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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 (PDF)



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

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia (PDF)


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

Ambulatory 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)
Physical, Occupational and Speech Therapy (PDF)
Applied Behavioral Analysis (ABA) (PDF)


Gender Affirming Procedures (PDF)


Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)

Articular Cartilage Defect Repairs (PDF)


Genetic Testing and Pharmacogenetic Testing (PDF)


Post-Acute Care (PDF)
Artificial Retina (PDF)



Heart-Lung Transplant (PDF)

Posterior Nerve Stimulation for Voiding Dysfunction (PDF)

Assisted Reproductive Technology and Infertility (PDF)

Helicobacter Pylori Serology Testing (PDF)
Proton and Neutron Beam Therapy (PDF)



Autism Diagnosis and Treatment (PDF)



Holter Monitor (PDF)
Radial Head Implant (PDF)

Balloon Sinus Ostial Sinuplasty for Treatment of Chronic Sinusitis (PDF)

Home Births (PDF)



Radiofrequency Ablation of Uterine Fibroids (PDF)



Bariatric Surgery (PDF)

Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)




Reduction Mammoplasty & Gynecomastia Surgery (PDF)


Biofeedback (PDF)


Homocysteine Testing (PDF)



Refractive Surgery (PDF)


Bone Anchored Hearing Aids (BAHA)(PDF)


Hospice Care (PDF)

 

Repair of Nasal Valve Compromise (PDF)


Bronchial Thermoplasty (PDF)


Hyperemesis Gravidarum Treatment (PDF)


Sacroiliac Joint Fusion (PDF)

 

Burn Surgery (PDF)


Hyperhidrosis Treatments (PDF)



Sacroiliac Joint Interventions (PDF)


Cardiac Biomarker Testing for Acute MI (PDF)


Implantable Hypoglossal Nerve Stimulation (PDF)



Sclerotherapy for Varicose Veins (PDF)


Cardiac Risk Assessment Lab Tests (PDF)

Implantable Intrathecal Pain Pump (PDF)

 

Selective Dorsal Rhizotomy for Spasticity in Cerberal Palsy (PDF)



Cardiac Rehabilitation, Outpatient (PDF)

Implantable Wireless PAP Monitoring (PDF)

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



Caudal or Interlaminar Epidural Steroid Injections (PDF)

Inhaled Nitric Oxide Therapy (PDF)


Skilled Nursing Facility Leveling (PDF)
Cell-free Fetal DNA Testing (PDF)

Intensity- Modulated Radiography (PDF)



Skin Substitutes for Chronic Wounds (PDF)


Central Auditory Processing Disorder (PDF)

Intestinal and Multivisceral Transplant (PDF)


Spinal Cord Stimulation (PDF)

Clinical Trials (PDF)

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

Cochlear Implant Replacements (PDF)



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


Coverage of Experiemental Technologies (PDF)

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


Cystic Fibrosis Carrier Screening (PDF)

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

Testing for Select Genitourinary Conditions (PDF)



Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF)


Lung Transplantation (PDF)


Thymus Transplantation (PDF)



Dental Anesthesia (PDF)

Lysis of Epidural Lesions (PDF)


Thyroid Hormones and Insulin Testing in Pediatrics (PDF)


Diaphragmatic/ Phrenic Nerve Stimulation (PDF)

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



Total Artificial Heart (PDF)



Digital EEG Spike Analysis (PDF)


Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)



Disc Decompression Procedures (PDF)

Medical Necessity Criteria (PDF)


Transcatheter Closure of Patent Foramen Ovale (PDF)



Discography (PDF)


Multiple Sleep Latency Testing (PDF)
Transcranial Magnetic Stimulation (PDF)

Durable Medical Equipment  and Orthotics and Prosthetic Guidelines (PDF)


Neonatal Abstinence Syndrome Guidelines (PDF)

Trigger Point Injections for Pain Management (PDF)


DNA Analysis of Stool to Screen for Colorectal Cancer (PDF)
Neonatal Sepsis Management Guidelines (PDF)

Ultrasound in Pregnancy (PDF)


Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Stem Cell Transplantation (PDF)

Nerve Blocks for Pain Management (PDF)


Urinary Incontinence Devices and Treatments (PDF)


Double Balloon Enteroscopy (PDF)


Neurofeedback (PDF)

Urodynamic Testing (PDF)



EEG in the Evaluation of Headache (PDF)


Neuromuscular Electrical Stimulation (PDF)

Vagus Nerve Stimulation (PDF)



Elective Early Delivery Before 39 Weeks Gestational Age (PDF)


NICU Apnea Bradycardia Guidelines (PDF)


Ventricular Assist Devices (VAD) (PDF)


Electric Tumor Treating Fields (PDF)
NICU Discharge Guidelines (PDF)
Video EEG (PDF)


Electromyography and Nerve Conduction Studies (PDF)
Non-Emergency Ambulance Transportation (PDF)

Voice Therapy (PDF)


Endometrial Ablation (PDF)

Non-Invasive Home Ventilator (PDF)
Wheelchair Seating (PDF)



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



Essure Removal (PDF) 

Obstetrical Home Health Programs (PDF) 25-hydroxyvitamin D Testing in Children and Adolescents (PDF)

 


Evoked Potentials (PDF)


Optic Nerve Decompression Surgery (PDF)  


Experimental Technologies (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