Healthfirst NY Billing Guide for Behavioral

Healthfirst

Healthfirst (NY)

Provider guide for Healthfirst NY — Medicaid managed care, HARP, and Medicare Advantage credentialing, VOB, authorization, and billing for behavioral health.

Quick Reference

Payer Type

Medicaid MCO

Parent Company

Provider-sponsored nonprofit (founded by NYC hospital systems)

Headquarters

New York, NY

Provider Portal

Open Portal

Portal Guide

View Guide →

Credentialing

CAQH ProView plus NY state Medicaid enrollment

Timeline

60-120 days

Coverage

1 states

Last Verified

Apr 19, 2026

Published

Apr 19, 2026

Reading Time

11 min

Covered Levels of Care

• Medically Managed Detoxification
• Residential Treatment (via NY 1115 SUD waiver)
• Partial Hospitalization (PHP)
• Intensive Outpatient (IOP)
• Outpatient Treatment
• Crisis Stabilization
• Medication-Assisted Treatment (MAT)
• Health and Recovery Plan (HARP) Rehabilitation Services
• Peer Support and Recovery Services

Medical Necessity Criteria

• New York State Medicaid Clinical Criteria
• ASAM Criteria (for SUD level of care determinations)
• LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) for NYS SUD

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Overview

Healthfirst is a provider-sponsored, not-for-profit managed care organization headquartered in New York City. Founded in 1993 by a consortium of New York City hospital systems — including Montefiore Medical Center, Mount Sinai Health System, New York-Presbyterian Hospital, and Northwell Health — Healthfirst was established to extend high-quality managed care to low-income New Yorkers. Unlike the large for-profit national insurance conglomerates, Healthfirst is governed by and accountable to its founding provider-hospital network, giving it a mission alignment with the communities it serves. As of the mid-2020s, Healthfirst serves approximately 1.5 million members, making it one of the largest Medicaid managed care plans in New York City and one of the largest provider-sponsored plans in the United States.

Healthfirst operates exclusively within New York State, primarily serving New York City’s five boroughs (Manhattan, Brooklyn, Queens, the Bronx, and Staten Island) along with portions of Westchester, Nassau, Suffolk, Sullivan, and Orange counties. The plan offers Medicaid Managed Care, Child Health Plus (for children not eligible for Medicaid), the Health and Recovery Plan (HARP) for adults with serious mental illness or substance use disorders, Medicare Advantage plans including a Dual Eligible Special Needs Plan (D-SNP), and Qualified Health Plans through the New York State of Health marketplace. This breadth of coverage means that behavioral health providers serving the New York City area may encounter Healthfirst across multiple product lines.

For behavioral health treatment providers, Healthfirst is a critical payer relationship for any facility or practice operating in New York City or the surrounding counties within the plan’s service area. The plan’s strong ties to the New York City hospital system, combined with its HARP product and the New York State Medicaid behavioral health benefit design — one of the most comprehensive in the country — make Healthfirst a significant source of Medicaid behavioral health revenue for community-based treatment organizations. Providers should understand both the standard Medicaid managed care product and the HARP-specific billing and authorization rules, as these are materially different workflows.

Behavioral Health Coverage

Healthfirst covers behavioral health services consistent with the New York State Medicaid managed care program, which is among the most extensive Medicaid behavioral health benefit packages in the United States. Covered services across the standard Medicaid Managed Care product include outpatient individual, group, and family therapy; psychiatric evaluation and medication management; intensive outpatient programs (IOP); partial hospitalization programs (PHP); crisis intervention services; and medication-assisted treatment for opioid and alcohol use disorders. New York’s robust SUPPORT Act implementation means that all FDA-approved MAT medications are covered without prior authorization barriers in the standard Medicaid product.

