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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Manufacturer Withdrawal 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Effective January 1, 2026, several drug manufacturers have voluntarily withdrawn from participation in the Medicaid Drug Rebate Program (MDRP).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
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
  
Provider Alerts - Practice Guidelines and Tips - 2025
Applied Behavior Analysis (ABA) Supervision Requirements

Effective October 1, 2025, the New York State Department of Health (NYS DOH) will implement updated supervision standards for Licensed Behavior Analysts (LBAs) overseeing unlicensed individuals/technicians delivering Applied Behavior Analysis (ABA) services.

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Administration
Medicaid
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Prior Authorization No Longer Required for Select EviCore Codes Starting January 1, 2026

Effective January 1, 2026, Healthfirst will remove 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 - 2025
Prior Authorization Requirements for Select Services Starting January 1, 2026

CPT codes, newly released by the Centers for Medicare & Medicaid Services (CMS) and effective January 1, 2026, will include prior authorization requirements.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Prior Authorization Requirements for Select Services Starting April 1, 2026

Effective April 1, 2026, Healthfirst will add prior authorization requirements for select medical services for Medicare Plans only.

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Administration
Healthfirst Plans
Medicare
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2025
Over-the-Counter (OTC) Plus Card Changes for 2026

Starting January 1, 2026, Healthfirst members enrolled in our Life Improvement Plan (HMO D-SNP) and Connection Plan (HMO D-SNP) will need to qualify for Special Supplemental Benefit for the Chronically Ill (SSBCI) to use their OTC Plus Card for healthy food and home utilities.

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Administration
Healthfirst Plans
  
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