Políticas clínicas y de pago

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Home State Health Clinical Policy Manual apply to Home State Health members. Policies in the Home State Health Clinical Policy Manual may have either a Home State Health or a “Centene” heading.  Home State Health utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Home State Health clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Home State Health. In addition, Home State Health may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by Home State Health.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-G H-Q R-Z
Acupuncture (PDF) H Pylori Testing (PDF)
Effective Date: 6/1/18
Radial Head Implant (PDF)
ADHS Assessment and Treatment (PDF)
Effective Date: 1/1/18
Heart-Lung Transplant (PDF) Sacroiliac Joint Fusion (PDF)
ADHD Assessment and Treatment (PDF) Holter Monitors (PDF) Sclerotherapy for Varicose Veins (PDF)
Allergy Testing (PDF)
Effective Date: 1/1/18
Homocysteine Testing (PDF) Sickle Cell Disease Observation (PDF)
Ambulatory EEG (PDF)
Effective Date: 1/1/18
Hospice (PDF) Spinal Cord Stimulation (PDF)
Ambulatory Surgical Center (PDF)
Effective Date: 1/1/18
Hospice Clinical Coverage (PDF) Testing for Rupture of Fetal Membranes (PDF)
Anesthesia Services for GI Endoscopy (PDF) Hyperhidrosis Treatments (PDF) Therapy Services (PDF)
Articular Cartilage Defect Repairs (PDF) Implantable Wireless PAP Monitoring (PDF) Thyroid Testing in Pediatrics (PDF)
Effective Date: 1/1/18
Bariatric Surgery (PDF) In Network Referrals (PDF)
Effective Date: 1/1/18
TPN IDPN (PDF)
Biofeedback (PDF) Inhaled Nitric Oxide (PDF) Ultrasound in Pregnancy (PDF)
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Intensity-Modulated Radiotherapy (PDF) Urodynamic Testing (PDF)
Effective Date: 1/1/18
Cardiac Biomarker Testing (PDF)
Effective Date: 11/1/18
Intestinal & Multivisceral Transplant (PDF) Vitamin D Testing in Children (PDF)
Effective Date: 6/1/18
Cardiac Biomarket Testing for Acute Myocardial Infarction (PDF)
Effective Date: 6/1/18
Laser Skin Treatment (PDF)
Effective Date: 1/1/18

Wheelchair Seating (PDF)

Effective Date: 10/1/2018 

Cardiac Rehabilitation (PDF) Laser Therapy for Skin Conditions (PDF)

Wireless Motility Capsule (PDF)
Effective Date: 1/1/18

Carrier Screening in Pregnancy (PDF) Long Term Care PLacement Criteria (PDF) Zika Virus Testing (PDF)
Cell-Free Fetal DNA Testing (PDF) Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18
 
Clinical Trials (PDF) Lysis of Epidural Lesions (PDF)  
Cochlear Implant Replacements (PDF) Mechanical Stretch Devices (PDF)  
Cystic Fibrosis Carrier Screening (PDF) Measure Serum 1,25 Vitamin (PDF)
Effective Date: 6/1/18
 
Dental Anesthesia (PDF) Medical Necessity Criteria (PDF)  
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
Monitored Anesthesia Care (PDF)  
Digital Analysis of EEGS (PDF)
Effective Date: 1/1/18
Multiple Sleep Latency Testing (PDF)  
Digital Breast Tomosynthesis (DBT) (PDF)
Effective Date: 1/1/18
Neonatal Abstinence Syndrome Guidelines (PDF)  
Disc Decompression Procedures (PDF) Neonatal Sepsis Management Guidelines (PDF)  
Discography (PDF) NICU Apnea Bradycardia Guidelines (PDF)  
DME (PDF) NICU Discharge Guidelines (PDF)  
DNA Analysis of Stool (PDF)
Effective Date: 1/1/18
OB Home Health Programs (PDF)  
EEG in Evaluation of Headache (PDF)
Effective Date: 6/1/18
Outpatient Testing for DOA (PDF)  
Endometrial Ablation (EA) (PDF)
Effective Date: 1/1/18
Percutaneous LAAD Stroke Prevention (PDF)  
Epifix Wound Treatment (PDF)
Effective Date: 1/1/18
Preventative Health and CPG Policy (PDF)  
Evoked Potentials (PDF)
Effective Date: 1/1/18
PROM Testing (PDF)
Effective Date: 1/1/18
 
