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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
  
Provider Alerts - Behavioral Health and Foster Care - Policy, Billing, or Coverage Update - 2022
Four Behavioral Health Home and Community Based Services Transitioning to New Community Oriented Recovery and Empowerment Services

To improve access to rehabilitative care, New York State received federal approval to transition four Behavioral Health Home and Community Based Services (BH HCBS) to a new service array called Community Oriented Recovery and Empowerment (CORE) Services starting February 1, 2022.

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Mental & Behavioral Health
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2022
Healthfirst Reimbursement Policy Updates - Effective March 1, 2022

As a part of Healthfirst’s continuing efforts to ensure that our reimbursement policy standards are up to date and compliant with state and national industry standards, our reimbursement policy will undergo several changes effective March 1, 2022. These changes will maintain compliance with industry-accepted coding and reimbursement practices, as well as with state and national regulatory requirements.

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Documentation
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2022
Changes to Authorization Guidelines for Selected Medical Services

Effective April 1, 2022, Healthfirst will change its authorization guidelines for selected medical services. These changes are part of Healthfirst’s ongoing responsibility to evaluate its medical policies compared to the latest scientific evidence and specialty society guidance.

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Prior Authorization
  
Provider Alerts - Coronavirus (COVID-19) - Policy, Billing, or Coverage Update - 2022
New York Medicaid Guidance for Billing Monoclonal Antibody Treatments

New York State (NYS) Medicaid will reimburse NY Medicaid-enrolled pharmacies for administration or dispensing of COVID-19 therapeutics, including monoclonal antibody (mAb) treatments with no member cost share.

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COVID-19
  
Provider Alerts - Policy, Billing, or Coverage Update - 2022
Prior Authorization Waiver Expiration: Post-Acute Discharge

Effective December 31, 2021, Healthfirst has waived authorization requirements for transfers or discharges from an acute inpatient facility to another acute inpatient facility, a skilled nursing facility (SNF), acute rehabilitation facility (AR), or long-term acute care hospital (LTACH).

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Prior Authorization
  
Provider Alerts - Policy, Billing, or Coverage Update - 2022
Healthfirst Reimbursement of Developmental Screening in Primary Care

Effective April 1, 2022, Healthfirst will begin to reimburse Developmental Screening (CPT 96110) in primary care as per New York State Medicaid guidance.

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Reimbursement
  
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