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

Effective October 1, 2026, Healthfirst will require prior authorization for select medical services.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Practice Guidelines and Tips - 2026
Interoperability and Prior Authorization Final Rule Requirements

Healthfirst is updating prior authorization and concurrent review decision timeframes to comply with the CMS Interoperability and Prior Authorization Final Rule. Effective January 1, 2026, standard authorization decisions for applicable Medicaid and Medicare lines of businesses.

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Administration
Healthfirst Plans
Medicaid
Medicare
  
Provider Alerts - Behavioral Health and Foster Care - Practice Guidelines and Tips - 2026
Clinical Document Submission for Healthfirst Personal Wellness Plan

Frequently asked questions related to the submission of clinical documents by Behavioral Health providers for HARP/PWP members.

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Administration
Healthfirst Plans
Authorization
  
Provider Alerts - Claims & Billing - Practice Guidelines and Tips - 2026
Request a Continuous Glucose Monitoring Device for Healthfirst Medicare, Essential Plan, and Qualified Health Plan Members

Healthfirst members with Type 1 or Type 2 diabetes may qualify for a Continuous Glucose Monitoring (CGM) device if eligible. Available to Medicare, Essential Plan, and QHP members through an in-network DMEPOS provider, not a pharmacy.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Introducing Genetic and Molecular Coding Validation from Concert Genetics

Effective May 1, 2026, Healthfirst is updating reimbursement policies for genetic and molecular lab testing for all Healthfirst Plans with respect to our new partnership with Concert Genetics

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Administration
Healthfirst Plans
Authorization
Reimbursement Policy
  
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