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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2021
Healthfirst Reimbursement Policy Updates

Effective November 1, 2021, 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 - Claims & Billing - Policy, Billing, or Coverage Update - 2021
Prior Authorization: Home Visits - Effective February 1, 2021

Effective February 1, 2021, Healthfirst will require prior authorization for the codes listed in the document related to home visits. Claims for these services and other types of service will not be paid without prior approval. The authorization required for each visit remains open for 30 days.

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Prior Authorization
  
Provider Alerts - Coronavirus (COVID-19) - Practice Guidelines and Tips - 2021
Healthfirst Utilization Management

On December 23, 2020, the New York Department of Financial Services (DFS) issued Insurance Circular Letter No. 17, Coronavirus and the Suspension of Certain Utilization Review and Notification Requirements under the “Surge and Flex” Protocol. Access this document to learn about what Healthfirst is doing in response to this protocol and for more information.

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Utilization Review
  
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 - Claims & Billing - Policy, Billing, or Coverage Update - 2021
Drug Testing Policy

Healthfirst aims to ensure that our policy standards are up to date and are compliant with state and national industry standards. Effective February 1, 2021, Healthfirst has limited the reimbursement of drug testing as outlined in this document.

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Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2021
0077 21 Provider Alert Anesthesia Unit Policy v3 1 FINAL

Anesthesia services (00100–01999) are limited to a specific number of units per member, per provider group, per day. These limits are considered “typical” but may not reflect the actual services provided. If units are billed beyond our established limits, the total units allowed will be adjusted to the assigned maximum allowed; all other units will be denied. However, additional units can be considered for payment with supporting documentation upon appeal.

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Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2021
0078 21 Provider Alert Ambulance Diagnosis Policy v3 1 FINAL

Per CMS LCD L35162 (Jurisdiction H and L), emergency ambulance services (A0425–A0434) are a covered benefit when the services meet the medical necessity requirements as outlined in the CMS manuals and Federal Register sections listed in the CMS National Coverage Policy section indicated in this document. Providers should report the most appropriate ICD-10 code that adequately describes the patient’s medical condition at the time of transport as the primary diagnosis. 40TIn addition, a secondary diagnosis must be reported to indicate that transportation by any other means is medically contraindicated.

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Reimbursement
  
Provider Alerts - Coronavirus (COVID-19) - Policy, Billing, or Coverage Update - 2022
COVID-19 Coding Update for CPT 99072

Healthfirst aims to ensure that our reimbursement policy standards are up to date and compliant with state and national industry standards. Effective immediately, Healthfirst will not reimburse for CPT code 99072.

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COVID-19
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2021
0370 21 Reimbursement Policy Updates for 6121 v5

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, effective June 1, 2021, several changes will be made to our reimbursement policy. These changes will maintain compliance with industry-accepted coding and reimbursement practices, as well as state and national regulatory requirements. Policy updates for: Polysomnography and Sleep Studies, Unattended Polysomnography and Sleep Studies, and Home Polysomnography and Sleep Studies.

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Reimbursement
  
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 - Behavioral Health and Foster Care - Policy, Billing, or Coverage Update - 2021
Delayed: Applied Behavioral Analysis (ABA) Benefit Carve Out

The October 1, 2021 Applied Behavioral Analysis (ABA) benefit carve out into Managed Medicaid has officially been postponed by New York State Department of Health. Providers should continue to submit claims for ABA services to Medicaid Fee-For-Service directly until further notice.

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Medicaid
  
Provider Alerts - Quality Program Resources - General Update - 2022
Celebrating Top Performers from the 2020 Healthfirst Quality Incentive Program (HQIP)

Thank you to all our providers for your hard work in the Healthfirst Quality Incentive Program. We would like to recognize the top performers from the 2020 HQIP for achieving the highest overall quality ratings among their peers.

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HQIP
  
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