The Health and Recovery Plan (HARP) is Healthfirst’s specialized Medicaid product for adults with serious mental illness (SMI) or substance use disorders (SUD) who meet specific clinical eligibility criteria. HARP members access the standard Medicaid behavioral health benefit plus an additional Home and Community Based Services (HCBS) benefit delivered through the Health Home program. HCBS for HARP members includes community psychiatric support and treatment, psychosocial rehabilitation, family support and training, employment support, education support, and crisis respite. Providers delivering HARP HCBS must be separately enrolled in the HARP-HCBS network and must bill using the specific HCBS billing codes (generally T-codes) distinct from standard outpatient billing.

Residential SUD treatment coverage through Healthfirst follows New York State’s comprehensive Medicaid redesign 1115 waiver, which has expanded SUD benefits to include certified residential treatment settings operated under the New York Office of Addiction Services and Supports (OASAS). The state’s LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) tool is used for level-of-care determinations in SUD cases, and facilities must hold current OASAS certification at the appropriate level. Healthfirst follows the IMD exclusion framework modified by the NY 1115 waiver — confirm your facility’s certification status and the current waiver terms before admitting Healthfirst Medicaid members to residential programs.

For members under age 21, Healthfirst covers behavioral health services under the EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) benefit, which requires coverage of any medically necessary service to correct or ameliorate a condition even if not otherwise in the state plan. This standard is particularly relevant for adolescent residential and intensive community-based services. Medical necessity for both SUD and mental health services follows New York State Medicaid clinical criteria and, for SUD level-of-care placement, the LOCADTR tool or ASAM Criteria as recognized by the state.

Credentialing and Provider Enrollment

Healthfirst uses CAQH ProView as its primary credentialing data source. Before submitting a Healthfirst network participation application, ensure that all individual clinicians and your organization have fully attested CAQH ProView profiles. The profile must reflect current New York State licensure, National Provider Identifier (NPI) and taxonomy codes, professional liability coverage, and all applicable facility certifications. For behavioral health facilities, this includes OASAS certification for SUD programs and OMH (Office of Mental Health) facility operating certificates for mental health programs.

New York State Medicaid enrollment through eMedNY — the New York State Medicaid system administered by the Department of Health — is a prerequisite for joining the Healthfirst provider network. Enroll through the eMedNY enrollment portal before or concurrently with preparing your Healthfirst credentialing application. State enrollment can take several weeks to months, and Healthfirst claims will not pay until eMedNY enrollment is confirmed and active. For behavioral health facilities, the eMedNY enrollment process requires submission of OASAS or OMH operating certificates in addition to standard provider enrollment documentation.

Healthfirst serves a geographically defined service area concentrated in New York City and nearby counties. Confirm that your practice or facility locations fall within the Healthfirst service area before investing time in the credentialing process. Providers with locations outside the service area may not be contracted.

Facility credentialing requires current New York State behavioral health facility certification (OASAS or OMH), organizational NPI, general and professional liability insurance, Joint Commission or CARF accreditation if applicable, and a current W-9. After a complete application is received, the credentialing process typically takes 60 to 120 days. Recredentialing occurs on a standard three-year cycle. For providers seeking to deliver HARP HCBS services, a separate HARP-HCBS network enrollment process is required in addition to standard credentialing.

Verification of Benefits (VOB)

Benefit verification for Healthfirst members is a two-step process. First, confirm active New York State Medicaid enrollment and MCO assignment through eMedNY — the NYS Medicaid eligibility system. Use the eMedNY provider portal, the NYES (New York eligibility system) telephone line, or your practice management system’s 270/271 transaction to confirm the member is enrolled in Medicaid and assigned to Healthfirst on the date of service. If eMedNY does not show the member enrolled with Healthfirst, the plan will not pay regardless of what the Healthfirst portal shows.

Second, verify plan-specific behavioral health benefits, covered services, HARP enrollment status, authorization requirements, and any benefit limitations through the Healthfirst provider portal at provider.healthfirst.org. The portal provides eligibility and benefits verification, claim status inquiry, prior authorization submission and tracking, and access to state-specific provider manuals and billing guides. For HARP members, the portal will indicate HARP enrollment status and the member’s Health Home assignment, which affects billing and care coordination responsibilities.

