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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-F G-O P-Z
Acupuncture (PDF)
Effective Date: Dec 2013
Gastric Electrial Stimulation (PDF)
Effective Date: Sep 2009
Pancreas Transplantation (PDF)
Effective Date: Feb 2016
ADHD Assessment and Testing (PDF)
Effective Date: Aug 2016
Gender Reassignment Surgery (PDF)
Effective Date: Jun 2017
Panniculectomy (PDF)
Effective Date: Apr 2016
Allergy Testing and Therapy (PDF)
Effective Date: Feb 2016
Genetic Testing (PDF)
Effective Date: Nov 2013
Pediatric Heart Transplant (PDF)
Effective Date: Dec 2016
Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and B-Thalassemia (PDF)
Effective Date: Mar 2016
Heart-Lung Transplant (PDF)
Effective Date: Jun 2017
Pediatric Heart Transplant (PDF)
Effective Date: Dec 2016
Ambulatory Electroencephalography (EEG) (PDF)
Effective Date: Sep 2015
Helicobacter Pylori Serology Testing (PDF)
Effective Date: 9/14/2018
Pediatric Liver Transplant (PDF)
Effective Date: Feb 2018
Ambulatory Surgery Center Optimization (PDF)
Effective Date: Jan 2018
Holter Monitor (PDF)
Effective Date: Aug 2016
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
Effective Date: Jun 2017
Applied Behavioral Analysis for Autism (PDF)
Effective Date: Aug 2009
Homocysteine Testing (PDF)
Effective Date: Jul 2016
Posterior Nerve Stimulation for Voiding Dysfunction (PDF)
Effective Date: Oct 2016
Articular Cartilage Defect Repairs (PDF)
Effective Date: Oct 2008
Hospice Care (PDF)
Effective Care: Jul 2014
Proton and Neutron Beam Therapy (PDF)
Effective Date: Mar 2014
Autism Diagnosis and Treatment (PDF)
Effecitive: November 2018
Hyperbaric Oxygen Treament (PDF)
Effective Date: Jun 2009

Radial Head Implant (PDF)
Effective Date: Jul 2017

Assisted Reproductive Technology (PDF)
Effective Date: Mar 2014
Hyperemesis Gravidarum Treatment (PDF)
Effective Date: Mar 2009
Reduction Mammoplasty & Gynecomastia Surgery (PDF)
Effective Date: Aug 2012
Balloon Sinus Ostial Dilation (PDF)
Effective Date: Nov 2016
Hyperhidrosis Treatments (PDF)
Effective Date: Apr 2013
Robotic Surgery (PDF)
Effective Date: Oct 2018
Bariatric Surgery (PDF)
Effective Date: June 2009
Implantable Intracathecal Pain Pump (PDF)
Effective Date: Feb 2019
Sacroiliac Joint Fusion (PDF)
Effective Date: Sep 2016

Biofeedback (PDF)
Effective Date: Jun 2019

Implantable Wireless PAP Monitoring (PDF)
Effective Date: Apr 2018
Sacroiliac Joint Interventions for Pain Management (PDF)
Effective Date: Aug 2018
Bone Anchored Hearing Aids (PDF)
Effective Date: Dec 2015
Inhaled Nitric Oxide (PDF)
Effective Date: Apr 2013
Sclerotherapy for Varicose Veins (PDF)
Effective Date: May 2017
Bronchial Theroplasty (PDF)
Effective Date: Apr 2016
Intensity- Modulated Radiography (PDF)
Effective Date: Feb 2014

Selective Dorsal Rhizotomy for Spasticity in Cerberal Palsy (PDF)

Effective Date: Mar 2019

Cardiac Biomarker Testing for Acute Myocardial Infarction (PDF)

Effective Date: 9/14/18

Intestinal and Multivisceral Transplant (PDF)
Effective Date: Feb 2014
Selective Nerve Root Blocks and Transformational Epidural Steroid Injections (PDF)
Effective Date: Aug 2018
Cardiac Risk Assessment Lab Tests (PDF)
Effecitve Date: Sep 2018
Intradiscal Steroid Injections for Paint Management (PDF)
Effective Date: Aug 2018
Sickle Cell Observation (PDF)
Effective Date: Sep 2013
Carrier Screening in Pregnancy (PDF)
Effective Date: Jul 2013
Laser Therapy for Skin Diseases (PDF)
Effective Date: Jul 2016
Spinal Cord Stimulation (PDF)
Effective Date: Jul 2016
Caudal or Interlaminar Epidural Steroid Injections (PDF)
Effective Date: Aug 2018
Long Term Care (PDF)
Effective Date: May 2014

Stereotactic Body Radiation Therapy (PDF)
Effective Date: May 2013

Cell-free Fetal DNA Testing (PDF)
Effective Date: Jul 2013
Low-Frequency Ultrasound Therapy for Wound (PDF)
Effective Date: Jan 2017

