Reimbursement Policy: PO-RE-028 Measurement of Thromboxane Metabolites for ASA Resistance

Thromboxane A2 (TXA2) is a metabolite that causes platelet activation in the cyclooxygenase metabolic pathway (Abrams, 2023).

Provider Alert: Medicaid FFS Enrollment Requirement for Providers

Healthfirst has reinstated the Medicaid Management Information System (MMIS) enrollment requirement.

Reimbursement Policy: PO-RE-071v1 Modifier Usage

Modifiers have been defined by the American Medical Association (AMA) and adopted by the Centers for Medicare and Medicaid Services (CMS) to provide additional information regarding the services rendered.

Reimbursement Policy: PO-RE-075v1 Laboratory Procedures

To be considered for reimbursement, all outpatient laboratory claims should be submitted in accordance with: - AMA CPT and HCPCS coding and ICD-10 diagnosis coding guidelines - Other laboratory and pathology coding guidelines - All applicable regulatory guidelines This policy outlines additional requirements beyond the guidelines listed above that are required for reimbursement. Note that these guidelines are reviewed and updated periodically.

Reimbursement Policy: PO-RE-073v1 Ordering/Referring Provider NPI

The NPI number of the ordering/referring provider should be included in all claim’s submissions to Healthfirst for member service requests. Federal regulations require you to submit HIPAA standard electronic transactions with only your NPI number.

Reimbursement Policy: PO-RE-077v1 Photochemotherapy

Effective September 1, 2023, consistent with the American Academy of Dermatology Association and New York State, Healthfirst will update our policy regarding covered diagnoses for photochemotherapy treatment.

Reimbursement Policy: PO-RE-041 Serum Tumor Markers for Malignancies

Tumor biomarkers are proteins detected in the blood, urine, or other body fluids that are either produced by the tumor itself or in response to its presence.

Provider-Identified Overpayments

If a provider determines that Healthfirst has overpaid a claim, the provider shall, within 60 days of discovery, send a refund check made out to Healthfirst PHSP, Inc. in the amount of the overpayment. View the provider alert for details.

Reimbursement Policy: PO-RE-086v1 Place of Service

Healthfirst will reimburse services when reported with an appropriate Place of Service (POS).

Healthfirst Health Information Exchange Policies and Procedures

These policies and procedures govern the exchange of information through the health information exchange application (“HIE”) operated by Healthfirst, which allows the exchange of Member Data between and among Healthfirst and certain qualified participating providers. Providers that participate in the HIE may access information about Healthfirst members to coordinate services, improve quality, and manage the cost of care. Updated as of June 1, 2022.

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