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 PA Health & Wellness Clinical Policy Manual apply to PA Health & Wellness members. Policies in the PA Health & Wellness Clinical Policy Manual may have either a PA Health & Wellness or a “Centene” heading.  PA Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a PA Health & Wellness 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 PA Health & Wellness. In addition, PA Health & Wellness 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 PA Health & Wellness.   

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

Policy TitlePolicy Number
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157
Acupuncture (PDF)CP.MP.92
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.124
Adopted Clinical Practice and Preventive Health Guidelines (PDF)CPG Grid
Air Ambulance (PDF)CP.MP.175
Allergy Testinng and Therapy (PDF)CP.MP.100
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108
Ambulatory EEG (PDF)CP.MP.96
Ambulatory Surgery Center Optimization (PDF)CP.MP.158
Applied Behavior Analysis (PDF)CP.BH.104
Articular Cartilage Defect Repairs (PDF)CP.MP.26
Assisted Reproductive Technology (PDF)CP.MP.55
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.124
Bariatric Surgery (PDF)CP.MP.37
Behavioral Health Treatment Documentation Requirements (PDF)CP.BH.500
Biofeedback (PDF)CP.MP.168
Biofeedback for Behavioral Health Disorders (PDF)CP.BH.300
Bone-Anchored Hearing Aid (PDF)CP.MP.93
Bronchial Thermoplasty (PDF)CP.MP.110
Burn Surgery (PDF)CP.MP.186
Cardiac Biomarker Testing (PDF)CP.MP.156
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164
Clinical Trials (PDF)CP.MP.94
Cochlear Implant Replacements (PDF)CP.MP.14 
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V2.2023
Concert Genetic Testing: Cardiac Disorders (PDF)V2.2023
Concert Genetic Testing: Dermatologic Conditions (PDF)V2.2023
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V2.2023
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V2.2023
Concert Genetic Testing: Eye Disorders (PDF)V2.2023
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)V2.2023
Concert Genetic Testing: General Approach to Genetic Testing (PDF)V2.2023
Concert Genetic Testing: Hearing Loss (PDF)V2.2023
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)V2.2023
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V2.2023
Concert Genetic Testing: Kidney Disorders (PDF)V2.2023
Concert Genetic Testing: Lung Disorders (PDF)V2.2023
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V2.2023
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V2.2023
Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)V2.2023
Concert Genetic Testing: Pharmacogenetics (PDF)V2.2023
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V2.2023
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V2.2023
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)V2.2023
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V2.2023
Concert Genetics Oncology: Algorithmic Testing (PDF)V2.2023
Concert Genetics Oncology: Cancer Screening (PDF)V2.2023
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF) V2.2023
Concert Genetics Oncology: Cytogenetic Testing (PDF)V2.2023
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V2.2023
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.201
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203
Digital EEG Spike Analysis (PDF)CP.MP.105
Disc Decompression Procedures (PDF)CP.MP.114
Discography (PDF)CP.MP.115
Donor Lymphocyte Infusion (PDF)CP.MP.101
Drugs of Abuse: Definitive Testing (PDF)CP.MP.50
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (DME) (PDF)CP.MP.107
EEG in the Evaluation of Headache (PDF)CP.MP.155
Electric Tumor Treating Fields (Optune)(PDF)CP.MP.145
Endometrial Ablation (PDF)CP.MP.106
Evoked Potential Testing (PDF)CP.MP.134
Experimental Technologies (PDF)CP.MP.36
Facet Joint Interventions (PDF)CP.MP.171
Fecal Incontinence Treatments (PDF)CP.MP.137
