Skip to Main Content

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. 

All policies found in the Home State Health Clinical Policy Manual apply to Home State Health members. Policies in the Home State Health Clinical Policy Manual may have either a Home State Health or a “Centene” heading.  Home State Health utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Home State Health 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 Home State Health. In addition, Home State Health 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 Home State Health.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-G H-Q R-Z
Acupuncture (PDF)
H Pylori Serology Testing (PDF) 
Radial Head Implant (PDF)
ADHS Assessment and Treatment (PDF)
Effective Date: 1/1/18
Heart-Lung Transplant (PDF) Reduction Mammoplasty and Gynecomastia Surgery (PDF)
ADHD Assessment and Treatment (PDF)  Effective:  1/1/21 Holter Monitors (PDF) Sacroiliac Joint Fusion (PDF)
AHCT for Sickle Cell Anemia (PDF) Home Births (PDF) Sacroiliac Joint Interventions (PDF)
Allergy Testing and Therapy (PDF) Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) Sclerotherapy for Varicose Veins (PDF)
Ambulatory EEG (PDF) Homocysteine Testing (PDF)  Effective:  1/1/21 SNF Leveling (PDF)
Ambulatory Surgical Center (PDF)
Effective Date: 1/1/18
Hospice (PDF) Sickle Cell Disease Observation (PDF)
Anesthesia Services for GI Endoscopy (PDF) Hospice Clinical Coverage (PDF) Spinal Cord Stimulation (PDF)
Antithrombin III (Atryn Thrombate) (PDF) Hyperemesis Gravidarum Treatment (PDF) Stereotactic Body Radiation Therapy (PDF)
Articular Cartilage Defect Repairs (PDF) Hyperhidrosis Treatments (PDF) Tandem Transplant (PDF)
ASC Optimization (PDF) Implantable Intrathecal Pain Pump (PDF) Testing for Rupture of Fetal Membranes (PDF)
Assisted Reproductive Technology (PDF) Implantable Wireless PAP Monitoring (PDF) Testing Select GU conditions (PDF)
Balloon Sinus Ostial Dilation (PDF) In Network Referrals (PDF)
Effective Date: 1/1/18
Therapy Services (PDF)
Bariatric Surgery (PDF) Inhaled Nitric Oxide (PDF) Thyroid Testing in Pediatrics (PDF)
Biofeedback (PDF) Intensity-Modulated Radiotherapy (PDF)
TPN IDPN (PDF)
Bone-Anchored Hearing Aid (PDF) Intensity Modulated Radiation Therapy (PDF) Ultrasound in Pregnancy (PDF)
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Intestinal & Multivisceral Transplant (PDF) Urodynamic Testing (PDF)
Cardiac Biomarker Testing (PDF)
Effective Date: 11/1/18
Intradiscal Steroid Injections (PDF) Vagus Nerve Stimulation (PDF)
Cardiac Biomarket Testing for Acute Myocardial Infarction (PDF)
Effective Date: 6/1/18
Laser Skin Treatment (PDF)
Effective Date: 1/1/18
Ventriculectomy Cardiomyoplasty (PDF)
Cardiac Rehabilitation (PDF) Laser Therapy for Skin Conditions (PDF) Ventricular Assist Devices (PDF)
Carrier Screening in Pregnancy (PDF) Long Term Care PLacement Criteria (PDF) Video EEG Monitoring (PDF)
Caudal or Interlaminar ESI (PDF) Low-frequency US and NNWT (PDF) Vitamin D Testing in Children (PDF)
Effective Date: 6/1/18
Cell-Free Fetal DNA Testing (PDF) Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18
Wheelchair Seating (PDF)
Clinicial Policy Committee (PDF) Lung Transplantation (PDF)

Wireless Motility Capsule (PDF)
Effective Date: 1/1/18

Clinical Trials (PDF) Lysis of Epidural Lesions (PDF) Zika Virus Testing (PDF)
Cochlear Implant Replacements (PDF) Mechanical Stretch Devices (PDF)  
Cosmetic and Reconstructive Surgery (PDF) Medical Necessity Criteria (PDF)  
Cystic Fibrosis Carrier Screening (PDF) Measure Serum 1.25 Vitamin (PDF)  
Dental Anesthesia (PDF) Medical Necessity Criteria (PDF)  
Diabetes Prevention Program (PDF) Monitored Anesthesia Care (PDF)  
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
Multiple Sleep Latency Testing (PDF)  
Diaphragmatic Phernic Nerve Stimulation (PDF) Neonatal Abstinence Syndrome Guidelines (PDF)  
Digital Analysis of EEGS (PDF)

