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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-083 General Ophthalmological Exams

This reimbursement policy outlines the guidelines for the reimbursement of comprehensive ophthalmological exams and intermediate ophthalmological exams for service codes 92012 and 92014.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-075 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

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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-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
  
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