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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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Healthfirst Plans
  
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
Reimbursement
  
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
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-132 Obstetric Billing Guidelines

This policy describes the reimbursement of global obstetrical (OB) codes and the itemization of maternity care services.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-104 Principal and Chronic Care Management

This policy outlines Healthfirst reimbursement guidelines for Principal and Chronic Care Management (PCM and CCM) services in an outpatient setting

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-082 Testing of Homocysteine Metabolism-Related Conditions

Homocystinuria is a metabolic condition in which the body is unable to properly process certain amino acids, resulting in an abnormal accumulation of homocysteine and its metabolites in the blood and urine.

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Reimbursement Policy
  
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