Neonatal Sepsis Management Guidelines (PDF)  
Disc Decompression Procedures (PDF) Nerve Blocks (PDF)  
Discography (PDF) Nerve Blocks for Pain Management (PDF)  
DME (PDF) NICU Apnea Bradycardia Guidelines (PDF)  
DNA Analysis of Stool (PDF) NICU Discharge Guidelines (PDF)  
Donor Lymphocyte Infusion (PDF) Non-Invasive Home Ventilator (PDF)  
EEG headache (PDF) OB Home Health Programs (PDF)  
Endometrial Ablation (EA) (PDF) Optic nerve decompression surgery (PDF)  
Epifix Wound Treatment (PDF)
Effective Date: 1/1/18
Outpatient Testing for DOA (PDF)  


Essure Removal (PDF)
Oxygen Use and Concentrators (PDF)  
Evoked Potentials (PDF) Pancreas Transplantation (PDF)  

Experimental Policy (PDF)
Panniculectomy (PDF)  
Experimental Technologies (PDF) Pediatric Heart Transplant (PDF)  
Facet Joint Interventions (PDF) Pediatric Liver Transplant (PDF)  
Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18
Percutaneous LAAD Stroke Prevention (PDF)  
Ferriscan R2 MRI (PDF) Posterior Nerve Stimulation for Voiding Dysfunction (PDF)  
Fertility Preservation (PDF) Private Duty Nursing (PDF)  
Fetal Surgery in Utero (PDF) Presumptive Testing for Drugs of Abuse (PDF)  
Fixed Wing Air Transportation (PDF) Preventative Health and CPG Policy (PDF)  

Functional MRI (PDF)

PROM Testing (PDF)
Effective Date: 1/1/18
 
Gastric Electrical Stimulation (PDF) Proton and Neautron Beam Therapy (PDF)
Effective Date: 1/1/18
 
Genetic and Pharmacogenetic Testing (PDF)    
Genetic Testing (PDF)     
Grid (PDF)    
 

A-J

K-T

U-Z

ADHD Assessment and Treatment (PDF)
Effective Date: 1/1/21
Laser Skin Treatment (PDF)
Effective Date: 1/1/18
Ultrasound in Pregnancy (PDF)
AHCT for Sickle Cell Anemia (PDF) Low-frequency US and NNWT (PDF) Urodynamic Testing (PDF)
Allergy Testing and Therapy (PDF) Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18
 
Ventriculectomy Cardiomyoplasty (PDF)
Ambulatory EEG (PDF)
Effective Date: 1/1/18
Lung Transplantation (PDF) Ventricular Assist Devices (PDF)
Antithrombin III (Atryn Thrombate) (PDF) Lysis of Epidural Lesions (PDF) Video EEG Monitoring (PDF)
Articular Cartilage Defect Repairs (PDF) Measure Serum 1.25 Vitamin (PDF) Vitamin D Testing in Children (PDF)
Effective Date: 1/1/18
ASC Optimization (PDF) Mechanical Stretch Devices (PDF)
Effective Date: 1/1/18
Wheelchair Seating (PDF)
Assisted Reproductive Technology (PDF) Neonatal Abstinence Syndrome Guidelines (PDF) Wireless Motility Capsule (PDF)
Effective Date: 1/1/18
Balloon Sinus Ostial Dilation (PDF) Nerve Blocks for Pain Management (PDF)  
Bariatric Surgery (PDF) Non-Invasive Home Ventilator (PDF)  
Bevacizumab (PDF)
Effective Date: 1/1/18
OB Home Health Programs (PDF)  
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Outpatient Testing for DOA (PDF)  
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 1/1/18
Oxygen Use and Concentrators (PDF)  
Cell-Free Fetal DNA Testing (PDF) Paclitaxel (PDF)
Effective Date: 1/1/18
 