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248
Ferriscan R2-MRI (PDF)CP.MP.53
Fertility Preservation (PDF)CP.MP.130
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129
Functional MRI (PDF)CP.MP.43
Gastric Electrical Stimulation (PDF)CP.MP.40
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)CP.MP.209
Gender-Affirming Procedures (PDF)CP.MP.95
H. Pylori Serology Testing (PDF)CP.MP.153
Heart-Lung Transplant (PDF)CP.MP.132
Holter Monitors (PDF)CP.MP.113
Home Births (PDF)CP.MP.136
Home Ventilators (PDF)CP.MP.184
Homocysteine Testing (PDF)CP.MP.121
Hospice Services (PDF)CP.MP.54
Hyperhidrosis Treatments (PDF)CP.MP.62
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173
Implantable Loop Recorder (PDF)CP.MP.243
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.160
Intensity-Modulated Radiotherapy (PDF)CP.MP.69
Intestinal and Multivisceral Transplant (PDF)CP.MP.58
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.167
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61
Laser Therapy for Skin Conditions (PDF)CP.MP.123
Liposuction for Lipedema (PDF)CP.MP.244
Long Term Care Placement Criteria (PDF)CP.MP.71
Low-Frequency Ultrasound and Noncontact Normothermic Wound (PDF)CP.MP.139
Lung Transplantation (PDF)CP.MP.57
Lysis of Epidural Lesions (PDF)CP.MP.116
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.144
Multiple Sleep Latency Testing (PDF)CP.MP.24
Neonatal Abstinence Syndrome Guidelines (PDF)CP.MP.86
Neonatal Sepsis Management (PDF)CP.MP.85
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.170
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.48
NICU Apnea Bradycardia Guidelines (PDF)CP.MP.82
NICU Discharge Guidelines (PDF)CP.MP.81
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.141
Obstetrical Home Care Programs (PDF)CP.MP.91
Omisirge (omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249
Optic Nerve Decompression Surgery (PDF)CP.MP.128
Orthognathic Surgery (PDF)CP.MP.202
Osteogenic Stimulation (PDF)CP.MP.194
Outpatient Cardiac Rehabilitation (PDF)CP.MP.176
Outpatient Oxygen Use (PDF)CP.MP.190
Pancreas Transplantation (PDF)CP.MP.102
Panniculectomy (PDF)CP.MP.109
Pediatric Heart Transplant (PDF)CP.MP.138
Pediatric Kidney Transplant (PDF)CP.MP.246
Pediatric Liver Transplant (PDF)CP.MP.120
Pediatric Oral Function Therapy (PDF)CP.MP.188
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.147
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.150
Physical, Occupational, and Speech Therapy Services (PDF)CP.MP.49
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)CP.MP.181
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133
Proton and Neutron Beam Therapies (PDF)CP.MP.70
Pulmonary Function Testing (PDF)CP.MP.242
Reduction Mammaplasty and Gyncomastia Surgery (PDF)CP.MP.51
Repair of Nasal Valve Compromise (PDF)CP.MP.210
Sacroiliac Joint Fusion (PDF)CP.MP.126
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174
Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF)CP.MP.165
Short Inpatient Hospital Stay (PDF)CP.MP.182
Skilled Nursing Facility Leveling (PDF)CP.MP.206
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117
Stereotactic Body Radiation Therapy (PDF)CP.MP.22
Tandem Transplant (PDF)CP.MP.162
Testing for Select Genitourinary Conditions (PDF)CP.MP.97
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)CP.MP.164
Total Artificial Heart (PDF)CP.MP.127
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163
Transcather Closer of Patent Foramen Ovale (PDF)CP.MP.151
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)CP.MP.200
Transplant Service Documentation Requirements (PDF)CP.MP.247
Trigger Point Injections for Pain Management (PDF)CP.MP.169
Ultrasound in Pregnancy (PDF)CP.MP.38
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142
Urodynamic Testing (PDF)CP.MP.98
Vagus Nerve Stimulation (PDF)CP.MP.12
Ventricular Assist Devices (PDF)CP.MP.46
Wheelchair Seating (PDF)CP.MP.99
Wireless Motility Capsule (PDF)CP.MP.143

