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 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.   

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

A-E F-NI NO-Z
Acupuncture (PDF)
Effective Date: Dec 2013
Fecal Calprotectin Assay (PDF)
Effective Date: Nov 2016
Non-Myeoablative Allogeneic Stem Cell Transplants (PDF)
Effective Date: Mar 17
Allergy Testing and Therapy (PDF)
Effective Date: Feb 2016
Fecal Incontinence (PDF)
Effective Date: Dec 2016
Obstetrical Home Health Programs (PDF)
Effective Date: Jan 2014
Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and B-Thalassemia (PDF)
Effective Date: Mar 2016
Fertility Preservation (PDF)
Effective Date: Sep 2016
Optic Nerve Decompression Surgery (PDF)
Effective Date: Sep 2016
Ambulatory Electroencephalography (EEG) (PDF)
Effective Date: Sep 2015
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)
Effective Date: Oct 2016
Outpatient Tresting for Drugs of Abuse (PDF)
Effective Date: Sep 2012
Applied Behavioral Analysis for Autism (PDF)
Effective Date: Aug 2009
Fractional Exhaled Nitric Oxide (PDF)
Effective Date: Dec 2015
Pancreas Transplantation (PDF)
Effective Date: Feb 2016
Articular Cartilage Defect Repairs (PDF)
Effective Date: Oct 2008
Functional MRI (PDF)
Effective Date: Sep 2009
Panniculectomy (PDF)
Effective Date: Apr 2016
Assisted Reproductive Technology (PDF)
Effective Date: Mar 2014
Gastric Electrial Stimulation (PDF)
Effective Date: Sep 2009
Pediatric Heart Transplant (PDF)
Effective Date: Dec 2016
Balloon Sinus Ostial Dilation (PDF)
Effective Date: Nov 2016
Gender Reassignment Surgery (PDF)
Effective Date: Jun 2017
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
Effective Date: Jun 2017
Bariatric Surgery (PDF)
Effective Date: June 2009
Genetic Testing (PDF)
Effective Date: Nov 2013
Posterior Nerve Stimulation for Voiding Dysfunction (PDF)
Effective Date: Oct 2016
Biofeedback (PDF)
Effective Date: Jun 2019
Heart-Lung Transplant (PDF)
Effective Date: Jun 2017
Proton and Neutron Beam Therapy (PDF)
Effective Date: Mar 2014
Bone-Anchored Hearing Aid (PDF)
Effective Date: Dec 2013
Holter Monitor (PDF)
Effective Date: Aug 2016
Radial Head Implant (PDF)
Effective Date: Jul 2017
Bronchial Theroplasty (PDF)
Effective Date: Apr 2016
Homocysteine Testing (PDF)
Effective Date: Jul 2016
Reduction Mammoplasty & Gynecomastia Surgery (PDF)
Effective Date: Aug 2012
Cell-free Fetal DNA Testing (PDF)
Effective Date: Jul 2013
Hospice Clinical Coverage (PDF)
Effective Date: May 2013
Sacroiliac Joint Fusion (PDF)
Effective Date: Sep 2016
Clinical Trials (PDF)
Effective Date: Jan 2014
Hyperbaric Oxygen Therapy (PDF)
Effective Date: Jun 2009
Sclerotherapy for Varicose Veins (PDF)
Effective Date: May 2017
Cochlear Implant Replacements (PDF)
Effective Date: Feb 2009
Hyperemesis Gravidum Treatment (PDF)
Effective Date: Mar 2009
Sickle Cell Observation (PDF)
Effective Date: Sep 2013
Cosmetic and Reconstructive Surgery (PDF)
Effective Date: Oct 2004
Hyperhidrosis Treatments (PDF)
Effective Date: Apr 2013
Spinal Cord Stimulation (PDF)
Effective Date: Jul 2016
Coverage of Experiemental Technologies (PDF)
Effective Date: Sep 2015
Inhaled Nitric Oxide (PDF)
Effective Date: Apr 2013
Stereotactic Body Radiation Therapy (PDF)
Effective Date: May 2013
Cystic Fibrosis Carrier Screening (PDF)
Effective Date: Jul 2013
Injections for Pain Management (PDF)
Effective Date: Aug 2016

Tandem Transplant (PDF)