Clinicial Policy Committee (PDF) Pancreas Transplantation (PDF)  
  Panniculectomy (PDF)  
Cosmetic and Reconstructive Surgery (PDF) Pediatric Heart Transplant (PDF)  
Dental Anesthesia (PDF) Pediatric Liver Transplant (PDF)  
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
Presumptive Testing for Drugs of Abuse (PDF)  
  Private Duty Nursing (PDF)  
Diaphragmatic Phernic Nerve Stimulation (PDF)

PROM (PDF)

Effective Date:  1/15/20

 
Digital Analysis of EEGS (PDF) Proton and Neutron Beam Therapy (PDF)
Effective Date: 1/1/18
 
DME (PDF) Rituximab (PDF)
Effective Date: 1/1/18
 
DNA Analysis of Stool (PDF)
Effective Date: 1/1/18
Short Inpatient Hospital Stay (PDF)  
Donor Lymphocyte Infusion (PDF) SNF Leveling (PDF)  


EEG headache (PDF)
Spinal Cord Stimulation (PDF)  
Endometrial Ablation EA (PDF)
Effective Date: 1/1/18
Stereotactic Body Radiation Therapy (PDF)  
EpiFix Wound Treatment (PDF)
Effective Date: 1/1/18
Testing Select GU conditions (PDF)  
Essure Removal (PDF) Thyroid Testing in Pediatrics (PDF)  
Evoked Potentials (PDF)    
Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18
   
FeNo Testing (PDF)
Effective Date: 1/1/18
   
Ferriscan R2 MRI (PDF)    
Fertility Preservation (PDF)    
Functional MRI (PDF)    
Gastric Electrical Stimulation (PDF)    
Genetic and Pharmacogenetic Testing (PDF)    
H Pylori Serology Testing (PDF)     
Holter Monitors (PDF)
Effective Date: 1/1/18
   
Home Births (PDF)    
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)    
Homosysteine Testing (PDF)
Effective Date: 1/1/21
   
Hyperemesis Gravidarum Treatment (PDF)    
Hyperhidrosis Treatments (PDF)    
Inhaled Nitric Oxide (PDF)    
Intensity-Modulated Radiotherapy (PDF)    
Clinical Policies
A-F G-O P-Z
Adjacent-Tissue-Transfer-Grafts-involving-Eyelid (PDF) Glaucoma (PDF) Pediatric-Eye-Examinations (PDF)
Age-Related-Macular-Degeneration (PDF) Glaucoma-Screening (PDF) Photodynamic-and-Intravitreal-Therapies-and-Pharmaceuticals (PDF)
Amblyopia (PDF) Gonioscopy (PDF) Probing-and-Closure-of-the-Lacrimal-Duct-System (PDF)
Amniotic-Membrane-Placement-on-Ocular-Surface (PDF) Guidelines-for-Dilation-Protocol-during-Examination-of-the-Eye (PDF) Prophylaxis-of-Retinal-Detachment (PDF)
Anterior-Segment-Photography-with-Fluorescein-Angiography (PDF) Indocyanine-Green-(ICG)-Angiography (PDF) Refractive-Surgery (PDF)
Aqueous-Shunt (PDF) Infracture-of-the-Inferior-Turbinate (PDF) Refraction (PDF)
Blepharoplasty-Ptosis-Repair-and-Canthoplasty (PDF) Iris-Coloboma (PDF) Repair-of-Retinal-Detachment (PDF)
Canthotomy (PDF) Keratoplasty (PDF) Scanning-Computerized-Ophthalmic-Diagnostic-Imaging (PDF)
Cataract-Extraction (PDF) Laser-Iridotomy-and-Iridectomy (PDF) Secondary-Intraocular-Lens-(IOL) (PDF)
Chemodenervation (PDF) Laser-Trabeculoplasty (PDF) Sensorimotor-Examination (PDF)
Complex-Cataract-Extraction (PDF) Low-Vision-Evaluations-and-Aids (PDF) Serial-Tonometry (PDF)
Corneal-Erosion-and-Photo-Keratectomy (PDF) Ocular-Prosthesis (PDF) Specular-Microscopy (PDF)
Corneal-Hysteresis (PDF) Ocular-Surface-Reconstruction (PDF) Surgical-Excision-of-Eyelid-Lesions (PDF)
Corneal-Pachymetry (PDF) Ophthalmic-Biometry (PDF) Surgical-Strabismus-Repair (PDF)
Corneal-Topography (PDF) Ophthalmic-B-scans (PDF) Teleretinal-Screening-for-Diabetic-Retinopathy (PDF)
Dark-Adaption-and-Color-Vision-Examinations (PDF)   Trabeculectomy-Ab-Externo (PDF)
Destruction-of-Localized-Lesion-of-Choroid (PDF)   Visual-Field-Testing (PDF)
Destruction-of-Localized-Lesion-of-the-Retina (PDF)   Visual-Therapy (PDF)
Destruction-of-Retinopathy (PDF)   Vitrectomy (PDF)
Ectropion-Entropion-Repair (PDF)   Yttrium-Aluminium-Garnet-(YAG)-Laser-Capsulotomy (PDF)
Electroretinography (PDF)    
Eyelid-Reanimation (PDF)    
Examination-Guidelines-for-Diabetic-Patients (PDF)    
Extended-Ophthalmoscopy (PDF)    
External-Ocular-Photography (PDF)    
Fluorescein-Angiography (PDF)    
Fundus-Photography (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 Home State Health Payment Policy Manual apply with respect to Home State Health members. Policies in the Home State Health Payment Policy Manual may have either a Home State Health or a “Centene” heading.  In addition, Home State Health 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 Home State Health.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-H I-Q R-Z
3-Day Payment Window (PDF)
Effective Date: 1/1/18
Inpatient Consultation (PDF)

