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Provider Alerts - Practice Guidelines and Tips - 2023
1167 22 Provider Alert NPPES Updates FINA Lwr

Healthfirst would like to remind you to review your National Provider Identifier (NPI) data in the National Plan & Provider Enumeration System (NPPES) as soon as possible to ensure that the provider data displayed is accurate. Providers are legally required to keep their NPPES data current. The Centers for Medicare & Medicaid Services (CMS) also encourages Medicare Advantage Organizations to use NPPES as a resource for our online provider directories. By using NPPES, we may be able to change how often we contact you to validate directory information and provide more reliable information to Medicare beneficiaries

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Documentation
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2022
Changes to Authorization Guidelines for Selected Services

Effective November 1, 2022, Healthfirst will make changes to its authorization guidelines for selected services. The service codes that newly require a prior authorization include pathology and laboratory services and non-oral and injectable chemotherapy drugs.

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Prior Authorization
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2023
1511 22 MA MOOP Calculation Provider Alert v5 FINAL wr

Effective 1/1/2023, the maximum out-of-pocket (MOOP) limit for a Medicare Advantage (MA) plan (after which the plan pays 100% of MA costs) will be calculated based on the accrual of all Medicare-covered cost sharing, not the supplemental benefits, in the plan benefit.

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Documentation
  
Provider Alerts - Pharmacy Resources & Formularies - Claims & Billing - 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
  
Claims & Billing - General Update - 2023
eviCore Medical Oncology Frequently Asked Questions

See answers to frequently asked questions about eviCore healthcare’s medical oncology program.

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Prior Authorization
  
Provider Alerts - Claims & Billing - Practice Guidelines and Tips - 2023
eviCore Medical Oncology HCPCS Codes and Descriptions

All providers who request/order any medical oncology services must secure prior authorization for services before the service is rendered in an office or outpatient setting. View this document for more information.

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Prior Authorization
  
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)
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2023
Expansion of Lactation Service Coverage

Consistent with new requirements established for NYS Medicaid Managed Care (MMC) plans (including mainstream MMC plans, Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV-SNPs), and Health and Recovery Plans (HARPs)), Healthfirst has expanded lactation services coverage under those plans to include reimbursement eligibility for providers certified by nationally recognized accrediting agencies.

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Medicaid Managed Care
  
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
  
Provider Alerts - Coronavirus (COVID-19) - Policy, Billing, or Coverage Update - 2023
Billing Guidance for COVID-19 Vaccine Under Healthfirst’s Plans

Healthfirst continues to monitor COVID-19 vaccine updates from the state and federal government and from other healthcare agencies. This guidance provides billing information on COVID-19 vaccines. (Updated June 2023)

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Billing
  
Provider Alerts - Practice Guidelines and Tips - 2024
Tips to Increase Colorectal Screenings

Remind patients to schedule a colorectal cancer exam starting at age 45. A screening can detect cancer early, when it’s easier to treat. Review these tips.

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Preventive Measures
  
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