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Provider Alerts - Plans & Benefits - Patient Resource - 2023
Provider Alert - 2023 FPL Expansion

Thanks to expanded eligibility, more Medicare beneficiaries will qualify for the Medicare Savings Program (MSP) in 2023.

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Medicare
  
Provider Alerts - Plans & Benefits - Policy, Billing, or Coverage Update - 2023
Important: Recertifications are Resuming in 2023

New York State will resume eligibility reviews and renewals for members of with a recertification date after June 2023. If your patients do not renew on time, they risk losing health coverage and could face unexpected costs or even a gap in care. This Provider Alert contains instructions on how members can renew their coverage...

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Recertification
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2023
Authorization Requirement Update for Vision Services

Effective May 1, 2023, Healthfirst no longer requires authorization for selected vision services.

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Authorization
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2023
Introducing Coding Validation from Cotiviti

Effective Sept. 1, 2023, consistent with the recommendations of the Office of Inspector General and the Centers for Medicare & Medicaid Services, Healthfirst will implement Cotiviti’s Coding Validation, an enhanced program based on nationally sourced guidelines regarding modifier usage.

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Reimbursement
  
Provider Alerts - Behavioral Health and Foster Care - Patient Care Resources - Provider Resources - 2023
Children’s Home and Community-Based Services (HCBS) Frequently Asked Questions

Children's Home and Community-Based Services (HCBS) are provided in the community and help children and youth be successful at home, in school, and in other environments. HCBS are personal and flexible and are meant to meet the physical health, behavioral health, and/or developmental needs of each child/youth.

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Children & Family
  
Provider Alerts - Pharmacy Resources & Formularies - Policy, Billing, or Coverage Update - 2023
NYRx Transition Fill Period Ending

Effective April 1, 2023, Medicaid members enrolled in Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARP), and HIV-Special Needs Plans (SNPs) began receiving their pharmacy benefits through NYRx, the Medicaid Pharmacy program.

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Pharmacy
  
Provider Alerts - Behavioral Health and Foster Care - Policy, Billing, or Coverage Update - 2023
BH | Prior Authorization Guidelines

Review this provider alert for BH prior authorization guidelines that apply to in-network providers only.

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Prior Authorization
  
Provider Alerts - Behavioral Health and Foster Care - Plans & Benefits - Practice Guidelines and Tips - 2023
FAQ: Health and Recovery Plans (HARP) and Healthfirst’s Personal Wellness Plan (PWP)

See answers to frequently asked questions about Health and Recovery Plans and Healthfirst’s Personal Wellness Plan.

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HARP Health And Recovery Plan
  
Provider Alerts - Claims & Billing - Practice Guidelines and Tips - 2023
New Prior Authorization Guidelines for Select Services

Effective Nov. 1, 2023, Healthfirst will change its authorization guidelines for select services due to newly created codes on the CMS code list. As of that date, the services requiring prior authorization will include spinal surgery services managed through OrthoNet™, as well as radiation therapy and laboratory services managed through eviCore.

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Prior Authorization
  
Provider Alerts - Coding - Practice Guidelines and Tips - 2023
Invalid ICD-10-CM Diagnosis Codes are Expiring

Healthfirst is updating our ICD-10-CM diagnosis code set to meet the specificity requirements established by the Centers for Medicare & Medicaid Services (CMS).

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Coding
  
Provider Alerts - Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Provider-Identified Overpayments

If a provider determines that Healthfirst has overpaid a claim, the provider shall, within 60 days of discovery, send a refund check made out to Healthfirst PHSP, Inc. in the amount of the overpayment. View the provider alert for details.

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Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2023
Provider Alert - Cost Sharing for Medicare Part B Drugs

Details regarding cost sharing policy changes due to the Inflation Reduction Act.

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Cost Sharing
  
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