Renal Hemodialysis (PDF)

Effective:  1/1/21

30-Day Readmission (PDF)
Effective Date: 1/1/18
Inpatient Only Procedures (PDF) Robotic Surgery (PDF)
Effective Date: 1/1/18
Assistant Surgeon (PDF) IV Hydration (PDF) Same Day Visits (PDF)


BH Services for Children with Severe Trauma (PDF)
Leveling of Care: Evaluation and Management Overcoding (PDF) Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective Date: 1/1/18
Bilateral Procedures (PDF) Leveling of ER Services (PDF)
Effective Date: 1/1/19
Sleep Studies Place of Service (PDF)
Effective Date: 1/1/18

Cerumen Removal (PDF)
Maximum Units (PDF) Status "B" Bundled Services (PDF)
Clinic Facility Charge (PDF) Moderate Conscious Sedation (PDF) Status "P" Bundled Services (PDF)
Effective Date: 1/1/18

Clean Claims (PDF)
Modifer 25 Clinical Validation (PDF)

Supplies Billed on Same Day As Surgery (PDF)


Cosmetic Procedures (PDF)


Modifer 59 Clinical Validation (PDF)
Transgender Related Services (PDF)



Coding Overview (PDF)





Modifer DOS Validation (PDF)
Unbundled Professional Services (PDF)

Distinct Procedural Modifiers (PDF)



Modifer to Procedure Code Validation (PDF)
Unbundled Surgical Procedures (PDF)
Duplicate Primary Code Billing (PDF)

MPPR for Ophthalmology (PDF)
Effective 01/01/2021
Unlisted Procedure Codes (PDF)
EM Bundling Edits (PDF) Multiple CPT Code Replacement (PDF) Urine Specimen Validity Testing (PDF)
E&M Medical Decision-Making (PDF) Multiple Diagnosis Cardiovascular (PDF)

Visual Field Testing (PDF)
Effective Date: 1/1/18
Extended Ophthalmoscopy (PDF)
Effective Date: 1/1/18
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective 01/01/2021

Wheelchair Seating (PDF)

Effective Date: 10/1/2018 

External Ocular Photography (PDF)
Effective Date: 1/1/18
NCCI Unbundling (PDF)

 


Fluorescein Angiography (PDF)
Effective Date: 1/1/18
Never Paid Events (PDF)

 
Fundus Photography (PDF)
Effective Date: 1/1/18
New Patient (PDF)

 


Global Maternity Billing (PDF)
Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF)
Effective 01/01/2021
 
Gonioscopy (PDF)
Effective Date: 1/1/18
Outpatient Consultation (PDF)  
Hospital Visit Codes Billed with Labs (PDF)
Physician's Office Lab Testing (PDF)

