Tag: #reimbursement

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 #aetna, Education, Payer Updates, Payers and CPT reinbursement, Training

AETNA Commercial Plans: compression supplies non covered codes.

Posted on by KR2Medical Billing

Please note that this policy update applies to the members that have commercial plan types.

The affected codes: for any DOS on or after Jan 1st 2026, Aetna will consider the following codes for compression stockings to be a disposable supply and a standard benefit exclusion.

Codes:

For Texas Providers:

These changes apply to fully insured plans written in Texas and only if such changes are in accordance with applicable regulatory requirements. Changes for all other plans will be as outlined in this article.

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