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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
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-157 ESRD Oral-Only Renal Dialysis Services – Drugs & Biologicals

Effective January 1, 2025, in accordance with CMS updates to the ESRD Prospective Payment System (PPS), oral-only renal dialysis service drugs and biologicals, specifically phosphate binders, will be incorporated into the ESRD PPS bundled payment model.

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Reimbursement Policy
  
Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2026
Reimbursement Policy: PO-RE-144 Advanced Primary Care Management (APCM) Services

This reimbursement policy outlines the guidelines and procedures for billing and reimbursement of Advanced Primary Care Management (APCM) services, including newly added Behavioral Health Integration (BHI) and Collaborative Care Model (CoCM) services.

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Reimbursement Policy
  
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