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Accessing Clinical Guidelines for Medicare Basic Services

Posted Feb 23, 2024

As of Jan. 1, 2024, Healthfirst members and participating network providers may access clinical guidelines for prior authorization (PA) requests for all Medicare basic healthcare services.

Read the Provider Alert in English, Spanish, or Chinese for details.

As part of the administrative simplification effort at Healthfirst to be transparent in the clinical guidelines we use when reviewing authorizations, a new feature has been added on our Provider Portal: Clinical Guidelines.

For instructions on how to access and use the tool, see the Healthfirst Clinical Guidelines document, which contains access instructions and outlines the clinical criteria Healthfirst uses to support member care decisions.

Please note: Guidelines for authorizations managed by our delegated vendors can be found by visiting the respective delegated vendor websites found on the provider alert.