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Provider Alerts - Claims & Billing - Pharmacy Resources & Formularies - Plans & Benefits - Policy, Billing, or Coverage Update - 2023
Transition of the Pharmacy Benefit from Managed Care to Fee-for-Service

Effective April 1, 2023, Medicaid members enrolled in Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will receive their pharmacy benefits through the NYRx Pharmacy program, formerly known as the NYS Fee-for-Service (FFS) Pharmacy program.

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Pharmacy
  
Provider Alerts - Claims & Billing - Coronavirus (COVID-19) - Policy, Billing, or Coverage Update - 2023
Coverage Update: Monoclonal Antibody Therapies

As of December 1, 2022, bebtelovimab is not FDA-approved and will not be covered by Healthfirst. View details.

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COVID-19
  
Provider Alerts - Policy, Billing, or Coverage Update - 2023
Inflation Reduction Act Impacts Cost Sharing for Medicare Part B Drugs

Beginning April 1, 2023, cost sharing for Medicare Part B Drugs will be impacted in accordance with §11101 and §11407 of the Inflation Reduction Act (IRA, P.L. 117-169)*

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Quality and Compliance
  
Provider Alerts - Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Provider Alert: Medicaid FFS Enrollment Requirement for Providers

Healthfirst has reinstated the Medicaid Management Information System (MMIS) enrollment requirement.

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Medicaid
  
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 - Education Events & Patient Care Resources - Behavioral Health and Foster Care - 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 - Coding - Policy, Billing, or Coverage Update - 2023
Acceptable Procedure Code/Modifier Combinations

Effective Sept. 1, 2023, Healthfirst is updating internal systems to deny procedure code/modifier combinations that are specifically flagged as invalid or inactive. These changes are based on New York State Medicaid (NYSM), American Medical Association (AMA), and Centers for Medicare & Medicaid Services (CMS) guidelines.

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Coding
  
Provider Alerts - Policy, Billing, or Coverage Update - 2023
Change in Level of Service Determinations and Prior Authorizations for Assertive Community Treatment

Effective June 20, 2023, Healthfirst, in accordance with the State of New York, will no longer require Level of Service Determinations (LOSD) or prior authorization for Assertive Community Treatment (ACT)

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ACT
  
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
  
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