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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.

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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) Holter Monitors (PDF) Sacroiliac Joint Fusion (PDF)
Allergy Testing (PDF)
Effective Date: 1/1/18
Home Births (PDF) Sacroiliac Joint Interventions (PDF)
Ambulatory EEG (PDF) Homocysteine Testing (PDF) Sclerotherapy for Varicose Veins (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)
Articular Cartilage Defect Repairs (PDF) Hyperemesis Gravidarum Treatment (PDF) Stereotactic Body Radiation Therapy (PDF)
Assisted Reproductive Technology (PDF) Hyperhidrosis Treatments (PDF) Tandem Transplant (PDF)
Balloon Sinus Ostial Dilation (PDF) Implantable Intrathecal Pain Pump (PDF) Testing for Rupture of Fetal Membranes (PDF)
Bariatric Surgery (PDF) Implantable Wireless PAP Monitoring (PDF) Testing Select GU conditions (PDF)
Biofeedback (PDF) In Network Referrals (PDF)
Effective Date: 1/1/18
Therapy Services (PDF)
Bone-Anchored Hearing Aid (PDF) Inhaled Nitric Oxide (PDF) Thyroid Testing in Pediatrics (PDF)
Effective Date: 1/1/18
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Intensity-Modulated Radiotherapy (PDF) TPN IDPN (PDF)
Cardiac Biomarker Testing (PDF)
Effective Date: 11/1/18
Intensity Modulated Radiation Therapy (PDF) Ultrasound in Pregnancy (PDF)
Cardiac Biomarket Testing for Acute Myocardial Infarction (PDF)
Effective Date: 6/1/18
Intestinal & Multivisceral Transplant (PDF) Urodynamic Testing (PDF)

Cardiac Rehabilitation (PDF) Intradiscal Steroid Injections (PDF) Vagus Nerve Stimulation (PDF)
Carrier Screening in Pregnancy (PDF) Laser Skin Treatment (PDF)
Effective Date: 1/1/18
Ventriculectomy Cardiomyoplasty (PDF)
Caudal or Interlaminar ESI (PDF) Laser Therapy for Skin Conditions (PDF) Ventricular Assist Devices (PDF)
Cell-Free Fetal DNA Testing (PDF) Long Term Care PLacement Criteria (PDF) Vitamin D Testing in Children (PDF)
Effective Date: 6/1/18
Clinicial Policy Committee (PDF) Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18
Wheelchair Seating (PDF)
Clinical Trials (PDF) Lung Transplantation (PDF)

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

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)
Effective Date: 1/1/18
Outpatient Testing for DOA (PDF)  
Experimental Policy (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
 
Genetic and Pharmacogenetic Testing (PDF)    
Gastric Electrical Stimulation (PDF)    
Genetic Testing (PDF)     
Grid (PDF)    
 

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ADHD Assessment and Treatment (PDF)
Effective Date: 1/1/18
Laser Skin Treatment (PDF)
Effective Date: 1/1/18
Ultrasound in Pregnancy (PDF)
Effective Date: 1/1/18
Allergy Testing (PDF)
Effective Date: 1/1/18
Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18
Urodynamic Testing (PDF)
Effective Date: 1/1/18
Ambulatory EEG (PDF)
Effective Date: 1/1/18
Measure Serum 1,25 Vitamin D (PDF)
Effective Date: 1/1/18
Ventriculectomy Cardiomyoplasty (PDF)
Articular Cartilage Defect Repairs (PDF) Mechanical Stretch Devices (PDF)
Effective Date: 1/1/18
Ventricular Assist Devices (PDF)
Assisted Reproductive Technology (PDF) Outpatient Testing for DOA (PDF) Vitamin D Testing in Children (PDF)
Effective Date: 1/1/18
Bevacizumab (PDF)
Effective Date: 1/1/18
Paclitaxel (PDF)
Effective Date: 1/1/18
Wheelchair Seating (PDF)
Effective Date: 1/1/18
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Pancreas Transplantation (PDF) Wireless Motility Capsule (PDF)
Effective Date: 1/1/18
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 1/1/18
Panniculectomy (PDF)  
Cell-Free Fetal DNA Testing (PDF) Pediatric Liver Transplant (PDF)  
Clinicial Policy Committee (PDF)