Experimental Policy (PDF) Proton and Neautron Beam Therapy (PDF)
Effective Date: 1/1/18
 
Experimental Technologies (PDF)    
Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18
   
Fixed Wing Air Transportation (PDF)    
Genetic Testing (PDF)     
Grid (PDF)    
 

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ADHD Assessment and Treatment (PDF)
Effective Date: 1/1/18
Laser Skin Treatment (PDF)
Effective Date: 1/1/18
Ultrasound in Pregnancy (PDF)
Effective Date: 1/1/18
Allergy Testing (PDF)
Effective Date: 1/1/18
Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18
Urodynamic Testing (PDF)
Effective Date: 1/1/18
Ambulatory EEG (PDF)
Effective Date: 1/1/18
Measure Serum 1,25 Vitamin D (PDF)
Effective Date: 1/1/18
Vitamin D Testing in Children (PDF)
Effective Date: 1/1/18
Bevacizumab (PDF)
Effective Date: 1/1/18
Mechanical Stretch Devices (PDF)
Effective Date: 1/1/18
Wheelchair Seating (PDF)
Effective Date: 1/1/18
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Paclitaxel (PDF)
Effective Date: 1/1/18
Wireless Motility Capsule (PDF)
Effective Date: 1/1/18
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 1/1/18

PROM (PDF)

Effective Date:  1/15/20

 
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
Proton and Neutron Beam Therapy (PDF)
Effective Date: 1/1/18
 
Digitial Analysis of EEGs (PDF)
Effective Date: 1/1/18
Rituximab (PDF)
Effective Date: 1/1/18
 
DNA Analysis of Stool (PDF)
Effective Date: 1/1/18
Thyroid Testing in Pediatrics (PDF)
Effective Date: 1/1/18
 
EEG in Evaluation of Headache (PDF)
Effective Date: 1/1/18
   
Endometrial Ablation EA (PDF)
Effective Date: 1/1/18
   
EpiFix Wound Treatment (PDF)
Effective Date: 1/1/18
   
Evoked Potentials (PDF)
Effective Date: 1/1/18
   
Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18
   
FeNo Testing (PDF)
Effective Date: 1/1/18
   
H Pylori Testing (PDF)
Effective Date: 1/1/18
   
Holter Monitors (PDF)
Effective Date: 1/1/18
   
Homosysteine Testing (PDF)
Effective Date: 1/1/18
   

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Home State Health Payment Policy Manual apply with respect to Home State Health members. Policies in the Home State Health Payment Policy Manual may have either a Home State Health or a “Centene” heading.  In addition, Home State Health may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Home State Health.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-H I-Q R-Z
3-Day Payment Window (PDF)
Effective Date: 1/1/18
Inpatient Consultation (PDF)
Robotic Surgery (PDF)
Effective Date: 1/1/18
30-Day Readmission (PDF)
Effective Date: 1/1/18
Inpatient Only Procedures (PDF)
Same Day Visits (PDF)

Assistant Surgeon (PDF)

IV Hydration (PDF)
Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective Date: 1/1/18
Bilateral Procedures (PDF)

Leveling of ER Services (PDF)
Effective Date: 1/1/19
Sleep Studies Place of Service (PDF)
Effective Date: 1/1/18
Cerumen Removal (PDF)

Maximum Units (PDF)
Status "B" Bundled Services (PDF)

Clinic Facility Charge (PDF)

Moderate Conscious Sedation (PDF)

Status "P" Bundled Services (PDF)
Effective Date: 1/1/18
Clean Claims (PDF)

Modifer 25 Clinical Validation (PDF)

Supplies Billed on Same Day As Surgery (PDF)


Cosmetic Procedures (PDF)

 

Modifer 59 Clinical Validation (PDF)

Transgender Related Services (PDF)

Coding Overview (PDF) Modifer DOS Validation (PDF)

Unbundled Professional Services (PDF)

Distinct Procedural Modifiers (PDF) Modifer to Procedure Code Validation (PDF)

Unbundled Surgical Procedures (PDF)

Duplicate Primary Code Billing (PDF) Multiple CPT Code Replacement (PDF)

Unlisted Procedure Codes (PDF)

EM Bundling Edits (PDF) NCCI Unbundling (PDF)

Urine Specimen Validity Testing (PDF)

E&M Medical Decision-Making (PDF) Never Paid Events (PDF)

Visual Field Testing (PDF)
Effective Date: 1/1/18
Extended Ophthalmoscopy (PDF)
Effective Date: 1/1/18
New Patient (PDF)

