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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
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. The intention of this policy is to promote access to necessary healthcare services and support for individuals managing diabetes. By waiving cost-sharing for specific services, Healthfirst aims to enhance diabetes management, improve health outcomes, and reduce long-term healthcare costs.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-122 Pasteurized Human Donor Milk Coverage

Healthfirst provides coverage for Pasteurized Human Donor Milk (PDHM) under certain programs/lines of business. This policy describes Healthfirst’s reimbursement guidelines for PDHM as it relates to both inpatient and outpatient settings.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-123 Intensity-Modulated Radiation Therapy

This policy outlines the reimbursement guidelines for Intensity Modulated Radiation Therapy (IMRT) services provided by healthcare providers. IMRT is a specialized form of radiation therapy that allows for precise targeting of radiation to cancerous tumors while minimizing exposure to surrounding healthy tissue. Coverage for IMRT is subject to specific clinical indications as defined by the Centers for Medicare & Medicaid Services (CMS) policy.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-119 Intensity-Modulated Radiation Therapy (IMRT) Frequency Limitations

This policy outlines the reimbursement guidelines for Intensity-Modulated Radiation Therapy (IMRT) services provided by healthcare providers. IMRT, specifically represented by CPT code 77301 (Intensity-modulated radiotherapy [IMRT] plan), is subject to frequency limitations to ensure appropriate billing practices and compliance with regulatory requirements.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-120 Urodynamic Studies

This policy outlines the reimbursement guidelines for healthcare providers regarding the measurement of post-voiding residual urine by ultrasound when performed in conjunction with urodynamic studies.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-124 Medicare Health Equity Services

This policy outlines the reimbursement guidelines for services related to the Health Equity Services framework established by the Centers for Medicare & Medicaid Services (CMS).

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-121 Reduction Mammaplasty

This policy outlines the reimbursement criteria for Reduction Mammaplasty procedures under Healthfirst coverage. Reduction Mammaplasty (CPT code 19318) is a surgical procedure aimed at reducing the size of the breast for medical reasons.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-078 Telemedicine

This policy describes the services covered, provider requirements and reimbursement for Telehealth and Virtual health services.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-108 Transportation Services

The purpose of this policy is to define the reimbursement guidelines for transportation coverage provided by Healthfirst, including ancillary services and out-of-state emergency transportation services negotiation.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-113 Doula Services

Effective January 1, 2025, Healthfirst will provide coverage of Doula Services provided in accordance with 42 CFR section 440.130(c). This policy outlines Healthfirst guidelines for the reimbursement of Doula Services.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-111 Lactation Services

Healthfirst has expanded lactation services coverage under those plans to include reimbursement eligibility for providers certified by nationally recognized accrediting agencies.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-116 CPT Category III Codes

This policy applies to all healthcare providers submitting claims to Healthfirst for services that include CPT Category III codes.

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Reimbursement Policy
  
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