Tandem Transplant
Effective Date: Jul 2018

Clinical Trials (PDF)
Effective Date: Jan 2014
Lung Transplantation (PDF)
Effective Date: Jan 2014

Testing for Rupture of Membranes (PDF)
Effective Date: Aug 2017

Cochlear Implant Replacements (PDF)
Effective Date: Feb 2009
Lysis of Epidural Lesions (PDF)
Effective Date: Jul 2016
Testing for Select Genitourinary Conditions (PDF)
Effective Date: Jun 2016
Coverage of Experiemental Technologies (PDF)
Effective Date: Sep 2015
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: 9/14/18
Therapy Services (PT OT ST) (PDF)
Effective Date: Apr 2011
Cystic Fibrosis Carrier Screening (PDF)
Effective Date: Jul 2013
Mechanical Stretching Devicesfor Joint Stiffness and Contracture (PDF)
Effective Date: Apr 2017
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: Sep 2018
Dental Anesthesia (PDF)
Effective Date: Sep 2013
Medical Necessity Criteria (PDF)
Effective Date: Jun 2013
Total Artificial Heart (PDF)
Effective Date: Sep 2016
Digital EEG Spike Analysis (PDF)
Effective Date: Jan 2016
Microvolt T-Wave (PDF)
Effecitive Date: Sep 2018
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition 
Effective Date: May 2016
Disc Decompression Procedures (PDF)
Effective Date: Jul 2016
Monitored Anesthesia Care (PDF)
Effective Date: May 2018
Transcatheter Closure of Patent Foramen Ovale (PDF)
Effective Date: Dec 2018
Discography (PDF)
Effective Date: Aug 2016
Multiple Sleep Latency Testing (PDF)
Effective Date: Oct 2008
Trigger Point Injections for Pain Management (PDF)
Effective Date: Aug 2018
DME and O&P Criteria (PDF)
Effective Date: Jun 2009
Neonatal Abstinence Syndrome Guidelines (PDF)
Effective Date: Oct 2013
Ultrasound in Pregnancy (PDF)
Effective Date: Apr 2017
DNA Analysis of Stool (PDF)
Effective Date: Sep 2016
Neonatal Intensive Care Unit (NICU) Discharge Guidelines (PDF)
Effective Date: Jun 2013
Urinary Incontinence Devices and Treatments (PDF)
Effective Date: Apr 2017
Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Stem Cell Transplantation (PDF)
Effective Date: Nov 2015
Neonatal Sepsis Management (PDF)
Effective Date: Aug 2013
Urodynamic Testing (PDF)
Effective Date: Oct 2015
EEG in the Evaluation of Headache
Effective Date: 9/14/18
Nerve Blocks for Pain Management (PDF)
Effective: Aug 2018
Vagus Nerve Stimulation (PDF)
Effective Date: Sep 2013
Electric Tumor Treating Fields (PDF)
Effective Date: Apr 2017

Neurofeedback (PDF)
Effective Date: Jan 2019
Ventricular Assist Devices (VAD) (PDF)
Effective Date: Dec 2009
Endometrial Ablation (PDF)
Effective Date: Feb 2016
NICU Apnea Brachycardia Guidelines (PDF)
Effective Date: Jun 2013
Ventriculectomy & Cardiomyplasty (PDF) 
Effective Date: May 2013
EpiFix Wound Treatment (PDF) 
Effective Date: Apr 2017
Non-Myeoablative Allogeneic Stem Cell Transplants (PDF)
Effective Date: Mar 17
Wheelchair Seating (PDF)
Effective Date: Oct 2015
Essure Removal (PDF) 
Effective Date: Nov 2016
Obstetrical Home Health Programs (PDF)
Effective Date: Jan 2014
Wireless Motility Capsule (PDF)
Effective Date: Apr 2017
Evoked Potential Testing (PDF)
Effective Date: Jan 2017
Optic Nerve Decompression Surgery (PDF)
Effective Date: Sep 2016
Zika Virus Testing (PDF)
Effective Date: May 2016
Facet Join Interventions
Effective Date: Sept 2018
Outpatient Cardiac Rehabilitation (PDF)
Effective Date: May 2019
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)
Effective Date: Sept 2018
Fecal Incontinence (PDF)
Effective Date: Dec 2016
Outpatient Tresting for Drugs of Abuse (PDF)
Effective Date: Sep 2012
 
Ferriscan (PDF)
Effective Date: Jan 2019
   
Fetal Surgery in Utero for Prenatally Diagnosed Malformation (PDF)
Effective Date: Nov 2018
   
Fertility Preservation (PDF)
Effective Date: Sep 2016
   
Fixed Wing Air Transportation (PDF)
Effective Date: My 2019
   
Fractional Exhaled Nitric Oxide (PDF)
Effective Date: Dec 2015
   
Functional MRI (PDF)
Effective Date: Sep 2009
   

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