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Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Required for Select Services Starting October 1, 2026

CPT/HCPCS Level II codes newly released by the American Medical Association (AMA) and The Centers for Medicaid and Medicare Services - effective October 1, 2026 - will require prior authorization and will be managed by Healthfirst’s delegated vendor(s) EviCore, under the EviCore Lab Program and Integra.

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Administration
Healthfirst Plans
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2026
Prior Authorization Requirements for Select Codes Starting December 30, 2026

Effective December 30, 2026, Healthfirst will require prior authorization for select codes. These changes are part of Healthfirst’s ongoing responsibility to evaluate its medical policies compared to the latest scientific evidence and specialty society guidance.

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Administration
Healthfirst Plans
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-141 Interprofessional Consultation for Behavioral Health Services

This reimbursement policy outlines the guidelines for billing and reimbursement of interprofessional consultations in behavioral health services as established by the Centers for Medicare & Medicaid Services (CMS) starting in 2025.

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Reimbursement Policy
  
Provider Alerts - Policy, Billing, or Coverage Update - 2026
Public Charge Regulation Update

USCIS updated Public Charge guidance, expanding case-by-case consideration of individual circumstances. Healthfirst encourages members to seek guidance before making changes to their or their children’s health coverage.

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Administration
Healthfirst Plans
Reimbursement
  
Documentation & Coding - Video - 2026
Video - Documentation and Coding of Non-Pressure Ulcer

This video offers guidance on proper clinical documentation and coding of Non-Pressure Ulcer

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Clinical Documentation Improvement
Video
  
Documentation & Coding - Practice Guidelines and Tips - 2026
Documentation and Coding: Secondary Diagnosis

This tip sheet is intended to assist providers and coding staff with the documentation and ICD-10-CM selection on services submitted to Healthfirst—Secondary Diagnosis.

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Clinical Documentation Improvement
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-135 PCP Scope of Reimbursement

The purpose of this policy is to outline the reimbursement guidelines for services provided by Primary Care Physicians (PCPs).

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-086 Place of Service

Healthfirst will reimburse services when reported with an appropriate Place of Service (POS).

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
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
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-071 Modifier Usage

Modifiers have been defined by the American Medical Association (AMA) and adopted by the Centers for Medicare and Medicaid Services (CMS) to provide additional information regarding the services rendered.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-073 Ordering/Referring Provider NPI

Healthfirst requires the National Provider Identifier (NPI) of the ordering or referring provider to be reported on all applicable claims and encounters when an ordering or referring provider is required by CMS, New York State Medicaid, or other applicable regulatory requirements.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
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
  
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