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Quality Program Resources - Patient Care Resources - Plans & Benefits - Provider Resources - 2024
2024 Special Needs Plan (SNP) Model of Care (MOC) Provider Training

This presentation will help educate providers, delegated vendors, and appropriate staff on the Healthfirst Special Needs Plan (SNP) Model of Care (MOC), the goal of which is to enhance member health outcomes through the use of an integrated care delivery system.

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Special Needs Plan
  
Plans & Benefits - Policy, Billing, or Coverage Update - 2021
Medical Necessity Form (MNF) Form FAQs

Effective May 1, 2021, providers must fill out a Medical Necessity Form (MNF) to schedule Advanced Life Support (ALS) or Basic Life Support (BLS) non-emergent transportation for Healthfirst members to any provider approved by the Centers for Medicare & Medicaid Services (CMS). Here are some frequently asked questions.

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Medicare
  
Provider Alerts - Claims & Billing - Pharmacy Resources & Formularies - Plans & Benefits - Provider Resources - 2023
Inflation Reduction Act Changes to Member Inflation Reduction Act Changes to Member

Healthfirst would like to alert you to new requirements around the Inflation Reduction Act of 2022 (IRA) provisions applicable for 2023 regarding cost sharing for Part B and Part D drugs

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Quality and Compliance
  
Provider Alerts - Plans & Benefits - Policy, Billing, or Coverage Update - 2023
Signature Medicare by Healthfirst - Out-of-Network Providers’ QRG

This Medicare Advantage plan offers additional benefits on top of Original Medicare, like dental, vision, hearing, and fitness. Members have the option of going in-network or out-of-network and visiting any doctor and hospital in the U.S. that accepts Medicare. Out-of-network providers may reference this QRG for more information.

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Signature (PPO)
  
Coding - Practice Guidelines and Tips - 2024
Documentation and Coding: Sepsis, CMS-HCC_V28 Model Updates

This tip sheet is intended to assist providers and coding staff with the documentation and ICD-10-CM selection, along with the Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Category (HCC) Version 28 Model Updates, on services submitted to Healthfirst—specifically for sepsis.

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Clinical Documentation Improvement
CMS-HCC_V28 Model Updates
  
Quality Program Resources - Patient Care Resources - Patient Resource - 2022
Help Your Patients Fight the Flu

Helpful guidance from Healthfirst and the CDC for making a strong flu shot recommendation to help patients make an informed health decision.

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Seasonal Flu
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-084 Radiological Chest Examination

Healthfirst will no longer reimburse for chest X-Ray procedures with service codes 71045 and 71046 unless there is a diagnosis of pertinent signs, symptoms, or diseases.

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Reimbursement Policy
  
Coding - Policy, Billing, or Coverage Update - 2024
Medicare Physician and Practitioner Providers - Medical Record Request for Calendar Year 2022 (CY22) Part C Improper Payment Measure (Part C IPM)

This request is based on diagnosis data submitted to the Centers for Medicare & Medicaid Services (CMS) as a result of services you provided to MA beneficiaries during calendar year 2021 (CY21). The purpose of this request is to validate diagnoses that were sent to CMS to determine health status-adjusted payments under risk adjustment.

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Risk Adjustment Data Validation Audit
  
Coding - Policy, Billing, or Coverage Update - 2024
Medicare Hospitals - Medical Record Request for Calendar Year 2022 (CY22) Part C Improper Payment Measure (Part C IPM)

This request is based on diagnosis data submitted to the Centers for Medicare & Medicaid Services (CMS) as a result of services you provided to MA beneficiaries during calendar year 2021 (CY21). The purpose of this request is to validate diagnoses that were sent to CMS to determine health status-adjusted payments under risk adjustment.

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Risk Adjustment Data Validation Audit
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-085 Chest X-Rays for Lung Cancer Screening

This policy outlines the reimbursement guidelines for chest X-ray procedures performed for the sole purpose of lung cancer screening or assessing nicotine use/dependence.

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Reimbursement Policy
  
Coding - Practice Guidelines and Tips - 2023
Documentation and Coding: Hepatitis C, CMS-HCC_V28 Model Updates

This tip sheet is intended to assist providers and coding staff with the documentation and ICD-10-CM selection, along with the Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Category (HCC) Version 28 Model Updates, on services submitted to Healthfirst—specifically for chronic Hepatitis C.

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Clinical Documentation Improvement
CMS-HCC_V28 Model Updates
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-091 Trigger Point Injections

Healthfirst aims to ensure that its reimbursement policy for trigger point injections aligns with state and national industry standards. This policy outlines the limitations and guidelines for the reimbursement of trigger point injections provided to Healthfirst members.

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Reimbursement Policy
  
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