 
  Physician Visit Codes Billed with Labs (PDF)  
  Post-Operative Visits (PDF)s  
 
Pre-Operative Visits (PDF)
 
 

Professional Component (PDF)
 
 

Problem Oriented Visits with Preventative Visits (PDF)
 
  Problem Oriented Visits with Surgical Procedures (PDF)

 
  Pulse Oximetry (PDF)

 
  Place of Service Mismatch (PDF)
Effective Date: 11/1/18
 
A-J K-T U-Z
3 Day Payment Window (PDF)
Effective Date: 1/1/18
Maximum Units (PDF)
Effective Date: 1/1/18
Unbundled Professional Services (PDF)
Effective Date: 1/1/18
30-Day Readmission (PDF)
Effective Date: 1/1/18
Moderate Conscious Sedation (PDF)
Effective Date: 1/1/18
Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/18
Assistant Surgeon (PDF)
Effective Date: 1/1/18
Modifier-25 Clinical Validation (PDF)
Effective Date: 1/1/18
Unlisted Procedure Codes (PDF)
Effective Date: 1/1/18
Add on Code Billed Without Primary Code
Effective Date: 1/1/18
Modifier-59 Clinical Validation (PDF)
Effective Date: 1/1/18

Wheelchair Seating (PDF)

Effective Date: 01/01/2018 – 9/30/2018 

Wheelchair Seating (PDF)

Effective Date: 10/1/2018 

Bilateral Procedures (PDF)
Effective Date: 1/1/18
Modifier DOS Validation (PDF)
Effective Date: 1/1/18
NCCI Unbundling (PDF)
Effective Date: 1/1/18
Cerumen Removal (PDF)
Effective Date: 1/1/18
Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/18
 
Clean Claims (PDF)
Effective Date: 1/1/18
MPPR for Ophthalmology (PDF)
Effective 01/01/2021
 
Coding Overview (PDF)
Effective Date: 1/1/18
Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/18
 
Cosmetic Procedures (PDF)
Effective Date: 1/1/18
Multiple Diagnosis Cardiovascular (PDF)  
Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective 01/01/2021
 
Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18
Never Paid Events (PDF)
Effective Date: 1/1/18
 
EM Bundling Edits (PDF)
Effective Date: 1/1/18
New Patient (PDF)
Effective Date: 1/1/18
 
E&M Medical Decision-Making (PDF)
Effective Date: 1/1/18
Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF)
Effective 01/01/2021
 
Global Maternity Billing (PDF)
Effective Date: 1/1/18
Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 11/1/18
 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18
Outpatient Consultation (PDF)
Effective Date: 1/1/18
 
Inpatient Consultation (PDF)
Effective Date: 1/1/18

Physician Consultative Services (PDF)

Effective Date:  1/15/20

 
IV Hydration (PDF)

Physician's Office Lab Testing (PDF)

 
Inpatient Only Procedures (PDF)
Effective Date: 1/1/18
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18
 

Leveling of ER Services (PDF)

Effective Date:  1/15/20

Place of Service Mismatch (PDF)
Effective Date: 11/1/18
 
Leveling of Care: Evaluation and Management Overcoding (PDF) Post-Operative Visits (PDF)
Effective Date: 1/1/18
 
  Pre-Operative Visits (PDF)
Effective Date: 1/1/18
 

 

Problem Oriented Visits with Preventive Visits (PDF)

Effective Date:  1/15/20

 

 

Problem Oriented Visits with Surgical Procedures (PDF)

Effective Date:  1/15/20

 
  Professional Component (PDF)
Effective Date: 1/1/18
 
  Pulse Oximetry (PDF)
Effective Date: 1/1/18
 
 

Renal Hemodialysis (PDF)

Effective:  1/1/21

 
  Robotic Surgery (PDF)
Effective Date: 1/1/18
 

 

Same Day Visits (PDF)
Effective Date: 1/1/18
 
  Status "B" Bundled Services (PDF)
Effective Date: 1/1/18
 
  Status "P" Bundled Services (PDF)
Effective Date: 1/1/18
 
  Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/18
 
  Transgender Related Services (PDF)
Effective Date: 1/1/18