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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.

The policies do not mean approval or guarantee of coverage for any specific procedure, drug, service, or supply. Members and providers should refer to the member contract for specific information. They can find out if any exclusions, limitations or dollar limits apply to a particular procedure, drug, service, or supply. If there are any conflicts between clinical policy guidelines and applicable contract language, the contract language takes precedence. A clinical policy is not intended to override the policy that defines the member's benefits. Additionally, clinical policies do not dictate to providers how to practice medicine. The health plan reserves the right to amend its clinical policies without notice to providers or members.

Note for Medicaid and Medi-Cal members: When state Medicaid or Medi-Cal coverage provisions conflict with the coverage provisions in a clinical policy, state Medicaid or Medi-Cal coverage provisions take precedence. Please refer to the state Medicaid or Medi-Cal manual for any coverage provisions before applying these clinical policies.

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-O P-Z
Acupuncture (PDF)

Facet Joint Interventions (PDF)
Pancreas Transplantation (PDF)

ADHD Assessment and Testing (PDF)



Fecal Incontinence Treatments (PDF)
Panniculectomy (PDF)

Air Ambulance (PDF)


Ferriscan (PDF)
Pediatric Heart Transplant (PDF)

Allergy Testing and Therapy (PDF)



Fetal Surgery in Utero for Prenatally Diagnosed Malformation (PDF)
Pediatric Liver Transplant (PDF)

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and B-Thalassemia (PDF)


Fertility Preservation (PDF)
Pediatric Oral Function Therapy (PDF)

Ambulatory Electroencephalography (EEG) (PDF)


Fractional Exhaled Nitric Oxide (PDF)
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)

Ambulatory Surgery Center Optimization (PDF)


Functional MRI (PDF)
Photopheresis (PDF)

Antithrombin III (PDF)


Gastric Electrical Stimulation (PDF)


Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
Applied Behavioral Analysis for Autism (PDF)


Gender Affirming Procedures (PDF)


Post-Acute Care (PDF)

Articular Cartilage Defect Repairs (PDF)


Genetic Testing and Pharmacogenetic Testing (PDF)


Posterior Nerve Stimulation for Voiding Dysfunction (PDF)
Artificial Retina (PDF)



Heart-Lung Transplant (PDF)

Proton and Neutron Beam Therapy (PDF)

Autism Diagnosis and Treatment (PDF)

Helicobacter Pylori Serology Testing (PDF)
Radial Head Implant (PDF)


Assisted Reproductive Technology (PDF)



Holter Monitor (PDF)
Radiofrequency Ablation of Uterine Fibroids (PDF)

Balloon Sinus Ostial Dilation (PDF)

Home Births (PDF)



Reduction Mammoplasty & Gynecomastia Surgery (PDF)



Bariatric Surgery (PDF)

Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)



Refractive Surgery (PDF)


Biofeedback (PDF)


Homocysteine Testing (PDF)


Repair of Nasal Valve Compromise (PDF)


Bone Anchored Hearing Aids (PDF)


Hospice Care (PDF)

 

Sacroiliac Joint Fusion (PDF)


Bronchial Thermoplasty (PDF)


Hyperemesis Gravidarum Treatment (PDF)



Sacroiliac Joint Interventions for Pain Management (PDF)

 

Burn Surgery (PDF)


Hyperhidrosis Treatments (PDF)



Sclerotherapy for Varicose Veins (PDF)


Cardiac Biomarker Testing for Acute Myocardial Infarction (PDF)


Implantable Hypoglossal Nerve Stimulation (PDF)



Selective Dorsal Rhizotomy for Spasticity in Cerberal Palsy (PDF)


Cardiac Risk Assessment Lab Tests (PDF)

Implantable Intrathecal Pain Pump (PDF)

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)

 



Caudal or Interlaminar Epidural Steroid Injections (PDF)

Implantable Wireless PAP Monitoring (PDF)

Sickle Cell Observation (PDF)



Cell-free Fetal DNA Testing (PDF)

Inhaled Nitric Oxide (PDF)


Skilled Nursing Facility Leveling (PDF)
Central Auditory Processing Disorder (PDF)

Intensity- Modulated Radiography (PDF)


Skin Substitutes for Chronic Wounds (PDF)


Clinical Trials (PDF)

Intestinal and Multivisceral Transplant (PDF)


Spinal Cord Stimulation (PDF)

Cochlear Implant Replacements (PDF)

Intradiscal Steroid Injections for Paint Management (PDF)
Stereotactic Body Radiation Therapy (PDF)


Coverage of Experiemental Technologies (PDF)


Laser Therapy for Skin Diseases (PDF)
Tandem Transplant (PDF)


Cystic Fibrosis Carrier Screening (PDF)

Long Term Care (PDF)
Testing for Rupture of Membranes (PDF)


Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF)

Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)

Testing for Select Genitourinary Conditions (PDF)




Dental Anesthesia (PDF)

Lung Transplantation (PDF)


Therapy Services (PT OT ST) (PDF)



Diaphragmatic/ Phrenic Nerve Stimulation (PDF)

Lysis of Epidural Lesions (PDF)


Thymus Transplantation (PDF)


Digital EEG Spike Analysis (PDF)

Measurement of Serum 1,25-dihydroxyvitamin D (PDF)




Thyroid Hormones and Insulin Testing in Pediatrics (PDF)



Disc Decompression Procedures (PDF)

Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)

Total Artificial Heart (PDF)


Discography (PDF)


Medical Necessity Criteria (PDF)


Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)



Durable Medical Equipment  and Orthotics and Prosthetic Guidelines (PDF)


Multiple Sleep Latency Testing (PDF)
Transcatheter Closure of Patent Foramen Ovale (PDF)


