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Provider Alerts - Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Provider Alert: Medicaid FFS Enrollment Requirement for Providers

Healthfirst has reinstated the Medicaid Management Information System (MMIS) enrollment requirement.

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Medicaid
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
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.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
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.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
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.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023
Reimbursement Policy: PO-RE-077v1 Photochemotherapy

Effective September 1, 2023, consistent with the American Academy of Dermatology Association and New York State, Healthfirst will update our policy regarding covered diagnoses for photochemotherapy treatment.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-041 Serum Tumor Markers for Malignancies

Tumor biomarkers are proteins detected in the blood, urine, or other body fluids that are either produced by the tumor itself or in response to its presence.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-004 Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing

Parathyroid hormone (PTH), along with calcitriol and fibroblast growth factor 23 (FGF23), regulate calcium and phosphate homeostasis.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-007 Intracellular Micronutrient Analysis

Micronutrients are dietary components, often referred to as vitamins and minerals, which although only required by the body in small amounts, are vital to development, disease prevention, and wellbeing.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-011 Lyme Disease Testing

Lyme disease is a common multisystem inflammatory disease caused by spirochetes of the family Borreliaceae transmitted through the bite of an infected tick of the genus Ixodes (Barbour, 2022).

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-019 Human Immunodeficiency Virus (HIV)

Human immunodeficiency virus (HIV) is an RNA retrovirus that infects human immune cells, specifically CD4 cells, causing progressive deterioration of the immune system ultimately leading to acquired immune deficiency syndrome (AIDS) characterized by susceptibility to opportunistic infections and HIV-related cancers (CDC, 2014). HIV-1 is the dominant subtype of HIV infection, but another subtype, HIV-2, is a crucial subtype in certain areas of the world, such as Western Africa (Wood, 2023).

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-020 Onychomycosis Testing

Onychomycosis, also known as tinea unguium (Wollina et al., 2016), is a fungal infection of the nail typically caused by pathogenic fungal dermatophytes, such as Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccossum; onychomycosis may also be caused by yeasts, including Candida parapsilosis and Candida guilliermondii, or non-dermatophyte molds, including Neoscytalidium dimidiatum, Onychocola canadensis, the Aspergillus species, Scopulariopsis species, Alternaria species, Acremonium species, and Fusarium species (Ameen et al., 2014; Bongomin et al., 2018; Wollina et al., 2016).

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2024
Reimbursement Policy: PO-RE-025 Pediatric Preventive Screening

Preventive screening is a healthcare service with the goal of illness prevention and health management.

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Reimbursement Policy
  
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