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Provider Alerts - Claims & Billing - Practice Guidelines and Tips - 2024
New Prior Authorization Guidelines for Select Services effective July 1, 2024

Effective July 1, 2024, Healthfirst will change its authorization guidelines for select services on the CMS code list. As of that date, the services requiring prior authorization will include laboratory services (managed through eviCore). See the Provider Alert for a list of codes that will now require prior authorization.

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Authorization
  
Coding - Practice Guidelines and Tips - 2024
Documentation and Coding: Compression of Brain, 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 Compression of Brain (non-Traumatic).

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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-101 After Hours and Weekend Care

After hours or weekend care (CPT®) codes represent services provided when a Healthcare Provider is required to render the services outside of regular posted office hours to treat a patient's urgent illness or condition.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-100 Surgical Pathology

Healthfirst has established a policy regarding the number of units payable for surgical pathology services.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-099 Oral Sleep Apnea Device Appliance

Healthcare Common Procedure Coding System (HCPCS) E0485 and E0486 describe oral appliances which are used for the treatment of Obstructive Sleep Apnea (OSA).

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Reimbursement Policy
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2024
New Effective Date for Acupuncture, Occupational Therapy, Physical Therapy, and Speech Therapy Standard Fee Schedule Rates

The effective date for these changes has been delayed from April 1, 2024, to June 1, 2024.

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Reimbursement
  
Provider Alerts - Provider Resources - 2024
Announcing Essential Plan 200–250

Healthfirst is excited to announce our newest benefit plan, Essential Plan 200–250, launching on April 1, 2024. This new plan is part of New York State’s continued efforts to improve health insurance affordability and accessibility. Healthfirst is proud to be the only 5-star-rated Essential Plan in New York State.

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Healthfirst Plans
  
Coding - Practice Guidelines and Tips - 2024
Documentation and Coding: Aspiration Pneumonia, 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 types of Aspiration Pneumonia.

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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-096 New Physician Dispenser

Effective September 1, 2022, Medicaid pharmacy claims submitted from a physician dispenser will be rejected by Healthfirst’s pharmacy benefit manager, CVS Caremark.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-098 Monkeypox Vaccine Coverage

This policy outlines the reimbursement guidelines for coverage of the monkeypox vaccination and administration.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-102 Taxonomy

A taxonomy code is a unique 10-character alphanumeric code that signifies a provider’s classification and area of specialization.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-097 Nurse Practitioners and Physician Assistants

Effective April 1, 2019, Healthfirst will implement changes to its reimbursement policy for nurse practitioners (NPs) and physician assistants (PAs) to better align with existing Centers for Medicare & Medicaid Services (CMS) reimbursement policies regarding these types of physician extenders.

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Reimbursement Policy
  
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