Category: Payer Updates

Posted in #reimbursement, NY Providers, Payer Updates, Payers and CPT reinbursement, Pharmacy (Various Insurance Payers), Training

Healthfirst Pharmacy Update Contrast agent reimbursement

Posted on by KR2Medical Billing

The following information applies to the members in the following plans: Managed Medicaid Plans and Personal Wellness Plans (HARP)

Back in 2023, NYS DOH announced that there will be a change to the pharmacy benefits for MMC, HARP members- the pharmacy benefits will be covered but NYRx.

This change was finally implemented in April 2025.

To align closer with this policy Healthfist will NO LONGER reimburse separately for the the following contrast agents used in radiological testing.

Coding: the following codes are affected:

Images via Healthfirst website

NYS Medicaid Pharmacy website: information here

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Posted in #reimbursement, NY Providers, Payer Updates, Payers and CPT reinbursement, Training

NYS Medicaid to cover TCM (Therapeutic Transcranial Magnetic Stimulation)

Posted on by KR2Medical Billing

The information discussed below applies to straight NYS Medicaid members for the DOS 10/1/25 and effective for any DOS on or 11/1/25 and thereafter for any Managed Medicaid Members.

What is TC? A non-invasive form of brain stimulation using magnetic pulses on specific areas of the brain. This therapy is used to improve the symptoms of major depressive disorder when conventional treatments have failed.

Who can perform these services?

A qualified psychiatrist with specialized training and certification.

Coding: providers please use the following codes-

Images via NYS Medicaid

Criteria:

  1. Any patient 18 years and older
  2. With a DX of major depressive disorder (please see the image below)
  3. Documented failure to achieve a satisfactory clinical response following at least two trials of antidepressants at adequate dosage, duration, and adherence.
  4. TCM is not the first line treatment
Image via NYS DOH

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Posted in #reimbursement, HealthFirst, NY Providers, Payer Updates, Payers and CPT reinbursement, Training

HealthFirst Telehealth mental health modifier update

Posted on by KR2Medical Billing

This update applies to HealthFirst following plan types: Medicaid, Personal Wellness Plan (HARP), and Medicaid Advantage.

Which services are affected?

Telehealth services done through a NY OMH licensed and or designated outpatient program.

Please refer to OMH modifier and rate code chart here.

Image via NYS OMH

To ensure the providers receive proper reimbursement, please make sure you go over payment rate changes and use the proper modifiers:

Modifier FQ- used for outpatient telehealth services, audio-only, for dual enrolled members.

Modofier 93- OMH providers – use this modifier for qualifying telehealth and audio-only mental health services, for members that are only enrolled in Medicaid.

The changes apply to the services performed on or after July 1st 2025.

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