Compliance, Regulatory & Policies

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-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-162 Diagnostic Laboratory

This policy outlines Healthfirst's standards and requirements for the reimbursement of diagnostic laboratory services.

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Reimbursement Policy

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

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

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

Reimbursement Policy: PO-RE-112 By Report

The By Report (BR) reimbursement policy outlines the guidelines for reimbursing Medicaid service codes that are designated “By Report” (“BR”) on the NYS Medicaid Physician Manual Fee Schedule and on the Ordered Ambulatory Fee Schedule.

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Reimbursement Policy

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

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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Reimbursement Policy

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

Reimbursement Policy: PO-RE-158 Hospital Acquired Conditions (HAC)

Hospital Acquired Conditions (HACs) are serious conditions that develop during an inpatient hospital stay and are considered preventable when proper evidence-based procedures are followed.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-156 Non-Covered Codes – Medicaid Managed Care and Child Health Plus

This policy outlines the reimbursement guidelines for non-covered CPT® and HCPCS codes billed to Healthfirst for Medicaid Managed Care and Child Health Plus.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-155 Non-Covered Codes – Medicare

This policy outlines the reimbursement approach for non-covered Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes submitted by providers participating in Healthfirst Medicare Advantage (MA) plans.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-102 Taxonomy

A taxonomy code is a unique 10-character alphanumeric code that signifies a provider’s classification and area of specialization.

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Reimbursement Policy

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

Reimbursement Policy: PO-RE-137 Appropriate Use of Manifestation Diagnosis Codes

Healthfirst is committed to ensuring accurate and compliant claims submission through the correct use of diagnosis coding, specifically emphasizing the appropriate application of Manifestation Codes.

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Reimbursement Policy

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

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-162 Diagnostic Laboratory

Reimbursement Policy: PO-RE-116 CPT Category III Codes

Reimbursement Policy: PO-RE-112 By Report

Reimbursement Policy: PO-RE-108 Transportation Services

Reimbursement Policy: PO-RE-158 Hospital Acquired Conditions (HAC)

Reimbursement Policy: PO-RE-156 Non-Covered Codes – Medicaid Managed Care and Child Health Plus

Reimbursement Policy: PO-RE-155 Non-Covered Codes – Medicare

Reimbursement Policy: PO-RE-102 Taxonomy

Reimbursement Policy: PO-RE-137 Appropriate Use of Manifestation Diagnosis Codes

Resource Type

Filter

Year

Sort By

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

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-162 Diagnostic Laboratory

Reimbursement Policy: PO-RE-116 CPT Category III Codes

Reimbursement Policy: PO-RE-112 By Report

Reimbursement Policy: PO-RE-108 Transportation Services

Reimbursement Policy: PO-RE-158 Hospital Acquired Conditions (HAC)

Reimbursement Policy: PO-RE-156 Non-Covered Codes – Medicaid Managed Care and Child Health Plus

Reimbursement Policy: PO-RE-155 Non-Covered Codes – Medicare

Reimbursement Policy: PO-RE-102 Taxonomy

Reimbursement Policy: PO-RE-137 Appropriate Use of Manifestation Diagnosis Codes

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