Compliance, Regulatory & Policies

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

Reimbursement Policy: PO-RE-168 NYS Medicaid Breast Cancer Selective Program

This reimbursement policy outlines Healthfirst requirements for provider eligibility and claim reimbursement under the New York State (NYS) Medicaid Breast Cancer Selective Program.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-169 Medical Dental and Oral Health Coverage

Healthfirst recognizes that certain dental services are medically necessary and eligible for reimbursement when covered under a member’s medical benefit in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines and applicable state and federal regulations.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-165 Outpatient Facility and Professional Claim Reimbursement – Lesser-of Methodology

This policy outlines Healthfirst’s standard reimbursement methodology for outpatient facilities and professional claims.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-115 Digital Mental Health Treatment (DMHT) Device

A Digital Mental Health Treatment (DMHT) device is a device similar to a mobile device that allows billing practitioners to provide behavioral health services in conjunction with ongoing behavioral health care treatment.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-094 Avoidable Readmission

Healthfirst's Avoidable Readmission reimbursement policy is designed to reduce avoidable readmissions and improve quality of care.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-128 Part B Custodial Services-Skilled Therapy and Vaccine Services

This policy outlines the guidelines for the reimbursement of Skilled Therapy and Vaccine services provided under Medicare Part B for custodial Healthfirst Medicare members.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-127 Canalith Repositioning Procedure

Healthfirst adheres to the Centers for Medicare & Medicaid Services (CMS) guidelines for Canalith Repositioning Procedures. This policy outlines the reimbursement criteria and procedure for the CPT code 95992, which is designated for the therapeutic management of benign paroxysmal positional vertigo (BPPV).

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025

Reimbursement Policy: PO-RE-134 Prenatal and Postpartum Services Cost-Sharing Waiver

Starting January 1, 2025, a new NY State of Health (NYSOH) program under New York’s Section 1332 waiver will enhance access and affordability for pregnant and postpartum Qualified Health Plan (QHP) members.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-126 Diabetes Cost-sharing Waiver

This policy outlines Healthfirst’s reimbursement guidelines regarding the waiver of cost-sharing for Essential Plan (EP) and Qualified Health Plan (QHP) members diagnosed with Type 1, Type 2, or Gestational Diabetes.

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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 additional office and outpatient services billed in conjunction with Evaluation and Management (E&M) services and other qualifying encounters, when performed on the same date of services for the same member by the same provider.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-074 Remote Patient Monitoring and Remote Therapeutic Monitoring

The purpose of this policy is to outline the reimbursement guidelines for Remote Patient Monitoring (RPM) services and Remote Therapeutic Monitoring (RTM) services offered by Healthfirst.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-166 Non-Coverage of CPT Code 80050

Effective July 1, 2026, Healthfirst will no longer reimburse for CPT code 80050 (General Health Panel).

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Reimbursement Policy

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Reimbursement Policy: PO-RE-168 NYS Medicaid Breast Cancer Selective Program

Reimbursement Policy: PO-RE-169 Medical Dental and Oral Health Coverage

Reimbursement Policy: PO-RE-165 Outpatient Facility and Professional Claim Reimbursement – Lesser-of Methodology

Reimbursement Policy: PO-RE-115 Digital Mental Health Treatment (DMHT) Device

Reimbursement Policy: PO-RE-094 Avoidable Readmission

Reimbursement Policy: PO-RE-128 Part B Custodial Services-Skilled Therapy and Vaccine Services

Reimbursement Policy: PO-RE-127 Canalith Repositioning Procedure

Reimbursement Policy: PO-RE-134 Prenatal and Postpartum Services Cost-Sharing Waiver

Reimbursement Policy: PO-RE-126 Diabetes Cost-sharing Waiver

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

Reimbursement Policy: PO-RE-074 Remote Patient Monitoring and Remote Therapeutic Monitoring

Reimbursement Policy: PO-RE-166 Non-Coverage of CPT Code 80050

Resource Type

Filter

Year

Sort By

Reimbursement Policy: PO-RE-168 NYS Medicaid Breast Cancer Selective Program

Reimbursement Policy: PO-RE-169 Medical Dental and Oral Health Coverage

Reimbursement Policy: PO-RE-165 Outpatient Facility and Professional Claim Reimbursement – Lesser-of Methodology

Reimbursement Policy: PO-RE-115 Digital Mental Health Treatment (DMHT) Device

Reimbursement Policy: PO-RE-094 Avoidable Readmission

Reimbursement Policy: PO-RE-128 Part B Custodial Services-Skilled Therapy and Vaccine Services

Reimbursement Policy: PO-RE-127 Canalith Repositioning Procedure

Reimbursement Policy: PO-RE-134 Prenatal and Postpartum Services Cost-Sharing Waiver

Reimbursement Policy: PO-RE-126 Diabetes Cost-sharing Waiver

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

Reimbursement Policy: PO-RE-074 Remote Patient Monitoring and Remote Therapeutic Monitoring

Reimbursement Policy: PO-RE-166 Non-Coverage of CPT Code 80050

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