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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-162 Diagnostic Laboratory

This policy outlines Healthfirst's standards and requirements for the reimbursement of diagnostic laboratory services.

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Reimbursement Policy
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Introducing Genetic and Molecular Coding Validation from Concert Genetics

Effective May 1, 2026, Healthfirst is updating reimbursement policies for genetic and molecular lab testing for all Healthfirst Plans with respect to our new partnership with Concert Genetics

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Healthfirst Plans
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Reimbursement Policy
  
Provider Alerts - Plans & Benefits - Policy, Billing, or Coverage Update - 2026
New York State Essential Plan 200-250 Coverage to End Effective 7/1/2026

The New York State Essential Plan coverage for individuals with incomes between 200% and 250% of the Federal Poverty Level (FPL) will end effective July 1, 2026.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-166 Non-Coverage of CPT Code 80050

Effective July 1, 2026, Healthfirst will no longer reimburse for CPT code 80050 (General Health Panel).

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-163 Online Digital (e-Visit) Services

This policy outlines Healthfirst’s criteria for reimbursing e-Visits, a form of asynchronous, patient-initiated communication that takes place through a secure, HIPAA-compliant digital platform, most commonly a patient portal.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-109 Vaccine Administration

Healthfirst acknowledges the importance of vaccination in promoting public health and aims to align its reimbursement policies with the Centers for Disease Control (CDC)/ Advisory Committee on Immunization Practices (ACIP), and other applicable New York State and local public health authorities, including New York State Department of Health (NYSDOH) and New York City Department of Health and Mental Hygiene (NYC DOHMH).

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Reimbursement Policy
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Introducing Claim Pattern Review Program from Cotiviti

Effective August 1, 2026, Healthfirst will implement Cotiviti’s Claim Pattern Review Program to conduct ongoing reviews of specific professional claims.

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Administration
Healthfirst Plans
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Required for Select Codes Starting July 1, 2026

Effective July 1, 2026, Healthfirst will require prior authorization requirements for several CPT codes.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Required for Select Codes Starting June 1, 2026

The following codes newly released by the Centers for Medicare and Medicaid Services (CMS) on April 1, 2026, will include prior authorization requirements starting June 1, 2026.

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Administration
Healthfirst Plans
Authorization
Reimbursement
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Physical Therapy Authorization and Approval Guidance Effective January 31, 2026

A provider questionnaire will now accompany initial prior authorization requests for Adult Physical Therapy across all Healthfirst plans to support efficient reviews and appropriate care decisions.

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Administration
Healthfirst Plans
Authorization
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Provider Alerts - Practice Guidelines and Tips - 2026
Somatus Care Management Program for Patients with Chronic Kidney Disease or End Stage Renal Disease

As part of our continued effort to provide members with the best possible quality care, Healthfirst has partnered with Somatus Inc. (Somatus) to support members diagnosed with Chronic Kidney Disease (CKD) or End Stage Renal Disease (ESRD).

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Administration
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-133 Therapeutic Drug Monitoring for 5-Fluorouracil

Chemotherapeutic agents are incredibly potent drugs, often carrying cytotoxic side effects.

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Reimbursement Policy
  
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