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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-104 Principal and Chronic Care Management

This policy outlines Healthfirst reimbursement guidelines for Principal and Chronic Care Management (PCM and CCM) services in an outpatient setting.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Claims & Billing - Policy, Billing, or Coverage Update - 2023
Frequently Asked Questions: Healthfirst Laboratory Benefit Management Program

Effective June 1, 2023, Healthfirst will apply updated billing and reimbursement policies to claims reporting laboratory services performed in office, hospital outpatient, and independent laboratory locations. Review these answers to frequently asked questions.

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Policy Reminder
  
Provider Alerts - Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
New Reimbursement Policies for Laboratory Services

Effective June 1, 2023, Healthfirst is updating reimbursement policies for laboratory service providers with respect to our new partnership with Avalon.

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Policy Reminder
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Reimbursement Policy: PO-RE-028 Measurement of Thromboxane Metabolites for ASA Resistance

Thromboxane A2 (TXA2) is a metabolite that causes platelet activation in the cyclooxygenase metabolic pathway (Abrams, 2023).

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Reimbursement Policy
  
Provider Alerts - Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Provider Alert: Medicaid FFS Enrollment Requirement for Providers

Healthfirst has reinstated the Medicaid Management Information System (MMIS) enrollment requirement.

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Medicaid
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Reimbursement Policy: PO-RE-071v1 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 - 2023
Reimbursement Policy: PO-RE-075v1 Laboratory Procedures

To be considered for reimbursement, all outpatient laboratory claims should be submitted in accordance with: - AMA CPT and HCPCS coding and ICD-10 diagnosis coding guidelines - Other laboratory and pathology coding guidelines - All applicable regulatory guidelines This policy outlines additional requirements beyond the guidelines listed above that are required for reimbursement. Note that these guidelines are reviewed and updated periodically.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Reimbursement Policy: PO-RE-073v1 Ordering/Referring Provider NPI

The NPI number of the ordering/referring provider should be included in all claim’s submissions to Healthfirst for member service requests. Federal regulations require you to submit HIPAA standard electronic transactions with only your NPI number.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Reimbursement Policy: PO-RE-077v1 Photochemotherapy

Effective September 1, 2023, consistent with the American Academy of Dermatology Association and New York State, Healthfirst will update our policy regarding covered diagnoses for photochemotherapy treatment.

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Reimbursement Policy
  
Provider Alerts - Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Provider-Identified Overpayments

If a provider determines that Healthfirst has overpaid a claim, the provider shall, within 60 days of discovery, send a refund check made out to Healthfirst PHSP, Inc. in the amount of the overpayment. View the provider alert for details.

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Reimbursement
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Reimbursement Policy: PO-RE-086v1 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 - 2022
Healthfirst Health Information Exchange Policies and Procedures

These policies and procedures govern the exchange of information through the health information exchange application (“HIE”) operated by Healthfirst, which allows the exchange of Member Data between and among Healthfirst and certain qualified participating providers. Providers that participate in the HIE may access information about Healthfirst members to coordinate services, improve quality, and manage the cost of care. Updated as of June 1, 2022.

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Documentation
  
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