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

The Clinical Policy Manuals may be accessed through the link below.  This site allows you to:

Search all folders by keyword by entering a search term in the keyword prompt and then pressing enter. Or you may browse by catalog subject by selecting the manual drop-downs on the left hand side. 

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

California Health & Wellness Clinical Policies

 

IMPORTANT REMINDER

These Clinical Policies have been developed by appropriately experienced and licensed health care professionals based on a thorough review and consideration of generally accepted standards of medical practice, peer-reviewed medical literature, government agency/program approval status, and other indicia of medical necessity.

The purpose of these policies is to clarify existing policy and practice with respect to determining the medical necessity of healthcare benefits. Benefit determinations should be based in all cases on the applicable contract provisions governing plan benefits (“Benefit Plan Contract”) and applicable state and federal requirements, as well as applicable plan-level administrative policies and procedures. To the extent there are any conflicts between these policies and the Benefit Plan Contract provisions, the Benefit Plan Contract provisions will control.

These policies are intended to be reflective of current scientific research and clinical thinking. These policies are not intended to dictate to providers how to practice medicine, nor does it constitute a contract or guarantee regarding payment or results. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members.

Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this policy.

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

California Health & Wellness’s payment policies may also use or be based on Medicare National Coverage Determination (NCDs), or Local Coverage Determinations (LCDs), for payment policy decisions. Medicare NCDs and LCDs are applied to the Medicare population and can be found at the following address: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

The Payment Policy Manuals may be accessed through the link below.  This site allows you to:

Search all folders by keyword by entering a search term in the keyword prompt and then pressing enter. Or you may browse by catalog subject by selecting the manual drop-downs on the left hand side. 

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

California Health & Wellness Payment Policies



IMPORTANT REMINDER

This policy is current at the time of publication. Centene Corporation retains the right to change or amend this policy at any time. 

While this policy provides guidance regarding reimbursement, it is not intended to address every reimbursement situation.  In instances that are not specifically addressed by this policy, or addressed by another policy or contract, Centene Corporation retains the right to use reasonable discretion in interpreting this policy and applying it (or not applying it) to the reimbursement of services provided to all or certain members. The provider is responsible for the accuracy of all claims.

This policy is the property of Centene Corporation. Unauthorized copying, use, and distribution of this policy or any information contained herein are strictly prohibited. 

This policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT® codes and descriptions are copyrighted 2014, American Medical Association. All rights reserved. CPT® codes and CPT® descriptions are from current 2016 manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

Providers and members are bound by the foregoing terms and conditions, in addition to the Site Use Agreement for Health Plans associated with Centene Corporation.

Note: For Medicaid members, when state Medicaid coverage provisions are controlling and conflict with the coverage provisions in this policy, state Medicaid coverage provisions take precedence. In such instance, please refer to the state Medicaid manual for any coverage provisions pertaining to this policy.