Clinical & Payment Policies

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-H I-Q R-Z
Allergy Testing (PDF)
Effective Date: 1/1/18
In Network Referrals (PDF)
Effective Date: 1/1/18
Sickle Cell Disease Observation (PDF)
ADHS Assessment and Treatment (PDF)
Effective Date: 1/1/18
Inhaled Nitric Oxide (PDF) Thyroid Testing in Pediatrics (PDF)
Effective Date: 1/1/18
Ambulatory EEG (PDF)
Effective Date: 1/1/18
Intensity-Modulated Radiotherapy (PDF) Ultrasound in Pregnancy (PDF)
Effective Date: 1/1/18
Ambulatory Surgical Center (PDF)
Effective Date: 1/1/18
Intestinal & Multivisceral Transplant (PDF) Urodynamic Testing (PDF)
Effective Date: 1/1/18
Articular Cartilage Defect Repairs (PDF) Laser Skin Treatment (PDF)
Effective Date: 1/1/18
Vitamin D Testing in Children (PDF)
Effective Date: 6/1/18
Acupuncture (PDF) Long Term Care PLacement Criteria (PDF) Wheelchair Seating (PDF)
Effective Date: 1/1/18
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18
Wireless Motility Capsule (PDF)
Effective Date: 1/1/18
Cardiac Biomarker Testing (PDF)
Effective Date: 11/1/18
Measure Serum 1,25 Vitamin (PDF)
Effective Date: 6/1/18
 
Cardiac Biomarket Testing for Acute Myocardial Infarction (PDF)
Effective Date: 6/1/18
Medical Necessity Criteria (PDF)  
Cell-Free Fetal DNA Testing (PDF) Mechanical Stretch Devices (PDF)
Effective Date: 1/1/18
 
Clinical Trials (PDF) Neonatal Abstinence Syndrome Guidelines (PDF)  
Cystic Fibrosis Carrier Screening (PDF) Neonatal Sepsis Management Guidelines (PDF)  
Dental Anesthesia (PDF) NICU Apnea Bradycardia Guidelines (PDF)  
Digital Analysis of EEGS (PDF)
Effective Date: 1/1/18
NICU Discharge Guidelines (PDF)  
Digital Breast Tomosynthesis (DBT) (PDF)
Effective Date: 1/1/18
OB Home Health Programs (PDF)  
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
PROM Testing (PDF)
Effective Date: 1/1/18
 
DNA Analysis of Stool (PDF)
Effective Date: 1/1/18
Proton and Neautron Beam Therapy (PDF)
Effective Date: 1/1/18
 
EEG in Evaluation of Headache (PDF)
Effective Date: 6/1/18
   
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
   
Experimental Policy (PDF)    

Fecal Calprotectin Assay (PDF)

Effective Date: 1/1/18

   

FeNo Testing (PDF)

Effective Date: 1/1/18

   
Genetic Testing (PDF)     

H Pylori Testing (PDF)

Effective Date: 6/1/18

   

Holter Monitors (PDF)

Effective Date: 1/1/18

   
Hospice Clinical Coverage (PDF)    

Homocysteine Testing (PDF)

Effective Date: 1/1/18

   
Hyperhidrosis Treatments (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.

A-H I-Q R-Z
  Inpatient Only Procedures (PDF)
Effective Date: 1/1/18
 
  Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 11/1/18
 
  Place of Service Mismatch (PDF)
Effective Date: 11/1/18
 

 

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)
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)

CLIA Number (PDF)

Modifer 59 Clinical Validation (PDF)

Transgender Related Services (PDF)

Cosmetic Procedures (PDF)
Modifer DOS Validation (PDF)

Unbundled Professional Services (PDF)

Coding Overview (PDF)
Modifer to Procedure Code Validation (PDF)

Unbundled Surgical Procedures (PDF)

Distinct Procedural Modifiers (PDF)
Multiple CPT Code Replacement (PDF)

Unlisted Procedure Codes (PDF)

Duplicate Primary Code Billing (PDF)
NCCI Unbundling (PDF)

Urine Specimen Validity Testing (PDF)

EM Bundling Edits (PDF)
Never Paid Events (PDF)

Visual Field Testing (PDF)
Effective Date: 1/1/18
E&M Medical Decision-Making (PDF)
New Patient (PDF)

Wheelchair Accessories (PDF)
Effective Date: 1/1/18
Extended Ophthalmoscopy (PDF)
Effective Date: 1/1/18
Outpatient Consultation (PDF)

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

 
Fundus Photography (PDF)
Effective Date: 1/1/18
Post-Operative Visits (PDF)s

 
Global Maternity Billing (PDF)
Pre-Operative Visits (PDF)

 
Gonioscopy (PDF)
Effective Date: 1/1/18
Professional Component (PDF)

 
Hospital Visit Codes Billed with Labs (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