A-KL-Z

72 Hour Supply of Medication (PDF)

Effective Date: 06/01/2006


Lost, Stolen, Spilled or Broken Medications (PDF)

Effective Date: 04/01/2007

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

Effective Date: 05/01/2012


Medication Safety Policy (PDF)

Effective Date: 07/01/2017

Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)

Effective Date: 11/01/2001


Pharmaceutical Management (PDF)

Effective Date: 02/01/2003

Dose Escalation of Biologics (PDF)

Effective Date: 09/01/2017


Pharmacy and Therapeutics Committee (PDF)

Effective Date: 08/19/2011

Drug Recall Notification Process (PDF)

Effective Date: 07/01/2008


Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)

Effective Date: 07/09/2010


Drug Utilization Review (PDF)

Effective Date: 04/01/2007

Progesterone (Crinone, Endometrin) (PDF)

Effective Date: 11/16/2016

Filgrastim (Neupogen, Zarxio) (PDF)

Effective Date: 11/16/2016

Somatropin (HGH) (PDF)

Effective Date: 11/16/2016

Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)

Effective Date: 12/01/2016

Lumacaftor-Ivacaftor (Orkambi) (PDF)

Effective Date: 05/01/2016

Ibalizumab-uiyk (Trogarzo) (PDF)

Effective Date: 04/17/2018

Nusinersen (Spinraza®)(PDF)

Effective Date: 11/28/2017

Brentuximab Vedotin (Adcetris) (PDF)

Effective Date: 02/01/2017

Somatropin (Growth Hormone) (PDF)

Effective Date: 03/01/2011

Interferon Gamma- 1b (Actimmune) (PDF)

Effective Date: 06/01/2010

Step Therapy (PDF)

Effective Date: 08/01/2017

Bendamustine (Bendeka®, Treanda®) (PDF)

Effective Date: 02/01/2017

Riociguat (Adempas®) (PDF)

Effective Date: 03/01/2016

Belimumab (Benlysta) (PDF)

Effective Date: 10/01/2011

Tadalafil (Adcirca®) (PDF)

Effective Date: 03/01/2016

C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF)

Effective Date: 03/01/2016

Tocilizumab (Actemra) (PDF)

Effective Date: 07/01/2016

Immune Globulins (PDF)

Effective Date: 08/01/2012

OnabotulinumtoxinA (Botox) (PDF)

Effective Date: 07/01/2016

Blinatumomab (Blincyto) (PDF)

Effective Date: 02/01/2017

Vandetanib (Caprelsa®) (PDF)

Effective Date: 10/01/2011

Ibandronate sodium (Boniva®) (PDF)

Effective Date: 11/15/2017

Reslizumab (Cinqair) (PDF)

Effective Date: 05/01/2016

Bosutinib (Bosulif) (PDF)

Effective Date: 10/01/2012

Tesamorelin (Egrifta) (PDF)

Effective Date: 03/01/2014

Cerliponase alfa (Brineura) (PDF)

Effective Date: 07/01/2017

Perampanel (Fycompa) (PDF)

Effective Date: 11/16/2016

Carglumic acid (Carbaglu®) (PDF)

Effective Date: 05/01/2016

Taliglucerase Alfa (Elelyso) (PDF)

Effective Date: 02/01/2016

Imiglucerase (Cerezyme) (PDF)

Effective Date: 02/01/2016

Pralatrexate (Folotyn®) (PDF)

Effective Date: 02/01/2017

Certolizumab (Cimzia) (PDF)

Effective Date: 08/01/2016

Teriparatide (Forteo®) (PDF)

Effective Date: 11/15/2017

Cabozantinib (Cometriq®, Cabometyx®) (PDF)

Effective Date: 06/01/2013

Levoleucovorin (Fusilev®) (PDF)

Effective Date: 11/09/2017

Glatiramer (Copaxone, Glatopa) (PDF)

Effective Date: 08/01/2016

Teduglutide (Gattex) (PDF)

Effective Date: 05/01/2013

Daratumumab (Darzalex) (PDF)

Effective Date: 07/01/2017

Obinutuzumab (Gazyva®) (PDF)

Effective Date: 02/01/2017

Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF)

Effective Date: 05/01/2016

Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)

Effective Date: 06/01/2016

Deferoxamine (Desferal) (PDF)

Effective Date: 11/01/2015

Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)

Effective Date: 03/01/2016

Dupilumab (Dupixent) (PDF)

Effective Date: 05/01/2017

Topotecan (Hycamtin)(PDF)

Effective Date: 06/01/2011

AbobotulinumtoxinA (Dysport) (PDF)

