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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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Reimbursement Policy
  
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 - 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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Reimbursement Policy
  
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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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-122 Pasteurized Human Donor Milk Coverage

Healthfirst provides coverage for Pasteurized Human Donor Milk (PDHM) under certain programs/lines of business. This policy describes Healthfirst’s reimbursement guidelines for PDHM as it relates to both inpatient and outpatient settings.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-123 Intensity-Modulated Radiation Therapy

This policy outlines the reimbursement guidelines for Intensity Modulated Radiation Therapy (IMRT) services provided by healthcare providers. IMRT is a specialized form of radiation therapy that allows for precise targeting of radiation to cancerous tumors while minimizing exposure to surrounding healthy tissue. Coverage for IMRT is subject to specific clinical indications as defined by the Centers for Medicare & Medicaid Services (CMS) policy.

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Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-119 Intensity-Modulated Radiation Therapy (IMRT) Frequency Limitations

This policy outlines the reimbursement guidelines for Intensity-Modulated Radiation Therapy (IMRT) services provided by healthcare providers. IMRT, specifically represented by CPT code 77301 (Intensity-modulated radiotherapy [IMRT] plan), is subject to frequency limitations to ensure appropriate billing practices and compliance with regulatory requirements.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-120 Urodynamic Studies

This policy outlines the reimbursement guidelines for healthcare providers regarding the measurement of post-voiding residual urine by ultrasound when performed in conjunction with urodynamic studies.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-124 Medicare Health Equity Services

This policy outlines the reimbursement guidelines for services related to the Health Equity Services framework established by the Centers for Medicare & Medicaid Services (CMS).

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Reimbursement Policy
  
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