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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. 

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 Testing (PDF)
Effective Date: 6/1/18
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 (PDF)
Effective Date: 1/1/18
Homocysteine Testing (PDF)  Effective:  1/1/21 Sclerotherapy for Varicose Veins (PDF)
Ambulatory EEG (PDF) Hospice (PDF) Sickle Cell Disease Observation (PDF)
Ambulatory Surgical Center (PDF)
Effective Date: 1/1/18
Hospice Clinical Coverage (PDF) Spinal Cord Stimulation (PDF)
Anesthesia Services for GI Endoscopy (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)
Effective Date: 1/1/18
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)    
Cochlear Implant Replacements (PDF) Lysis of Epidural Lesions (PDF) Zika Virus Testing (PDF)
Cosmetic and Reconstructive Surgery (PDF) Mechanical Stretch Devices (PDF)  
Cystic Fibrosis Carrier Screening (PDF) Medical Necessity Criteria (PDF)  
Dental Anesthesia (PDF) Measure Serum 1,25 Vitamin (PDF)
Effective Date: 6/1/18
 
Diabetes Prevention Program (PDF) Medical Necessity Criteria (PDF)  
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
Monitored Anesthesia Care (PDF)  
Digital Analysis of EEGS (PDF)

Multiple Sleep Latency Testing (PDF)  
Disc Decompression Procedures (PDF) Neonatal Abstinence Syndrome Guidelines (PDF)  
Discography (PDF) Neonatal Sepsis Management Guidelines (PDF)  
DME (PDF) Nerve Blocks (PDF)  
DNA Analysis of Stool (PDF) NICU Apnea Bradycardia Guidelines (PDF)  
EEG in Evaluation of Headache (PDF)
Effective Date: 6/1/18
NICU Discharge Guidelines (PDF)  
Endometrial Ablation (EA) (PDF) OB Home Health Programs (PDF)  


Epifix Wound Treatment (PDF)
Effective Date: 1/1/18
Optic nerve decompression surgery (PDF)  
Evoked Potentials (PDF)

Outpatient Testing for DOA (PDF)  
Experimental Policy (PDF) Oxygen Use and Concentrators (PDF)  
  Pancreas Transplantation (PDF)  
Experimental Technologies (PDF) Panniculectomy (PDF)  
Facet Joint Interventions (PDF) Pediatric Liver Transplant (PDF)  
Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18
Percutaneous LAAD Stroke Prevention (PDF)  
Fertility Preservation (PDF) Posterior Nerve Stimulation for Voiding Dysfunction (PDF)  


Fetal Surgery in Utero (PDF)
Preventative Health and CPG Policy (PDF)  
Fixed Wing Air Transportation (PDF) PROM Testing (PDF)
Effective Date: 1/1/18
 
Functional MRI (PDF) Proton and Neautron Beam Therapy (PDF)
Effective Date: 1/1/18
 
Gastric Electrical Stimulation (PDF)    
Genetic and Pharmacogenetic Testing (PDF)    
Genetic Testing (PDF)     
Grid (PDF)    
 

A-J

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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 (PDF)
Effective Date: 1/1/18
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)
Articular Cartilage Defect Repairs (PDF) Lysis of Epidural Lesions (PDF) Video EEG Monitoring (PDF)
ASC Optimization (PDF) Measure Serum 1,25 Vitamin D (PDF)
Effective Date: 1/1/18
Vitamin D Testing in Children (PDF)
Effective Date: 1/1/18
Assisted Reproductive Technology (PDF) Mechanical Stretch Devices (PDF)
Effective Date: 1/1/18
Wheelchair Seating (PDF)
Balloon Sinus Ostial Dilation (PDF) Neonatal Abstinence Syndrome Guidelines (PDF) Wireless Motility Capsule (PDF)
Effective Date: 1/1/18
Bevacizumab (PDF)
Effective Date: 1/1/18
Outpatient Testing for DOA (PDF)  
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Oxygen Use and Concentrators (PDF)  
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 1/1/18
Paclitaxel (PDF)
Effective Date: 1/1/18
 
Cell-Free Fetal DNA Testing (PDF) Pancreas Transplantation (PDF)  
Clinicial Policy Committee (PDF) Panniculectomy (PDF)  
Cosmetic and Reconstructive Surgery (PDF) Pediatric Liver Transplant (PDF)  
Dental Anesthesia (PDF)

PROM (PDF)

Effective Date:  1/15/20

 
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
Proton and Neutron Beam Therapy (PDF)
Effective Date: 1/1/18
 
Digital Analysis of EEGS (PDF) Rituximab (PDF)
Effective Date: 1/1/18
 
DME (PDF) Short Inpatient Hospital Stay (PDF)  


DNA Analysis of Stool (PDF)
Effective Date: 1/1/18
Spinal Cord Stimulation (PDF)  
EEG in Evaluation of Headache (PDF)
Effective Date: 1/1/18
Stereotactic Body Radiation Therapy (PDF)  
Endometrial Ablation EA (PDF)
Effective Date: 1/1/18
Testing Select GU conditions (PDF)  
  Thyroid Testing in Pediatrics (PDF)
Effective Date: 1/1/18
 
EpiFix Wound Treatment (PDF)
Effective Date: 1/1/18
   
Evoked Potentials (PDF)    
Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18
   
FeNo Testing (PDF)
Effective Date: 1/1/18
   
Fertility Preservation (PDF)    
Functional MRI (PDF)    
Gastric Electrical Stimulation (PDF)    
Genetic and Pharmacogenetic Testing (PDF)    
H Pylori Testing (PDF)
Effective Date: 1/1/18
   
Holter Monitors (PDF)
Effective Date: 1/1/18
   
Home Births (PDF)    
Homosysteine Testing (PDF)
Effective Date: 1/1/21
   
Hyperemesis Gravidarum Treatment (PDF)    
Hyperhidrosis Treatments (PDF)    
Inhaled Nitric Oxide (PDF)    
Intensity Modulated Radiation Therapy (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)
Effective Date: 1/1/1
 
  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)
Effective Date: 1/1/18

Physician Office Lab Testing (POLT) (PDF)

Effective Date:  1/15/20

 
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