Reimbursement Policy: PO-RE-054 Fecal Calprotectin Testing in Adults

Calprotectin is a small calcium-binding protein found in high concentration in the cytosol of neutrophils (Fagerhol et al., 1980) and to a lesser extent monocytes and macrophages (Hsu et al., 2009).

Reimbursement Policy: PO-RE-093v1 Obstetrical Ultrasound Procedures

Healthfirst has implemented the following reimbursement policy regarding the billing of CPT 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal) in conjunction with CPT 76801-76812 (Ultrasound, pregnant uterus, real time with image documentation, transabdominal)

Reimbursement Policy: Anesthesia Start and Stop Times

Healthfirst requires that providers include the start time, stop time, and duration of anesthesia in the note segment of the 5010 claim form.

Reimbursement Policy: PO-RE-092v1 Ultrasound Diagnostic Procedures

Healthfirst will no longer provide reimbursement for CPT 76856 (Ultrasound, pelvic [non-obstetric], real time with image documentation; complete) or CPT 76857 Ultrasound, pelvic [non-obstetric], real time with image documentation; limited or follow-up) when billed with CPT 76830 (Transvaginal ultrasound) unless extenuating circumstances are present to validate the necessity of both studies.

Reimbursement Policy: PO-RE-089v1 Radiopharmaceuticals

Healthfirst has updated its reimbursement policy for radiopharmaceuticals commonly used for myocardial perfusion imaging studies.

Reimbursement Policy: PO-RE-088v1 National Drug Code Billing Requirements

This policy describes the National Drug Code (NDC) information that is required on professional and outpatient facility drug claims that are reported for reimbursement.

Reimbursement Policy: PO-RE-086v1 Place of Service

Healthfirst will reimburse services when reported with an appropriate Place of Service (POS).

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.

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.

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.

Communicable Disease Reporting Form