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Coding - Practice Guidelines and Tips - 2024
Documentation and Coding: 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 pneumonia.

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Clinical Documentation Improvement
CMS-HCC_V28 Model Updates
  
Provider Alerts - Claims & Billing - Policy, Billing, or Coverage Update - 2024
Changes to Claims Submissions for Prenatal and Postpartum Services

Providers using bundled or global procedure codes for billing perinatal services must submit non-payment category II CPT codes for members in Medicaid, Personal Wellness Plans, Medicaid Advantage Plans, and Connection Plans.

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Medicaid
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-123 Intensity-Modulated Radiation Therapy

This policy outlines the reimbursement guidelines for Intensity Modulated Radiation Therapy (IMRT) services provided by healthcare providers. IMRT is a specialized form of radiation therapy that allows for precise targeting of radiation to cancerous tumors while minimizing exposure to surrounding healthy tissue. Coverage for IMRT is subject to specific clinical indications as defined by the Centers for Medicare & Medicaid Services (CMS) policy.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-119 Intensity-Modulated Radiation Therapy (IMRT) Frequency Limitations

This policy outlines the reimbursement guidelines for Intensity-Modulated Radiation Therapy (IMRT) services provided by healthcare providers. IMRT, specifically represented by CPT code 77301 (Intensity-modulated radiotherapy [IMRT] plan), is subject to frequency limitations to ensure appropriate billing practices and compliance with regulatory requirements.

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Reimbursement Policy
  
Education Events & Patient Care Resources - Practice Guidelines and Tips - 2024
Healthfirst 2024 Fall Provider Symposium (November 15, 2024)

The 2024 Fall Provider Symposium, Evolving Models of Care: Bridging the Gap Between Behavioral Health and Primary Care, will offer innovative solutions integrating primary and behavioral health care. The symposium will highlight pragmatic models to address the challenges and optimize the health and well-being of families and adults in pursuit of health equity for our communities.

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Provider Events
  
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
  
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