration
Healthfirst Plans
Medicare
Medicaid
  
Provider Alerts - Practice Guidelines and Tips - 2026
Access to Care and Appointment Availability Audits

This FAQ helps providers understand Access to Care and Appointment Availability (ACAA) standards and prepare for compliance audits.

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Administration
Healthfirst Plans
  
Provider Alerts - Claims & Billing - Coronavirus (COVID-19) - Policy, Billing, or Coverage Update - 2021
COVID-19 Testing — Billing Guidance

Healthfirst will cover medically appropriate COVID-19 testing at no cost share during the public health emergency when such testing is ordered by a physician or licensed healthcare professional for the purpose of diagnosis or treatment of COVID-19.

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COVID-19
  
Provider Alerts - Policy, Billing, or Coverage Update - 2026
Physical and Occupational Therapy Authorization and Approval Guidance

New Occupational Therapy Requirements Effective June 29, 2026

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Administration
Authorization
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Required for Newly Released Codes Starting July 1, 2026

Codes newly released by the American Medical Association will include prior authorization requirements starting July 1, 2026.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
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