Effective Date: July 2018

Dental Anesthesia (PDF)
Effective Date: Sep 2013
Intensity- Modulated Radiography (PDF)
Effective Date: Feb 2014
Testing for Rupture of Membranes (PDF)
Effective Date: Aug 2017
Diagnostic Digital Breast Tomosynthesis (PDF)
Effective Date: Nov 2011
Intestinal and Multivisceral Transplant (PDF)
Effective Date: Feb 2014
Testing for Select Genitourinary Conditions (PDF)
Effective Date: Jun 2016
Digital EEG Spike Analysis (PDF)
Effective Date: Jan 2016
Laser Therapy for Skin Diseases (PDF)
Effective Date: Jul 2016
Therapy Services (PT OT ST) (PDF)
Effective Date: Apr 2011
Disc Decompression Procedures (PDF)
Effective Date: Jul 2016
Low-Frequency Ultrasound Therapy for Wound (PDF)
Effective Date: Jan 2017
Ultrasound in Pregnancy (PDF)
Effective Date: Apr 2017
Discography (PDF)
Effective Date: Aug 2016
Lung Transplantation (PDF) 
Effective Date: Feb 2014
Urinary Incontinence Devices and Treatments (PDF)
Effective Date: Apr 2017
DME and O&P Criteria (PDF)
Effective Date: Jun 2009
Lysis of Epidural Lesions (PDF)
Effective Date: Jul 2016
Urodynamic Testing (PDF)
Effective Date: Oct 2015
DNA Analysis of Stool (PDF)
Effective Date: Sep 2016
Medical Necessity Criteria (PDF)
Effective Date: Jun 2013
Vagus Nerve Stimulation (PDF) 
Effective Date: Sep 2008
Donor Lymphocycte Infusion (PDF)
Effective Date: Dec 2015
Multiple Sleep Latency Testing (PDF)
Effective Date: Oct 2008
Ventricular Assist Devices (VAD) (PDF)
Effective Date: Dec 2009
Electric Tumor Treating Fields (PDF)
Effective Date: Apr 2017
Neonatal Abstinence Syndrome Guidelines (PDF)
Effective Date: Oct 2013
Ventriculectomy & Cardiomyplasty (PDF) 
Effective Date: May 2013
Endometrial Ablation (PDF) 
Effective Date: Feb 2016
Neonatal Intensive Care Unit (NICU) Discharge Guidelines (PDF)
Effective Date: Jun 2013
Wheelchair Seating (PDF)
Effective Date: Oct 2015
EpiFix Wound Treatment (PDF) 
Effective Date: Apr 2017
Neonatal Sepsis Management (PDF)
Effective Date: Aug 2013
Wireless Motility Capsule (PDF)
Effective Date: Apr 2017
Essure Removal (PDF) 
Effective Date: Nov 2016
NICU Apnea Brachycardia Guidelines (PDF)
Effective Date: Jun 2013
Zika Vrius Testing (PDF)
Effective Date: May 2016
Evoked Potential Testing (PDF)
Effective Date: Jan 2017
   

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 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.     

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: 3/1/18
Inpatient Consultation (PDF)
Effective Date: 3/10/18
Robotic Surgery (PDF)
Effective Date: 4/21/17
Add on Code Billed Without Primary Code (PDF)
Effective Date: 2/24/18
Inpatient Only Procedures (PDF)
Effective Date: 1/1/18
Same Day Visit as Surgery (PDF)
Effective Date: 3/1/18
Assistant Surgeon (PDF)
Effective Date: 3/1/18
IV Hydration (PDF)
Effective Date: 2/25/18
Sleep Studies Place of Service (PDF)
Effective Date: 5/1/17
Bilateral Procedures (PDF)
Effective Date: 5/11/18
Maximum Units (PDF)
Effective Date: 5/11/18
Status "B" Bundle Services (PDF)
Effective Date: 3/10/18
CA-Digital Breast Tomosynthesis (PDF)  Effective Date: 6/1/2017 Moderate Conscious Sedation (PDF)
Effective Date: 3/5/18
Status P Bundle Services (PDF)
Effective Date: 4/27/17
Cerumen Removal (PDF)
Effective Date: 2/28/18
Modifier -25 Clinical Validation (PDF) 
Effective Date: 2/24/18
Supplies Billed on Same Day Surgery (PDF)
Effective Date: 2/28/18
Clean Claims (PDF)
Effective Date: 6/9/18
Modifier -59 Clinical Validation (PDF)
Effective Date: 2/24/18
Transgender Related Services (PDF)
Effective Date: 2/15/18
CLIA Number (PDF)
Effective Date: 2/27/18
Modifier DOS Validation (PDF)
Effective Date: 2/24/18
Unbundled Professional Services (PDF)
Effective Date: 3/1/18
Coding Overview (PDF)
Effective Date: 6/9/18
Modifier to Procedure Code Validation (PDF)
Effective Date: 2/23/18
Unbundled Surgical Procedures (PDF)
Effective Date: 3/1/18
Cosmetic Procedures (PDF)
Effective Date: 6/20/18
Multiple CPT Code Replacement (PDF)
Effective Date: 2/28/18
Unlisted Procedure Codes (PDF)
Effective Date: 2/24/18
Distinct Procedural Modifers (PDF)
Effective Date: 3/10/18
NCCI Unbundling (PDF)
Effective Date: 9/9/16
Wheelchair Accessories (PDF)
Effective Date: 3/1/18
Duplicate Primary Code Billing (PDF)
Effective Date: 3/10/18
Never Paid Events (PDF)
Effective Date: 3/5/18
 
E&M Medical Decision-Making (PDF)
Effective Date: 8/7/17
New Patient (PDF)
Effective Date: 3/10/18
 
EM Bundling: Labs & Radiology (PDF)
Effective Date: 2/24/18
Outpatient Consultation (PDF)
Effective Date: 3/13/18
 
Global Maternity Billing (PDF)
Effective Date: 3/1/18

Physician's Consultation Services (PDF)

Effective Date: 11/25/2017

 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 6/20/18
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 3/13/18
 
  Post-Operative Visits (PDF)
Effective Date: 3/1/18
 
  Pre-Operative Visits (PDF)
Effective Date: 3/1/18
 
  Professional Component (PDF)
Effective Date: 6/28/18
 
  Pulse Oximetry (PDF)
Effective Date: 2/13/18