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Clinical & Payment Policies

 

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Acupuncture (PDF)H Pylori Serology Testing (PDF) Ultrasound in Pregnancy (PDF)
ADHD Testing and Treatment (PDF)Holter Monitors (PDF)Urinary Incontinence Devices and Treatments (PDF)
AHCT for Sickle Cell Anemia (PDF)Home Births (PDF)Urodynamic Testing (PDF)
Allergy Testing and Therapy (PDF)Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)US in Pregnancy (PDF)
Ambulatory EEG (PDF)
Effective Date: 1/1/18		Homosysteine Testing (PDF)
Effective Date: 1/1/21		Ventriculectomy Cardiomyoplasty (PDF)
Antithrombin III (Atryn Thrombate) (PDF)Hospice (PDF)Ventricular Assist Devices (PDF)
Applied Behavior Analysis (PDF)Hyperemesis Gravidarum Treatment (PDF)Video EEG Monitoring (PDF)
Articular Cartilage Defect Repairs (PDF)Hyperhidrosis Treatments (PDF)Vitamin D Testing in Children (PDF)
ASC Optimization (PDF)Implantable Hypoglossal Nerve Stim (PDF)Wheelchair Seating (PDF)
Assisted Reproductive Technology (PDF)Inhaled Nitric Oxide (PDF)Wireless Motility Capsule (PDF)
Balloon Sinus Ostial Dilation (PDF)Intensity-Modulated Radiotherapy (PDF) 
Bevacizumab (PDF)
Effective Date: 1/1/18		Laser Skin Treatment (PDF)
Effective Date: 1/1/18		 
Biofeedback (PDF)Low-frequency US and NNWT (PDF) 
Burn Surgery (PDF)Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18		 
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18		Lung Transplantation (PDF) 
Cardiac Biomarker Testing (PDF)Lysis of Epidural Lesions (PDF) 

Caudal or Interlaminar ESI (PDF)Measure Serum 1.25 Vitamin (PDF) 
Cell-Free Fetal DNA Testing (PDF)  
Clinicial Policy Committee (PDF)Mechanical Stretch Devices (PDF) 
Clinical Trials (PDF)Neonatal Abstinence Syndrome Guidelines (PDF) 
Cochlear Implant Replacements (PDF)Neonatal Sepsis Management Guidelines (PDF) 
Cosmetic and Reconstructive Procedures (PDF)Neurofeedback (PDF) 
CPG Grid (PDF)Neuromuscular Electrical Stimulation (PDF) 
Dental Anesthesia (PDF)Nerve Blocks and Neurolysis for Pain Management (PDF) 
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18		NICU Apnea Bradycardia Guidelines (PDF) 
Diaphragmatic Phernic Nerve Stimulation (PDF)Non-Invasive Home Ventilator (PDF) 
Digital Analysis of EEGS (PDF)Oncology Algorithmic Testing (PDF) 
Disc Decompression Procedures (PDF)Oncology Cancer Screening (PDF) 
Discography (PDF)Oncology Circulating Tumor DNA and Circulating Tumor Cells (Lqd Biopsy) (PDF) 
DME (PDF)Oncology Cytogenetic Testing (PDF) 
DNA Analysis of Stool (PDF)Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) 
Donor Lymphocyte Infusion (PDF)Optic nerve decompression surgery (PDF) 
EEG headache (PDF)Orthognathic Surgery (PDF) 
Electric Tumor Treating Fields (PDF)Outpatient Testing for DOA (PDF) 
Endometrial Ablation EA (PDF)
Effective Date: 1/1/18		Oxygen Use and Concentrators (PDF) 
EpiFix Wound Treatment (PDF)
Effective Date: 1/1/18		Paclitaxel (PDF) 
Essure Removal (PDF)Pancreas Transplantation (PDF) 
Evoked Potentials (PDF)Panniculectomy (PDF) 
Facet Joint Interventions (PDF)Pediatric Heart Transplant (PDF) 
Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18		Pediatric Liver Transplant (PDF) 
Fecal Incontinence Treatments (PDF)Pediatric Oral Function Therapy (PDF) 
Ferriscan R2 MRI (PDF)Percutaneous LAAD Stroke Prevention (PDF) 
Fetal Surgery in Utero (PDF)  
Fertility Preservation (PDF)PFO Closure Devices (PDF) 
Functional MRI (PDF)Post Acute Care (PDF) 
Gastric Electrical Stimulation (PDF)Presumptive Testing for Drugs of Abuse (PDF) 
Gastrointestinal Pathogen Nucleic Acid Detection Panel (PDF)Preventative Health and CPG Policy (PDF) 
Gender Affirming Procedures (PDF)Private Duty Nursing (PDF) 
Genetic and Pharmacogenetic Testing (PDF)

PROM (PDF)