Wheelchair Seating (PDF)

Effective Date: 01/01/2018 – 9/30/2018 

Wheelchair Seating (PDF)

Effective Date: 10/1/2018 

External Ocular Photography (PDF)
Effective Date: 1/1/18
Outpatient Consultation (PDF)

 
Fluorescein Angiography (PDF)
Effective Date: 1/1/18
Physician's Office Lab Testing (PDF)
Effective Date: 1/1/1
 
Fundus Photography (PDF)
Effective Date: 1/1/18
Physician Visit Codes Billed with Labs (PDF)

 
Global Maternity Billing (PDF) Post-Operative Visits (PDF)s

 
Gonioscopy (PDF)
Effective Date: 1/1/18
Pre-Operative Visits (PDF)

 
Hospital Visit Codes Billed with Labs (PDF) Professional Component (PDF)

 
  Problem Oriented Visits with Preventative Visits (PDF)

 
  Problem Oriented Visits with Surgical Procedures (PDF)

 
  Pulse Oximetry (PDF)

 
  Place of Service Mismatch (PDF)
Effective Date: 11/1/18
 
A-J K-T U-Z
3 Day Payment Window (PDF)
Effective Date: 1/1/18
Maximum Units (PDF)
Effective Date: 1/1/18
Unbundled Professional Services (PDF)
Effective Date: 1/1/18
30-Day Readmission (PDF)
Effective Date: 1/1/18
Moderate Conscious Sedation (PDF)
Effective Date: 1/1/18
Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/18
Assistant Surgeon (PDF)
Effective Date: 1/1/18
Modifier-25 Clinical Validation (PDF)
Effective Date: 1/1/18
Unlisted Procedure Codes (PDF)
Effective Date: 1/1/18
Add on Code Billed Without Primary Code
Effective Date: 1/1/18
Modifier-59 Clinical Validation (PDF)
Effective Date: 1/1/18

Wheelchair Seating (PDF)

Effective Date: 01/01/2018 – 9/30/2018 

Wheelchair Seating (PDF)

Effective Date: 10/1/2018 

Bilateral Procedures (PDF)
Effective Date: 1/1/18
Modifier DOS Validation (PDF)
Effective Date: 1/1/18
NCCI Unbundling (PDF)
Effective Date: 1/1/18
Cerumen Removal (PDF)
Effective Date: 1/1/18
Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/18
 
Clean Claims (PDF)
Effective Date: 1/1/18
Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/18
 
Coding Overview (PDF)
Effective Date: 1/1/18
Never Paid Events (PDF)
Effective Date: 1/1/18
 
Cosmetic Procedures (PDF)
Effective Date: 1/1/18
New Patient (PDF)
Effective Date: 1/1/18
 
Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18
Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 11/1/18
 
Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18
Outpatient Consultation (PDF)
Effective Date: 1/1/18
 
EM Bundling Edits (PDF)
Effective Date: 1/1/18

Physician Consultative Services (PDF)

Effective Date:  1/15/20

 
E&M Medical Decision-Making (PDF)
Effective Date: 1/1/18

Physician Office Lab Testing (POLT) (PDF)

Effective Date:  1/15/20

 
Global Maternity Billing (PDF)
Effective Date: 1/1/18
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18
 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18
Place of Service Mismatch (PDF)
Effective Date: 11/1/18
 
Inpatient Consultation (PDF)
Effective Date: 1/1/18
Post-Operative Visits (PDF)
Effective Date: 1/1/18
 
IV Hydration (PDF)
Effective Date: 1/1/18
Pre-Operative Visits (PDF)
Effective Date: 1/1/18
 
Inpatient Only Procedures (PDF)
Effective Date: 1/1/18

Problem Oriented Visits with Preventive Visits (PDF)

Effective Date:  1/15/20

 

Leveling of ER Services (PDF)

Effective Date:  1/15/20

Problem Oriented Visits with Surgical Procedures (PDF)

Effective Date:  1/15/20

 
  Professional Component (PDF)
Effective Date: 1/1/18
 
  Pulse Oximetry (PDF)
Effective Date: 1/1/18
 
  Robotic Surgery (PDF)
Effective Date: 1/1/18
 

 

Same Day Visits (PDF)
Effective Date: 1/1/18
 
  Status "B" Bundled Services (PDF)
Effective Date: 1/1/18
 
  Status "P" Bundled Services (PDF)
Effective Date: 1/1/18
 
  Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/18
 
  Transgender Related Services (PDF)
Effective Date: 1/1/18