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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.

Information about Payment policies is available here.

Clinical Policies

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