DNA Analysis of Stool (PDF)

Neonatal Abstinence Syndrome Guidelines (PDF)

Transcranial Magnetic Stimulation (PDF)


Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Stem Cell Transplantation (PDF)
Neonatal Intensive Care Unit (NICU) Discharge Guidelines (PDF)
Trigger Point Injections for Pain Management (PDF)


Double Balloon Enteroscopy (PDF)

Neonatal Sepsis Management (PDF)


Ultrasound in Pregnancy (PDF)


EEG in the Evaluation of Headache (PDF)

Nerve Blocks for Pain Management (PDF)


Urinary Incontinence Devices and Treatments (PDF)


Elective Early Delivery Before 39 Weeks Gestational Age (PDF)

Neurofeedback (PDF)


Urodynamic Testing (PDF)


Electric Tumor Treating Fields (PDF)

NICU Apnea Bradycardia Guidelines (PDF)


Vagus Nerve Stimulation (PDF)


Electromyography and Nerve Conduction Studies (PDF)
Non Emergency Ambulance Transportation (PDF)
Ventricular Assist Devices (VAD) (PDF)


Endometrial Ablation (PDF)
Non-Invasive Home Ventilator (PDF)

Video EEG (PDF)



Enhanced External Counterpulsation (PDF)
Non-Myeoablative Allogeneic Stem Cell Transplants (PDF)

Voice Therapy (PDF)


Essure Removal (PDF) 
Obstetrical Home Health Programs (PDF)

Wheelchair Seating (PDF)



Evoked Potentials (PDF)
Optic Nerve Decompression Surgery (PDF) Wireless Motility Capsule (PDF)


Experimental Technologies (PDF)

Outpatient Cardiac Rehabilitation (PDF) 25-hydroxyvitamin D Testing in Children and Adolescents (PDF)


Outpatient Tresting for Drugs of Abuse (PDF)  
  Oxygen Use and Concentrators (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 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-L M-Q R-Z
3 Day Payment Window (PDF)
Effective Date: 3/1/18
Maximum Units (PDF)
Effective Date: 6/14/19
Robotic Surgery (PDF)
Effective Date: 4/21/17
30 Day Readmission (PDF)
Effective Date: 11/1/19
Maximum Units of Service (PDF)
Effective Date: 7/5/19
Same Day Visit as Surgery (PDF)
Effective Date: 3/1/18
Add on Code Billed Without Primary Code (PDF)
Effective Date: 2/24/18
Moderate Conscious Sedation (PDF)
Effective Date: 3/5/18
Sleep Studies Place of Service (PDF)
Effective Date: 5/1/17
Assistant Surgeon (PDF)
Effective Date: 3/1/18
Modifier -25 Clinical Validation (PDF) 
Effective Date: 2/24/18
Status "B" Bundle Services (PDF)
Effective Date: 3/10/18
Bilateral Procedures (PDF)
Effective Date: 5/11/18
Modifier -59 Clinical Validation (PDF)
Effective Date: 2/24/18
Status P Bundle Services (PDF)
Effective Date: 4/27/17
CA-Digital Breast Tomosynthesis (PDF)  Effective Date: 6/1/2017 Modifier DOS Validation (PDF)
Effective Date: 2/24/18
Supplies Billed on Same Day Surgery (PDF)
Effective Date: 2/28/18
Cerumen Removal (PDF)
Effective Date: 2/28/18
Modifier to Procedure Code Validation (PDF)
Effective Date: 2/23/18
Transgender Related Services (PDF)
Effective Date: 2/15/18
Clean Claims (PDF)
Effective Date: 6/9/18
Multiple CPT Code Replacement (PDF)
Effective Date: 2/28/18
Unbundled Professional Services (PDF)
Effective Date: 3/1/18
Coding Overview (PDF)
Effective Date: 6/9/18
NCCI Unbundling (PDF)
Effective Date: 9/9/16
Unbundled Surgical Procedures (PDF)
Effective Date: 3/1/18
Cosmetic Procedures (PDF)
Effective Date: 6/20/18
Never Paid Events (PDF)
Effective Date: 3/5/18
Unlisted Procedure Codes (PDF)
Effective Date: 2/24/18
Distinct Procedural Modifers (PDF)
Effective Date: 3/10/18
New Patient (PDF)
Effective Date: 3/10/18
Urine Specimen Validity Testing  (PDF)
Effective Date: 12/27/18
Duplicate Primary Code Billing (PDF)
Effective Date: 3/10/18
Outpatient Consultation (PDF)
Effective Date: 3/13/18
Wheelchair Accessories (PDF)
Effective Date: 3/1/18
E&M Medical Decision-Making (PDF)
Effective Date: 8/7/17
Physician's Consultation Services (PDF)
Effective Date: 5/16/18
 
EM Bundling: Labs & Radiology (PDF)
Effective Date: 2/24/18
Physician's Office Lab Testing (PDF)
Effective Date: 7/5/19
 
Global Maternity Billing (PDF)
Effective Date: 3/1/18
Place of Service Mismatch (PDF)
Effective Date: 12/27/18
 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 6/20/18
Post-Operative Visits (PDF)
Effective Date: 3/1/18
 
Inpatient Consultation (PDF)
Effective Date: 3/10/18
Pre-Operative Visits (PDF)
Effective Date: 3/1/18
 
Inpatient Only Procedures (PDF)
Effective Date: 1/1/18
Professional Component (PDF)
Effective Date: 6/28/18
 
IV Hydration (PDF)
Effective Date: 2/25/18
Pulse Oximetry (PDF)
Effective Date: 2/13/18
 
Leveling of Emergency Room Services (PDF)
Effective Date: 7/1/19
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 3/13/18