For detailed behavioral health VOB — particularly for residential services, PHP, or members who may qualify for HARP benefits — contact Healthfirst provider services. Provider services contact information is available on provider.healthfirst.org and on the member’s Healthfirst insurance card. Medicaid eligibility can change monthly; re-verify on or near each date of service. Because Medicaid is the payer of last resort, screen for commercial or Medicare coverage before billing Healthfirst.

Prior Authorization Requirements

Healthfirst requires prior authorization for most facility-based and intensive behavioral health services. Services that typically require prior authorization include residential SUD treatment, medically managed detoxification, inpatient psychiatric hospitalization, and partial hospitalization programs. Intensive outpatient programs (IOP) may also require authorization — confirm the current requirement in the Healthfirst provider manual, as New York State Medicaid managed care authorization rules have evolved with the state’s managed care reform agenda.

Authorization requests are submitted through the Healthfirst provider portal or, for urgent and emergent situations, by phone to the utilization management team. Clinical documentation should cover the member’s diagnoses, presenting symptoms, psychiatric and substance use history, current functional status, prior treatment episodes, relevant risk factors, and the proposed treatment plan. For SUD services, organize the clinical narrative using the LOCADTR tool or the six ASAM Criteria dimensions, as Healthfirst follows New York State’s level-of-care determination framework. For mental health services, document against the New York State Medicaid clinical criteria applicable to the service type requested.

HARP members may have additional authorization requirements for HCBS services. HARP HCBS delivery requires a completed Health Home assessment, person-centered plan, and documented HCBS eligibility determination. These requirements are distinct from the prior authorization workflow for standard behavioral health services and must be completed before delivering and billing HCBS.

Concurrent reviews for residential and inpatient services are required at intervals established in the Healthfirst provider manual — typically every 5 to 7 days for residential SUD treatment and inpatient psychiatric care. Each review requires updated clinical documentation showing progress toward treatment goals, ongoing medical necessity, and active discharge planning. If a continued-stay request is denied, request a peer-to-peer review with the Healthfirst medical director before filing a formal appeal.

Claims and Billing

Healthfirst accepts electronic claims through standard EDI 837I (institutional, UB-04) and 837P (professional, CMS-1500) formats submitted via clearinghouses, and through the Healthfirst provider portal. Electronic submission is strongly preferred and results in faster processing. Confirm the correct Healthfirst payer ID with your clearinghouse or practice management vendor before submitting claims — Healthfirst uses separate payer IDs for its Medicaid managed care, HARP, Medicare Advantage, and marketplace products.

Billing codes and covered service definitions follow the New York State Medicaid fee schedule and the Healthfirst provider contract. New York Medicaid uses a combination of CPT codes for mental health services and H-codes and T-codes for SUD and HARP HCBS services respectively. HARP HCBS must be billed using the specific T-code bundle defined by the state; incorrect code selection is a leading cause of HARP claim denials. The current Healthfirst billing guide and New York State Medicaid billing guidance are available through provider.healthfirst.org.

Timely filing for Healthfirst Medicaid claims follows New York State Medicaid managed care contract requirements. New York Medicaid MCO contracts generally require initial claims to be submitted within 90 days of the date of service, though provider agreements may allow up to 12 months for some claim types. Corrected claims and coordination-of-benefits adjustments have their own separate timely filing windows. Reference the current Healthfirst provider manual for the controlling deadline applicable to your provider type and service category.

Common denial reasons include missing prior authorization, eMedNY ineligibility on the date of service, HARP HCBS billing errors (wrong T-codes or missing care management documentation), incorrect place-of-service codes, non-covered service for the member’s specific product, and third-party liability issues. For HARP HCBS denials, also review whether the required Health Home documentation and person-centered plan were complete before service delivery. Track denial patterns by reason code and product type to surface systemic billing issues.

