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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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Provider Alerts - Plans & Benefits - Policy, Billing, or Coverage Update - 2026
New York State Essential Plan 200-250 Coverage to End Effective 7/1/2026

The New York State Essential Plan coverage for individuals with incomes between 200% and 250% of the Federal Poverty Level (FPL) will end effective July 1, 2026.

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Healthfirst Plans
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Introducing Claim Pattern Review Program from Cotiviti

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

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

Effective July 1, 2026, Healthfirst will require prior authorization requirements for several CPT codes.

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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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Healthfirst Plans
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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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Healthfirst Plans
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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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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
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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
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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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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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