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Plans & Benefits - Practice Guidelines and Tips - 2026

Healthfirst at a Glance - Signature (HMO)

A Medicare Advantage plan for those looking for hospital, medical, and prescription drug coverage all in one plan with a flexible benefit card to help pay for member cost shares.

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Healthfirst Plans

Plans & Benefits - Practice Guidelines and Tips - 2026

Healthfirst at a Glance - Signature (PPO)

A Medicare Advantage plan with the option to see out-of-network providers without a referral and/or prior authorization.

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Healthfirst Plans

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

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.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

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.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

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.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-121 Reduction Mammaplasty

This policy outlines the reimbursement criteria for Reduction Mammaplasty procedures under Healthfirst coverage.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

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 - 2026

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.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-116 CPT Category III Codes

This policy applies to all healthcare providers submitting claims to Healthfirst for services that include CPT Category III codes.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

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 - 2026

Reimbursement Policy: PO-RE-111 Lactation Services

Healthfirst has expanded lactation services coverage under those plans to include reimbursement eligibility for providers certified by nationally recognized accrediting agencies.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026

Reimbursement Policy: PO-RE-108 Transportation Services

The purpose of this policy is to define the reimbursement guidelines for transportation coverage provided by Healthfirst, including ancillary services and out-of-state emergency transportation services negotiation.

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Reimbursement Policy