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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-031 Bone Turnover Markers Testing

Bone metabolism involves a continual, dynamic equilibrium between bone growth and resorption. Bone turnover markers (BTMs) are biochemical markers for assessment of bone formation or bone resorption.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-027 Cardiovascular Disease Risk Assessment

Cardiovascular risk assessment comprises the means and processes to predict the probability of developing a cardiovascular disease.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-022 Cervical Cancer Screening

Cervical cancer screening detects cervical precancerous lesions and cancer through cytology, human papillomavirus (HPV) testing, and if needed, colposcopy (Feldman et al., 2024).

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-021 Testing for Diagnosis of Active or Latent Tuberculosis

Infection by Mycobacterium tuberculosis (Mtb) results in a wide range of clinical presentations dependent upon the site of infection from classic signs and symptoms of pulmonary disease (cough greater than two to three weeks' duration, lymphadenopathy, fevers, night sweats, weight loss) to silent infection with a complete absence of signs or symptoms (Lewinsohn et al., 2017).

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-016 β-Hemolytic Streptococcus Testing

Streptococcus are Gram-positive, catalase-negative bacteria that are further divided into α-hemolytic, such as S. pneumoniae and S. mutans; β-hemolytic, such as S. pyogenes (Group A), S. agalactiae (Group B), and S. dysgalactiae subsp equisimilis (Groups C and G); and γ-hemolytic, such as Enterococcus faecalis and E. faecium (Wessels, 2024).

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-014 Diagnostic Testing of Common Sexually Transmitted Infections

Sexually transmitted infections (STIs), often referred to as sexually transmitted diseases or STDs, include a variety of pathogenic bacteria, virus, and other microorganisms that are spread through sexual contact and can cause a multitude of complications if left untreated.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-013 Urine Culture for Bacteria

Bacteriuria is the presence of bacteria in the urine. Urinary tract infections (UTIs) can occur in the urinary system and can be either symptomatic or asymptomatic.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-009 Diagnostic Testing of Influenza

Influenza is an acute respiratory illness caused by influenza A or B viruses resulting in upper and lower respiratory tract infection, fever, malaise, headache, and weakness.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-008 Venous and Arterial Thrombosis Risk Testing

A thrombosis, also known as a blood clot, occurs within blood vessels in the body. The two main types of thrombosis include venous thrombosis, which is when a vein is blocked due to a blood clot, and arterial thrombosis, which is when an artery is blocked due to a blood clot.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2025
Reimbursement Policy: PO-RE-002 Thyroid Disease Testing

Thyroid hormones are necessary for both prenatal and postnatal development, as well as metabolic activity in adults (Brent, 2024).

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
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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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
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. The intention of this policy is to promote access to necessary healthcare services and support for individuals managing diabetes. By waiving cost-sharing for specific services, Healthfirst aims to enhance diabetes management, improve health outcomes, and reduce long-term healthcare costs.

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