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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-079 Coronavirus Testing in the Outpatient Setting

Human coronaviruses, first characterized in the 1960s, are named based on the spiked proteins located on their surface.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-082 Testing of Homocysteine Metabolism-Related Conditions

Homocystinuria is a metabolic condition in which the body is unable to properly process certain amino acids, resulting in an abnormal accumulation of homocysteine and its metabolites in the blood and urine (NIH, 2023).

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-133 Therapeutic Drug Monitoring for 5-Fluorouracil

Chemotherapeutic agents are incredibly potent drugs, often carrying cytotoxic side effects. Most chemotherapeutic drugs have a steep dose-response relationship and a narrow therapeutic index (a range where an agent provides therapeutic effect without major side effects).

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
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 - 2025
Reimbursement Policy: PO-RE-134 Prenatal and Postpartum Services Cost-Sharing Waiver

Starting January 1, 2025, a new NY State of Health (NYSOH) program under New York’s Section 1332 waiver will enhance access and affordability for pregnant and postpartum Qualified Health Plan (QHP) members.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-132 Obstetric Billing Guidelines

This policy describes the reimbursement of global obstetrical (OB) codes and the itemization of maternity care services. Maternity care encompasses prenatal, delivery, antepartum, and postpartum care.

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Reimbursement Policy
  
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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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-015 Testing for Vector Borne Infections

Arthropod vectors, including mosquitoes, ticks, fleas, and mites, that feed on vertebrate hosts can spread bacteria, protozoa, and viruses during feeding to their susceptible host, resulting in a variety of infections and diseases.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-125 Serum Testing for Evidence of Mild Traumatic Brain Injury

Traumatic brain injury (TBI) is characterized by pathologic injuries to the brain resulting from external forces or trauma.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-068 Prenatal Screening (Nongenetic)

Prenatal screening encompasses any testing done to determine the health status of the pregnant individual and/or fetus. Biochemical prenatal screening encompasses screening for infectious diseases and conditions that may complicate the pregnancy.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-064 Immunopharmacologic Monitoring of Therapeutic Serum Antibodies

To manage loss of response due to the development of anti-drug antibodies, immunopharmacologic monitoring of circulating drug and anti-drug antibody levels has been proposed. The presence of anti-drug antibodies may promote adverse effects and diminish drug efficacy (Bendtzen, 2024; Tighe & McNamara, 2017).

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-063 General Inflammation Testing

Inflammatory response can occur due to tissue injury and/or various disorders, including arthritis, lupus, and infection. Acute phase reactants, such as serum C-reactive protein (CRP), are released in the acute phase response during inflammation and can be used to monitor inflammation.

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Reimbursement Policy
  
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