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Provider Alerts - Provider Resources - 2024
Changes to the Special Enrollment Period for Dual-Eligible and Low-Income Subsidy Recipients Beginning in 2025

The 2025 Centers for Medicare & Medicaid Services (CMS) Medicare Advantage and Part D Final Rule includes several changes to enrollment for our dual-eligible and Low-Income Subsidy (LIS) members.

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Healthfirst Plans
Medicare
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2024
Prior Authorization No Longer Required for Antiretroviral Prescription Medications

Healthfirst has removed prior authorization requirements from all antiretroviral medications prescribed for the treatment or prevention of Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS) for all Healthfirst plans.

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Authorization
Preventive Measures
Healthfirst Plans
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2024
Crisis Residence and Mobile Crisis Services Now Covered for Healthfirst Essential Plan, Leaf, and Leaf Premier Members

Starting January 1, 2025, Healthfirst will cover Crisis Residence Services and Mobile Crisis Services for our Essential Plan (EP) and Leaf and Leaf Premier Plan members (also known as our Qualified Health Plans). Additionally, these services will continue to be covered under the Medicaid, Personal Wellness Plans (HARP), Child Health Plus (CHPlus), and Medicaid Advantage Plan (MAP) lines of business.

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Medicaid
Behavioral Health and Mental Health
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2024
Changes to OASAS Comprehensive Outpatient Treatment Programs and Updated Billing Guidance

The New York State Office of Addiction Service and Supports (OASAS) is implementing several changes to integrate care within the OASAS outpatient clinic regulatory structure, including a merged Comprehensive Outpatient Treatment Program (COP) operating certificate, COP reimbursement updates, and inclusion of Opioid Treatment Program (OTP) bundles into APG methodology.

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Behavioral Health and Mental Health
Reimbursement
Medicaid
Healthfirst Plans
  
Provider Alerts - Policy, Billing, or Coverage Update - 2024
Two Additional Prior Authorization Codes Managed by EyeMed Effective Jan. 1, 2025

EyeMed manages Healthfirst’s prior authorization for surgical and therapeutic vision services as well as network management, related member and provider service calls, and claims payment for routine vision and medical optometry services. Starting Jan. 1, 2025, EyeMed will manage prior authorization for J2777 and J0177.

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Administration
Authorization
Dental and Vision
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2024
Enhancing Claims Processing Accuracy with ClaimsXten

ClaimsXten (CXT) is an industry-leading claims editing software that adjudicates claims more efficiently and aligns with Healthfirst standards. Review the provider alert for more information on CXT, including updated frequently asked questions.

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Administration
  
Provider Alerts - Claims & Billing - Practice Guidelines and Tips - 2024
Prior Authorization Guidelines for Select CPT and HCPCS Codes Effective Jan. 1, 2025

Starting Jan. 1, 2025, Healthfirst will change its authorization guidelines for select CPT and HCPCS codes. See the Provider Alert for a list of codes that will now require prior authorization.

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Administration
Authorization
  
Provider Alerts - Practice Guidelines and Tips - 2024
Healthfirst’s Eligibility Search Tool Will Fully Transition to Availity

Starting October 1, 2024, Healthfirst’s Eligibility Search tool will be accessible only through Availity Essentials. Access to the Eligibility Search tool via HFproviderportal.org will end after September 30, 2024, and providers will be redirected to log into Availity Essentials.

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Administration
  
Provider Alerts - Coronavirus (COVID-19) - Practice Guidelines and Tips - 2023
Medicaid Members Under Age 19 are Eligible for the Vaccines for Children Program

Children under age 19 can receive the COVID‑19 vaccine at Vaccines for Children (VFC)‑enrolled providers, including their practitioner’s office, public health clinics, most county health departments, and any Medicaid‑ or VFC‑enrolled pharmacy.

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Medicaid
  
Provider Alerts - Provider Resources - 2022
Healthfirst Connection Plan (HMO D-SNP) Announcement

Starting Jan. 1, 2024, Healthfirst will begin covering members in Healthfirst Connection Plan (HMO D-SNP), our newest Medicare Advantage Dual-Eligible Special Needs Plan. Read the Provider Alert for more details...

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Connection Plan
  
Provider Alerts - Compliance, Regulatory & Policies - Practice Guidelines and Tips - 2024
New State Requirements for Provider Compliance Programs

New York State has made changes to provider requirements for starting and maintaining compliance programs.

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Quality and Compliance
  
Provider Alerts - Policy, Billing, or Coverage Update - 2024
Mobile Crisis and Crisis Residence Service Changes

To improve access to crisis care, New York State received federal approval to consolidate and align its Mobile Crisis and Crisis Residence services. These Crisis Intervention State Plan Amendment (SPA) changes will start March 1, 2024.

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Preventive Measures
  
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