Effective Date: 07/01/2016

RimabotulinumtoxinB (Myobloc) (PDF)

Effective Date: 07/01/2016

Etanercept (Enbrel) (PDF)

Effective Date: 08/01/2016

Pegfilgrastim (Neulasta) (PDF)

Effective Date: 12/01/2016

Epoetin Alfa (Epogen® and Procrit) (PDF)

Effective Date: 06/01/2016

sorafenib (Nexavar) (PDF)

Effective Date: 07/01/2011

Cetuximab (Erbitux®) (PDF)

Effective Date: 02/01/2017

Mepolizumab (Nucala) (PDF)

Effective Date: 04/01/2016

Eteplirsen (PDF)

Effective Date: 12/01/2016

Obeticholic (Ocaliva) (PDF)

Effective Date: 11/01/2016

Deferasirox (Exjade Jadenu) (PDF)

Effective Date: 11/1/2015

Nivolumab (Opdivo) (PDF)

Effective Date: 07/01/2015

Aflibercept (Eylea®) (PDF)

Effective Date: 03/01/2016

Lumacaftor-ivacaftor (Orkambi) (PDF)

Effective Date: 05/01/2016

Agalsidase Beta (Fabrazyme) (PDF)

Effective Date: 02/01/2016

Pertuzumab (Perjeta) (PDF)

Effective Date: 06/01/2016

Deferiprone (Ferriprox) (PDF)

Effective Date: 11/01/2015

Peginterferon beta-1a (Plegridy) (PDF)

Effective Date: 08/01/2016

Degarelix acetate (Firmagon®) (PDF)

Effective Date: 11/09/2017

Pomalidomide (Pomalyst) (PDF)

Effective Date: 07/01/2013

Dalteparin (Fragmin) (PDF)

Effective Date: 05/01/2016

Necitumumab (Portrazza®) (PDF)

Effective Date: 03/01/2017

Enfuvirtide (Fuzeon) (PDF)

Effective Date: 06/01/2010

Palbociclib (Ibrance®) (PDF)

Effective Date: 10/01/2015

Fingolimod (Gilenya) (PDF)

Effective Date: 08/01/2016

Ponatinib (Iclusig) (PDF)

Effective Date: 06/01/2013

Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF)

Effective Date: 03/01/2012

Ibrutinib (Imbruvica) (PDF)

Effective Date: 10/01/2015

Imatinib (Gleevec) (PDF)

Effective Date: 06/01/2011

 

Eribulin Mesylate (Halaven®) (PDF)

Effective Date: 03/01/2017

 

Adalimumab (Humira) (PDF)

Effective Date: 08/01/2016

 

Hydroxyprogesterone Caproate (Makena®) (PDF)

Effective Date: 11/20/2017

 

Galsulfase (Naglazyme) (PDF)

Effective Date: 02/01/2016

 

Ixazomib (Ninlaro) (PDF)

Effective Date: 02/01/2017

 

belatacept (Nulojix®) (PDF)

Effective Date: 11/09/2017

 

abatacept (Orencia) (PDF)

Effective Date: 08/01/2016

 

irinotecan Liposome (Onivyde®) (PDF)

Effective Date: 02/01/2017

 

Apremilast (Otezla) (PDF)

Effective Date: 08/01/2016

 

Buprenorphine implant (Probuphine) (PDF)

Effective Date: 11/16/2016

 

Alirocumab (Praluent) (PDF)

Effective Date: 10/01/2015

 

Cysteamine oral (Cystagon, Procysbi) (PDF)

Effective Date: 02/01/2016

 

Denosumab (Prolia, Xgeva) (PDF)

Effective Date: 03/01/2011

 

Eltrombopag (Promacta®) (PDF)

Effective Date: 03/01/2016

 

Canakinumab (Ilaris) (PDF)

Effective Date: 08/01/2016

 

 

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 PA Health & Wellness Payment Policy Manual apply with respect to PA Health & Wellness members. Policies in the PA Health & Wellness Payment Policy Manual may have either a PA Health & Wellness or a “Centene” heading.  In addition, PA Health & Wellness 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 PA Health & Wellness.     