Effective Date:  1/15/20

 
Genetic Testing Aortopathies and Connective Tissue Disorder (PDF)Proton and Neutron Beam Therapy (PDF)
Effective Date: 1/1/18		 
Genetic Testing Cardiac Disorders (PDF)Pulmonary Function Testing (PDF) 
Genetic Testing Dermatologic Conditions (PDF)Radial Head Implant (PDF) 
Genetic Testing Epilepsy NeurodegenerativeNeuromuscular Disorder (PDF)Reduction Mammoplasty and Gynecomastia Surgery (PDF) 
Genetic Testing Exome and Genome Sequencing (PDF)Rituximab (PDF)
Effective Date: 1/1/18		 
Genetic Testing Eye Disorders (PDF)Sacroiliac Joint Interventions (PDF) 
Genetic Testing Gastroenterologic Disorders (Non-Cancerous) (PDF)Selective Dorsal Rhizotomy for Spasticity in CP (PDF) 
Genetic Testing General Approach to Genetic Testing (PDF)Short Inpatient Hospital Stay (PDF) 
Genetic Testing Hearing Loss (PDF)SNF Leveling (PDF) 


Genetic Testing Hematologic Conditions (non-cancerous) (PDF)

Spinal Cord Stimulation (PDF) 
Genetic Testing Hereditary Cancer Susceptibility (PDF)Stereotactic Body Radiation Therapy (PDF) 
Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF)Testing Select Genitourinary conditions (PDF) 
Genetic Testing Kidney Disorders (PDF)Thymus Transplant (PDF) 
Genetic Testing Lung Disorders (PDF)Thyroid Testing in Pediatrics (PDF) 
Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (PDF)Thyroid Insulin Tests in Pediatrics (PDF) 
Genetic Testing for  Multisystem Inherited Disorders, ID & DD (PDF)Total Artificial Heart (PDF) 
Genetic Testing Non-Invasive Prenatal Screening (NIPS) (PDF)  
Genetic Testing Pharmacogenetics (PDF)  
Genetic Testing Preimplantation Genetic Testing (PDF)  
Genetic Testing Prenatal and Precon Carrier Screening (PDF)  
Prenatal Diagnosis (Via Amniocentesis CVS or PUBS) & Pregnancy Loss (PDF)  
Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (PDF)  
GI Pathogen Nucleic Acid Detection Panel Testing (PDF)  

For Medicare information, please visit our Medicare Prior Authorization website.

Clinical Policies
A-FG-OP-Z
Adjacent-Tissue-Transfer-Grafts-involving-Eyelid (PDF)Glaucoma (PDF)Pediatric-Eye-Examinations (PDF)
Age-Related-Macular-Degeneration (PDF)Glaucoma-Screening (PDF)Photodynamic-and-Intravitreal-Therapies-and-Pharmaceuticals (PDF)
Amblyopia (PDF)Gonioscopy (PDF)Probing-and-Closure-of-the-Lacrimal-Duct-System (PDF)
Amniotic-Membrane-Placement-on-Ocular-Surface (PDF)Guidelines-for-Dilation-Protocol-during-Examination-of-the-Eye (PDF)Prophylaxis-of-Retinal-Detachment (PDF)
Anterior-Segment-Photography-with-Fluorescein-Angiography (PDF)Indocyanine-Green-(ICG)-Angiography (PDF)Refractive-Surgery (PDF)
Aqueous-Shunt (PDF)Infracture-of-the-Inferior-Turbinate (PDF)Refraction (PDF)
Blepharoplasty-Ptosis-Repair-and-Canthoplasty (PDF)Iris-Coloboma (PDF)Repair-of-Retinal-Detachment (PDF)
Canthotomy (PDF)Keratoplasty (PDF)Scanning-Computerized-Ophthalmic-Diagnostic-Imaging (PDF)
Cataract-Extraction (PDF)Laser-Iridotomy-and-Iridectomy for Glaucoma (PDF)Secondary-Intraocular-Lens-(IOL) (PDF)
Chemodenervation (PDF)Laser-Trabeculoplasty (PDF)Sensorimotor-Examination (PDF)
Complex-Cataract-Extraction (PDF)Low-Vision-Evaluations-and-Aids (PDF)Serial-Tonometry (PDF)
Corneal-Erosion-and-Photo-Keratectomy (PDF)Ocular-Prosthesis (PDF)Specular-Microscopy (PDF)
Corneal-Hysteresis (PDF)Ocular-Surface-Reconstruction (PDF)Surgical-Excision-of-Eyelid-Lesions (PDF)
Corneal-Pachymetry (PDF)Ophthalmic-Biometry (PDF)Surgical-Strabismus-Repair (PDF)
Corneal-Topography (PDF)Ophthalmic-B-scans (PDF)Teleretinal-Screening-for-Diabetic-Retinopathy (PDF)
Dark-Adaption-and-Color-Vision-Examinations (PDF) Trabeculectomy-Ab-Externo (PDF)
Destruction-of-Localized-Lesion-of-Choroid (PDF) Visual-Field-Testing (PDF)
Destruction-of-Localized-Lesion-of-the-Retina (PDF) Visual-Therapy (PDF)
Destruction-of-Retinopathy (PDF) Vitrectomy (PDF)
Ectropion-Entropion-Repair (PDF) Yttrium-Aluminium-Garnet-(YAG)-Laser-Capsulotomy (PDF)
Electroretinography (PDF)  
Eyelid-Reanimation (PDF)  
Examination-Guidelines-for-Diabetic-Patients (PDF)  
Extended-Ophthalmoscopy (PDF)  
External-Ocular-Photography (PDF)  
Fluorescein-Angiography (PDF)  
Fundus-Photography (PDF)  

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.