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Provider Alerts - Provider Resources - 2024
Announcing Essential Plan 200–250

Healthfirst is excited to announce our newest benefit plan, Essential Plan 200–250, launching on April 1, 2024. This new plan is part of New York State’s continued efforts to improve health insurance affordability and accessibility. Healthfirst is proud to be the only 5-star-rated Essential Plan in New York State.

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Healthfirst Plans
  
Provider Alerts - Policy, Billing, or Coverage Update - 2022
Coverage of Lung Cancer Screening with Low Dose Computed Tomography

Effective February 10, 2022, the Centers for Medicare & Medicaid Services (CMS) has expanded eligibility for people with Medicare to qualify for lung cancer screening with Low Dose Computed Tomography (LDCT) by lowering the starting age for screening from 55 to 50 years, and also by reducing the tobacco smoking history from at least 30 packs per year to at least 20 packs per year.

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Medicare
Medicaid
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2022
Healthfirst Reimbursement Policy Updates - Effective March 1, 2020

Healthfirst Reimbursement Policy Updates

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Reimbursement
  
Provider Alerts - Coronavirus (COVID-19) - Pharmacy Resources & Formularies - Provider Resources - 2023
Pharmacy Billing Guidance for COVID-19 Vaccine Under Healthfirst’s Medicaid Managed Care Plan (MMC) and Personal Wellness Plan

During the declared State of New York disaster emergency, pharmacies may bill for COVID-19 vaccines that have been authorized by the FDA under Emergency Use Authorization (EUA) under Healthfirst’s Medicaid Managed Care Plan (MMC) and Personal Wellness Plan (PWP). View PDF for billing instructions.

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Personal Wellness Plan
  
Provider Alerts - Coronavirus (COVID-19) - General Update - 2022
COVID-19 Vaccine Counseling Program

In accordance with Medicaid COVID-19 vaccine regulations, Healthfirst will reimburse eligible providers for vaccine counseling rendered to unvaccinated Medicaid and HARP members/enrollees during dates of service on or after December 1, 2021. For providers located in New York City, this coverage essentially replaces the Vaccine Outreach and Counseling Program (VOCP) Healthfirst launched in collaboration with the New York City Department of Mental Hygiene in the fall of 2021, and which ended on December 31, 2021. If you provided services under the VOCP and have not yet billed for them, please bill in accordance with the requirements of the VOCP

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COVID-19
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2022
Transcranial Dopplers: Coding, Billing, and Medical Requirements

To ensure appropriate payments and maintain billing efficiencies, Healthfirst is committed to informing providers of specific requirements for the usage of any medical device. This alert provides guidance on Healthfirst coding, billing, and medical requirements for Transcranial Dopplers (TCD).

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Billing
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2022
Billing for No-Cost Drugs and Biologicals

Healthfirst requires that providers record all substances administered to patients and that a charge be reported, even for no-cost drugs and biologicals. When this occurs, the provider or qualified healthcare professional should submit a token charge of $0 for the item.

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Prior Authorization
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2022
Healthfirst Reimbursement Policy Updates - Effective February 1, 2022

Healthfirst aims to ensure that our reimbursement policy standards are compliant with state and national industry standards. Effective February 1, 2022, several changes will be made to our reimbursement policy to maintain compliance with industry-accepted coding and reimbursement practices, as well as state and national regulatory requirements.

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Reimbursement
  
Provider Alerts - Coronavirus (COVID-19) - Pharmacy Resources & Formularies - Provider Resources - 2023
COVID-19 Vaccine Additional Doses for Immunocompromised Individuals Pharmacy Billing Guidance

On August 13, 2021, the Advisory Committee on Immunization Practices (ACIP) met and recommended an additional dose for immunocompromised individuals who have received the Pfizer-BioNTech or Moderna COVID-19 vaccine.

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Emergency Use Authorization
  
Provider Alerts - Coronavirus (COVID-19) - Pharmacy Resources & Formularies - Provider Resources - 2023
Pfizer-BioNtech, and Moderna, COVID-19 Booster Update Pharmacy Billing Guidance

The U.S. Food and Drug Administration has amended the emergency use authorization (EUA) for the Pfizer-BioNTech COVID-19 Vaccine and Moderna COVID-19 Vaccine to allow for a booster dose. Consult the individual EUA’s for current guidance.

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Emergency Use Authorization
  
Provider Alerts - Coronavirus (COVID-19) - Pharmacy Resources & Formularies - Provider Resources - 2023
Zero-Cost COVID-19 Oral Antivirals Pharmacy Billing Guidance

Claims that providers submit for zero-cost COVID-19 oral antivirals must have either $0.01 in the Ingredient Cost Submitted field (NCPDP field 4Ø9-D9) or the combination of $0.00 in the Ingredient Cost Submitted field (NCPDP field 4Ø9-D9) and a value of “15” in the Basis of Cost Determination field (NCPDP field 423-DN).

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Pharmacy Billing
  
Provider Alerts - Coronavirus (COVID-19) - Pharmacy Resources & Formularies - Provider Resources - 2023
New York Medicaid Guidance for At-Home COVID-19 Testing Coverage Update

Implementation of adjudication coding for at-home testing coverage for most New York Medicaid Managed Care Plan Sponsors should be completed by January 17, 2022. Providers receiving a reject message (e.g., reject code: 70 - NDC not covered, etc.) on COVID-19 at-home testing claims filled prior to January 17, 2022, should re-submit rejected claims after January 17, 2022.

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Pharmacy Billing
  
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