Compliance, Regulatory & Policies

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-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-109 Vaccine Administration

Healthfirst acknowledges the importance of vaccination in promoting public health and aims to align its reimbursement policies with the Centers for Disease Control (CDC)/ Advisory Committee on Immunization Practices (ACIP), and other applicable New York State and local public health authorities, including New York State Department of Health (NYSDOH) and New York City Department of Health and Mental Hygiene (NYC DOHMH).

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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

Provider Alerts - Compliance, Regulatory & Policies - Practice Guidelines and Tips - 2025

Important Notice Regarding U.S. Department of Justice Regulations on Sensitive Personal Data

The United States Department of Justice (DOJ) has issued new regulations titled the “Final Rule on Preventing Access to U.S. Sensitive Personal Data and United States Government-Related Data by Countries of Concern”, codified at 28 C.F.R. Part 202.

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

Reimbursement Policy: PO-RE-162 Diagnostic Laboratory

Reimbursement Policy: PO-RE-109 Vaccine Administration

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

Important Notice Regarding U.S. Department of Justice Regulations on Sensitive Personal Data

Resource Type

Filter

Year

Sort By

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

Reimbursement Policy: PO-RE-162 Diagnostic Laboratory

Reimbursement Policy: PO-RE-109 Vaccine Administration

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

Important Notice Regarding U.S. Department of Justice Regulations on Sensitive Personal Data

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