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

A-HI-QR-Z

3 Day Payment Window (PDF)

Effective Date: 07/01/2014

Inpatient Only Procedures Policy (PDF)

Effective Date: 1/1/18

Reporting the Global Maternity Package (PDF)

Effective Date: 01/01/2013

30 Day Readmission (PDF)

Effective Date: 01/01/2015

IV Hydration Policy (PDF)

Effective Date: 01/01/2013


Robotic Surgeries (PDF)

Effective Date: 08/01/2017

Add On Policy (PDF)

Effective Date: 01/01/2013

Inpatient Consultation (PDF)

Effective Date: 01/01/2014

Same Day Visits (PDF)

Effective Date: 01/01/2014

Assistant Surgeon (PDF)

Effective Date: 01/01/2014

Moderate Conscious Sedation (PDF)

Effective Date: 01/01/2013

Status B Bundled Services (PDF)

Effective Date: 01/01/2014

Bilateral Procedures (PDF)

Effective Date: 01/01/2014

Max Units Payment Policy (PDF)

Effective Date: 01/01/2013

Status P Bundled Services (PDF)

Effective Date: 01/01/2014

Cerumen Removal Policy (PDF)

Effective Date: 01/01/2014

Modifier DOS Validation (PDF)

Effective Date: 01/01/2015

Supplies Same Day as Surgery (PDF)

Effective Date: 01/01/2013

Clean Claims Policy (PDF)

Effective Date: 01/01/2013

Multiple CPT Code Replace (PDF)

Effective Date: 01/01/2013

Transgender Related Services (PDF)

Effective Date: 01/01/2017

Clinical Validation of Modifier 25 (PDF)
Effective Date: 01/01/201

Modifier to Procedure Code Validation (PDF)

Effective Date: 01/01/2013



Unbundled Professional Services (PDF)

Effective Date: 03/15/2017

Clinical Validation of Modifier 59 (PDF)
Effective Date: 01/01/2013

NCCI Unbundling (PDF)

Effective Date: 01/01/2013

Unbundled Surgical Procedures (PDF)

Effective Date: 03/15/2017

Code Editing Overview (PDF)
Effective Date: 01/01/2013

New Patient (PDF)

Effective Date: 01/01/2014

Unlisted Procedure Codes Policy (PDF)

Effective Date: 01/01/2013

Cosmetic Procedures (PDF)
Effective Date: 01/01/2014

Never Paid Events (PDF)

Effective Date: 01/01/2013

Urine Specimen Validity Testing (PDF)

Effective Date: 10/01/2017

Distinct Procedure Modifiers Policy (PDF)
Effective Date: 01/01/2013

Outpatient Consultation (PDF)

Effective Date: 01/01/2014

Visual Field Testing (PDF)

Effective Date: 01/01/2017

Duplicate Primary Code Billing (PDF)
Effective Date: 01/01/2014

Physician Visit Codes Billed with Labs (PDF)

Effective Date: 01/01/2013

Wheelchairs and Accessories (PDF)

Effective Date: 10/01/2015

EM Medical Decision Making (PDF)
Effective Date: 06/01/2017


Physicians Consultation Services (PDF)

Effective Date: 10/01/2017

Ultrasound in Pregnancy (PDF)

Effective Date: 01/31/2011

E&M Bundling with Labs and Radiology (PDF)
Effective Date: 01/01/2013

Postoperative Visits (PDF)

Effective Date: 01/01/2014

 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 01/01/2016

Preoperative Visits (PDF)

Effective Date: 01/01/2014

 
 

Problem Oriented Visits with Preventative Services (PDF)

Effective Date: 10/01/2017

 
 

Problem Oriented Visits with Surgical Procedures (PDF)

Effective Date: 10/01/2017

 
 

Professional Component Modifier (PDF)

Effective Date: 01/01/2013

 
 

Pulse Oximetry w Office Visits (PDF)

Effective Date: 01/01/2013

 
 

Place of Service Mismatch (PDF)

Effective Date: 09/01/2018

 
 

Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF)

Effective Date: 06/01/2018 

 
 

Not Medically Necessary Inpatient Service (PDF)

Effective Date: 06/01/2018