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Coding - Practice Guidelines and Tips - 2024
Documentation and Coding: Pressure Ulcer, 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 Pressure Ulcer.

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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-120 Urodynamic Studies

This policy outlines the reimbursement guidelines for healthcare providers regarding the measurement of post-voiding residual urine by ultrasound when performed in conjunction with urodynamic studies.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-124 Medicare Health Equity Services

This policy outlines the reimbursement guidelines for services related to the Health Equity Services framework established by the Centers for Medicare & Medicaid Services (CMS).

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-121 Reduction Mammaplasty

This policy outlines the reimbursement criteria for Reduction Mammaplasty procedures under Healthfirst coverage. Reduction Mammaplasty (CPT code 19318) is a surgical procedure aimed at reducing the size of the breast for medical reasons.

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Reimbursement Policy
  
Provider Alerts - Provider Resources - 2024
Changes to the Special Enrollment Period for Dual-Eligible and Low-Income Subsidy Recipients Beginning in 2025

The 2025 Centers for Medicare & Medicaid Services (CMS) Medicare Advantage and Part D Final Rule includes several changes to enrollment for our dual-eligible and Low-Income Subsidy (LIS) members.

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Healthfirst Plans
Medicare
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2024
Prior Authorization No Longer Required for Antiretroviral Prescription Medications

Healthfirst has removed prior authorization requirements from all antiretroviral medications prescribed for the treatment or prevention of Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS) for all Healthfirst plans.

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Authorization
Preventive Measures
Healthfirst Plans
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2024
Crisis Residence and Mobile Crisis Services Now Covered for Healthfirst Essential Plan, Leaf, and Leaf Premier Members

Starting January 1, 2025, Healthfirst will cover Crisis Residence Services and Mobile Crisis Services for our Essential Plan (EP) and Leaf and Leaf Premier Plan members (also known as our Qualified Health Plans). Additionally, these services will continue to be covered under the Medicaid, Personal Wellness Plans (HARP), Child Health Plus (CHPlus), and Medicaid Advantage Plan (MAP) lines of business.

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Medicaid
Behavioral Health and Mental Health
  
Coding - Practice Guidelines and Tips - 2024
Documentation and Coding: Breast Cancer, 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 breast cancer.

Open document
Clinical Documentation Improvement
CMS-HCC_V28 Model Updates
  
Coding - Practice Guidelines and Tips - 2024
Documentation and Coding: Colorectal and Bladder Cancer, 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 colorectal and bladder cancer.

Open document
Clinical Documentation Improvement
CMS-HCC_V28 Model Updates
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2024
Changes to OASAS Comprehensive Outpatient Treatment Programs and Updated Billing Guidance

The New York State Office of Addiction Service and Supports (OASAS) is implementing several changes to integrate care within the OASAS outpatient clinic regulatory structure, including a merged Comprehensive Outpatient Treatment Program (COP) operating certificate, COP reimbursement updates, and inclusion of Opioid Treatment Program (OTP) bundles into APG methodology.

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Behavioral Health and Mental Health
Reimbursement
Medicaid
Healthfirst Plans
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-108 Transportation Services

The purpose of this policy is to define the reimbursement guidelines for transportation coverage provided by Healthfirst, including ancillary services and out-of-state emergency transportation services negotiation.

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Reimbursement Policy
  
Provider Alerts - Policy, Billing, or Coverage Update - 2024
Two Additional Prior Authorization Codes Managed by EyeMed Effective Jan. 1, 2025

EyeMed manages Healthfirst’s prior authorization for surgical and therapeutic vision services as well as network management, related member and provider service calls, and claims payment for routine vision and medical optometry services. Starting Jan. 1, 2025, EyeMed will manage prior authorization for J2777 and J0177.

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Administration
Authorization
Dental and/or Vision
  
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