Compliance, Regulatory & Policies

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-135 PCP Scope of Reimbursement

The purpose of this policy is to outline the reimbursement guidelines for services provided by Primary Care Physicians (PCPs).

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-086 Place of Service

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

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-085 Chest X-Rays for Lung Cancer Screening

This policy outlines the reimbursement guidelines for chest X-ray procedures performed for the sole purpose of lung cancer screening or assessing nicotine use/dependence.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-071 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.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

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

Healthfirst requires the National Provider Identifier (NPI) of the ordering or referring provider to be reported on all applicable claims and encounters when an ordering or referring provider is required by CMS, New York State Medicaid, or other applicable regulatory requirements.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-084 Radiological Chest Examination

Healthfirst will no longer reimburse for chest X-Ray procedures with service codes 71045 and 71046 unless there is a diagnosis of pertinent signs, symptoms, or diseases.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-089 Radiopharmaceuticals

Healthfirst has updated its reimbursement policy for radiopharmaceuticals commonly used for myocardial perfusion imaging studies. This

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-092 Ultrasound Diagnostic Procedures

Healthfirst will no longer provide reimbursement for CPT 76856 (Ultrasound, pelvic [non-obstetric], real time with image documentation; complete) or CPT 76857 Ultrasound, pelvic [non-obstetric], real time with image documentation; limited or follow-up) when billed with CPT 76830 (Transvaginal ultrasound) unless extenuating circumstances are present to validate the necessity of both studies.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-093 Obstetrical Ultrasound Procedures

Healthfirst has implemented the following reimbursement policy regarding the billing of CPT 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal) in conjunction with CPT 76801-76812 (Ultrasound, pregnant uterus, real time with image documentation, transabdominal)

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-170 Additional Office and Outpatient Services Billed with Evaluation and Management (E&M)

This policy outlines Healthfirst's reimbursement methodology for Evaluation and Management (E/M) services and additional office and outpatient services billed on the same date of service.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-173 CCBHC Provider Billing Guidance (UB-04 Billing)

This reimbursement policy describes Healthfirst's reimbursement requirements for Certified Community Behavioral Health Clinic (CCBHC) services provided to eligible Healthfirst members.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-172 Multiple Procedure Reduction

Healthfirst applies multiple procedure payment reductions when multiple surgical or procedural services are performed during the same operative session for the same member.

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Reimbursement Policy

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Reimbursement Policy: PO-RE-135 PCP Scope of Reimbursement

Reimbursement Policy: PO-RE-086 Place of Service

Reimbursement Policy: PO-RE-085 Chest X-Rays for Lung Cancer Screening

Reimbursement Policy: PO-RE-071 Modifier Usage

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

Reimbursement Policy: PO-RE-084 Radiological Chest Examination

Reimbursement Policy: PO-RE-089 Radiopharmaceuticals

Reimbursement Policy: PO-RE-092 Ultrasound Diagnostic Procedures

Reimbursement Policy: PO-RE-093 Obstetrical Ultrasound Procedures

Reimbursement Policy: PO-RE-170 Additional Office and Outpatient Services Billed with Evaluation and Management (E&M)

Reimbursement Policy: PO-RE-173 CCBHC Provider Billing Guidance (UB-04 Billing)

Reimbursement Policy: PO-RE-172 Multiple Procedure Reduction

Resource Type

Filter

Year

Sort By

Reimbursement Policy: PO-RE-135 PCP Scope of Reimbursement

Reimbursement Policy: PO-RE-086 Place of Service

Reimbursement Policy: PO-RE-085 Chest X-Rays for Lung Cancer Screening

Reimbursement Policy: PO-RE-071 Modifier Usage

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

Reimbursement Policy: PO-RE-084 Radiological Chest Examination

Reimbursement Policy: PO-RE-089 Radiopharmaceuticals

Reimbursement Policy: PO-RE-092 Ultrasound Diagnostic Procedures

Reimbursement Policy: PO-RE-093 Obstetrical Ultrasound Procedures

Reimbursement Policy: PO-RE-170 Additional Office and Outpatient Services Billed with Evaluation and Management (E&M)

Reimbursement Policy: PO-RE-173 CCBHC Provider Billing Guidance (UB-04 Billing)

Reimbursement Policy: PO-RE-172 Multiple Procedure Reduction

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