Key Contact Information

Healthfirst serves: New York City (all five boroughs) and portions of Westchester, Nassau, Suffolk, Sullivan, and Orange counties, NY

• Provider Portal: https://provider.healthfirst.org ↗ (primary provider portal for all Healthfirst products)
• Credentialing: CAQH ProView ( https://proview.caqh.org ↗ ) plus NY State Medicaid enrollment via eMedNY; contact Healthfirst provider network development through the provider portal to initiate
• New York State Medicaid Enrollment: eMedNY — New York State Department of Health Medicaid enrollment portal
• Prior Authorization: Submit through provider.healthfirst.org; for urgent and emergent requests, contact the Healthfirst UM team via the number on the member’s insurance card
• HARP HCBS Enrollment: Separate HARP-HCBS network enrollment required; contact Healthfirst behavioral health network development
• Verification of Benefits: Two-step — eMedNY for state eligibility confirmation plus provider.healthfirst.org for plan-specific benefits; for complex cases, call provider services listed on the member’s card
• Claims Submission: Electronic 837I / 837P via clearinghouse (product-specific payer IDs) or provider.healthfirst.org
• Provider Manual: Available in the provider resources section of provider.healthfirst.org

Frequently Asked Questions

No. Healthfirst in New York is an independent, provider-sponsored nonprofit health plan founded by a consortium of New York City hospital systems including Montefiore Medical Center, Mount Sinai Health System, New York-Presbyterian Hospital, and others. It is entirely distinct from any health plan using a similar name in Minnesota, New Jersey, or other states. Healthfirst NY is one of the largest Medicaid managed care plans in New York City and serves Medicaid, Child Health Plus, HARP, and Medicare Advantage members exclusively within New York State. There is no corporate relationship to any for-profit national health insurance carrier.

The Health and Recovery Plan (HARP) is a specialized Medicaid managed care product for adults with serious mental illness or substance use disorders who need enhanced behavioral health services. Healthfirst operates a HARP product in New York City. HARP members have access to Home and Community Based Services (HCBS) delivered through a network of Health Home Care Managers and specialized behavioral health providers. HARP billing uses distinct billing codes and authorization pathways separate from standard Medicaid managed care. Providers serving HARP members through Healthfirst must be enrolled in the HARP-HCBS network and must follow the HARP-specific clinical documentation and authorization requirements published in the Healthfirst provider manual.

Residential SUD treatment coverage through Healthfirst NY depends on New York State's Medicaid program design and its active Section 1115 SUD waiver. New York has operated a comprehensive Medicaid redesign 1115 waiver that includes SUD benefit expansion allowing Medicaid payment for residential SUD treatment in qualifying facilities. Healthfirst follows the state's waiver terms, including any facility certification requirements, level-of-care definitions (using LOCADTR), and length-of-stay parameters. Before admitting a Healthfirst Medicaid member to a residential SUD program, confirm that your facility holds the required OASAS (Office of Addiction Services and Supports) certification, that the specific level of care is covered under NY Medicaid with the waiver, and that you have obtained the required prior authorization from Healthfirst.

Healthfirst uses CAQH ProView as its primary credentialing data source. Before applying, ensure that all individual clinicians and your facility have fully attested CAQH profiles with current New York State licensure, NPI, malpractice coverage, and OASAS or OMH (Office of Mental Health) facility certification as applicable. New York State Medicaid enrollment through eMedNY (the New York Medicaid system) is a prerequisite to joining the Healthfirst provider network. After both state enrollment and a complete Healthfirst credentialing application are submitted, the process typically takes 60 to 120 days. Healthfirst serves primarily NYC and surrounding counties — confirm that your practice location falls within the Healthfirst service area before applying.

Timely filing for Healthfirst Medicaid claims follows New York State Medicaid regulations. New York State Medicaid managed care organizations are generally required to accept claims filed within 90 days from the date of service, though contracted provider agreements may specify a different window — often up to 12 months for initial submissions. Corrected claims and claims with coordination-of-benefits adjustments typically have a shorter window measured from the date of the primary payer's determination. Always reference the current Healthfirst provider manual or your provider agreement for the controlling deadline. New York Medicaid claims filed after the timely filing limit have limited appeal rights, so build timely filing alerts into your billing workflow.

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