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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.

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Acupuncture (PDF)
Gastric Electrical Stimulation (PDF)

Pancreas Transplantation (PDF)

ADHD Assessment and Testing (PDF)

Gender Affirming Procedures (PDF)

Panniculectomy (PDF)

Air Ambulance (PDF)

Genetic Testing and Pharmacogenetic Testing (PDF)

Pediatric Heart Transplant (PDF)

Allergy Testing and Therapy (PDF)

Heart-Lung Transplant (PDF)

Pediatric Liver Transplant (PDF)

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

Helicobacter Pylori Serology Testing (PDF)

Pediatric Oral Function Therapy (PDF)

Ambulatory Electroencephalography (EEG) (PDF)

Holter Monitor (PDF)

Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)

Ambulatory Surgery Center Optimization (PDF)

Home Births (PDF)

Photopheresis (PDF)

Antithrombin III (PDF)

Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)



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

Homocysteine Testing (PDF)


Posterior Nerve Stimulation for Voiding Dysfunction (PDF)

Articular Cartilage Defect Repairs (PDF)

Hospice Care (PDF)


Proton and Neutron Beam Therapy (PDF)
Autism Diagnosis and Treatment (PDF)

Hyperemesis Gravidarum Treatment (PDF)


Radial Head Implant (PDF)
Assisted Reproductive Technology (PDF)

Hyperhidrosis Treatments (PDF)

Radiofrequency Ablation of Uterine Fibroids (PDF)

Balloon Sinus Ostial Dilation (PDF)

Implantable Hypoglossal Nerve Stimulation (PDF)

Reduction Mammoplasty & Gynecomastia Surgery (PDF)
Bariatric Surgery (PDF)

Implantable Intrathecal Pain Pump (PDF)



Refractive Surgery (PDF)

Biofeedback (PDF)

Implantable Wireless PAP Monitoring (PDF)


Sacroiliac Joint Fusion (PDF)

Bone Anchored Hearing Aids (PDF)

Inhaled Nitric Oxide (PDF)


Sacroiliac Joint Interventions for Pain Management (PDF)

Bronchial Thermoplasty (PDF)

Intensity- Modulated Radiography (PDF)

 

Sclerotherapy for Varicose Veins (PDF)

Burn Surgery (PDF)

Intestinal and Multivisceral Transplant (PDF)



Selective Dorsal Rhizotomy for Spasticity in Cerberal Palsy (PDF)

Cardiac Biomarker Testing for Acute Myocardial Infarction (PDF)

 

Intradiscal Steroid Injections for Paint Management (PDF)


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

Cardiac Risk Assessment Lab Tests (PDF)

Laser Therapy for Skin Diseases (PDF)


Sickle Cell Observation (PDF)

Carrier Screening in Pregnancy (PDF)

Long Term Care (PDF)

Skilled Nursing Facility Leveling 

 

Caudal or Interlaminar Epidural Steroid Injections (PDF)

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

Skin Substitutes for Chronic Wounds (PDF)

Cell-free Fetal DNA Testing (PDF)

Lung Transplantation (PDF)


Spinal Cord Stimulation (PDF)
Central Auditory Processing Disorder (PDF)

Lysis of Epidural Lesions (PDF)


Stereotactic Body Radiation Therapy (PDF)

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



Tandem Transplant (PDF)

Cochlear Implant Replacements (PDF)
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)

Testing for Rupture of Membranes (PDF)

Coverage of Experiemental Technologies (PDF)
Medical Necessity Criteria (PDF)

Testing for Select Genitourinary Conditions (PDF)

Cystic Fibrosis Carrier Screening (PDF)
Multiple Sleep Latency Testing (PDF)

Therapy Services (PT OT ST) (PDF)

Dental Anesthesia (PDF)
Neonatal Abstinence Syndrome Guidelines (PDF)



Thymus Transplantation (PDF)


Diaphragmatic/ Phrenic Nerve Stimulation (PDF)
Neonatal Intensive Care Unit (NICU) Guidelines (PDF)


Thyroid Hormones and Insulin Testing in Pediatrics (PDF)


Digital EEG Spike Analysis (PDF)
Neonatal Sepsis Management (PDF)



Total Artificial Heart (PDF)

Disc Decompression Procedures (PDF)
Nerve Blocks for Pain Management (PDF)



Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)


Discography (PDF)
Neurofeedback (PDF)


Transcatheter Closure of Patent Foramen Ovale (PDF)


Durable Medical Equipment  and Orthotics and Prosthetic Guidelines (PDF)
NICU Apnea Bradycardia Guidelines (PDF)


Transcranial Magnetic Stimulation (PDF)


DNA Analysis of Stool (PDF)
Non-Invasive Home Ventilator (PDF)

Trigger Point Injections for Pain Management (PDF)

Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Stem Cell Transplantation (PDF)
Non-Myeoablative Allogeneic Stem Cell Transplants (PDF)


Ultrasound in Pregnancy Medi-Cal (PDF)
Double Balloon Enteroscopy (PDF)


Obstetrical Home Health Programs (PDF)


Urinary Incontinence Devices and Treatments (PDF)

EEG in the Evaluation of Headache (PDF)
Optic Nerve Decompression Surgery (PDF)


Urodynamic Testing (PDF)

Electric Tumor Treating Fields (PDF)

Outpatient Cardiac Rehabilitation (PDF)


Vagus Nerve Stimulation (PDF)

Endometrial Ablation (PDF)
Outpatient Tresting for Drugs of Abuse (PDF)


Ventricular Assist Devices (VAD) (PDF)

Enhanced External Counterpulsation (PDF)
Oxygen Use and Concentrators (PDF)

Video EEG (PDF)


Essure Removal (PDF) 
  Voice Therapy (PDF)


Evoked Potential Testing (PDF)
  Wheelchair Seating (PDF)



Facet Joint Interventions (PDF)
  Wireless Motility Capsule (PDF)


Fecal Incontinence Treatments (PDF)
  25-hydroxyvitamin D Testing in Children and Adolescents (PDF)


Ferriscan (PDF)

   


Fetal Surgery in Utero for Prenatally Diagnosed Malformation (PDF)
   

Fertility Preservation (PDF)
   
Fractional Exhaled Nitric Oxide (PDF)    
Functional MRI (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.

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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