PROM (PDF)

Effective Date:  1/15/20

 
Cosmetic and Reconstructive Surgery (PDF) Proton and Neutron Beam Therapy (PDF)
Effective Date: 1/1/18
 
Dental Anesthesia (PDF) Rituximab (PDF)
Effective Date: 1/1/18
 
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
Short Inpatient Hospital Stay (PDF)  

Digital Analysis of EEGS (PDF)
Spinal Cord Stimulation (PDF)  
DME (PDF) Stereotactic Body Radiation Therapy (PDF)  
DNA Analysis of Stool (PDF)
Effective Date: 1/1/18
Thyroid Testing in Pediatrics (PDF)
Effective Date: 1/1/18
 
EEG in Evaluation of Headache (PDF)
Effective Date: 1/1/18
   
Endometrial Ablation EA (PDF)
Effective Date: 1/1/18
   
EpiFix Wound Treatment (PDF)
Effective Date: 1/1/18
   
Evoked Potentials (PDF)
Effective Date: 1/1/18
   
Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18
   
FeNo Testing (PDF)
Effective Date: 1/1/18
   
Genetic and Pharmacogenetic Testing (PDF)    
H Pylori Testing (PDF)
Effective Date: 1/1/18
   
Holter Monitors (PDF)
Effective Date: 1/1/18
   
Homosysteine Testing (PDF)
Effective Date: 1/1/18
   
Hyperemesis Gravidarum Treatment (PDF)    
Hyperhidrosis Treatments (PDF)    
Inhaled Nitric Oxide (PDF)    
Intensity Modulated Radiation Therapy (PDF)    

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None None Short Inpatient Hospital Stay (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.

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3-Day Payment Window (PDF)
Effective Date: 1/1/18
Inpatient Consultation (PDF)
Robotic Surgery (PDF)
Effective Date: 1/1/18
30-Day Readmission (PDF)
Effective Date: 1/1/18
Inpatient Only Procedures (PDF)
Same Day Visits (PDF)

Assistant Surgeon (PDF)

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

Bilateral Procedures (PDF)
Leveling of ER Services (PDF)
Effective Date: 1/1/19
Status "B" Bundled Services (PDF)
Cerumen Removal (PDF) Maximum Units (PDF) Status "P" Bundled Services (PDF)
Effective Date: 1/1/18

Clinic Facility Charge (PDF)
Moderate Conscious Sedation (PDF)

Supplies Billed on Same Day As Surgery (PDF)


Clean Claims (PDF)


Modifer 25 Clinical Validation (PDF)
Transgender Related Services (PDF)


Cosmetic Procedures (PDF)



Modifer 59 Clinical Validation (PDF)

Unbundled Professional Services (PDF)

Coding Overview (PDF)

Modifer DOS Validation (PDF)

Unbundled Surgical Procedures (PDF)
Distinct Procedural Modifiers (PDF) Modifer to Procedure Code Validation (PDF)

Unlisted Procedure Codes (PDF)
Duplicate Primary Code Billing (PDF) Multiple CPT Code Replacement (PDF) Urine Specimen Validity Testing (PDF)
EM Bundling Edits (PDF) Multiple Diagnosis Cardiovascular (PDF)

Visual Field Testing (PDF)
Effective Date: 1/1/18
E&M Medical Decision-Making (PDF) NCCI Unbundling (PDF)

Wheelchair Seating (PDF)

Effective Date: 10/1/2018 

Extended Ophthalmoscopy (PDF)
Effective Date: 1/1/18

Never Paid Events (PDF)

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

 

Fluorescein Angiography (PDF)
Effective Date: 1/1/18
Outpatient Consultation (PDF)  
Fundus Photography (PDF)
Effective Date: 1/1/18


Physician's Office Lab Testing (PDF)
Effective Date: 1/1/1
 
Global Maternity Billing (PDF) Physician Visit Codes Billed with Labs (PDF)  
Gonioscopy (PDF)
Effective Date: 1/1/18
Post-Operative Visits (PDF)s  
Hospital Visit Codes Billed with Labs (PDF)
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
 
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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
Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/18
 
Coding Overview (PDF)
Effective Date: 1/1/18
Multiple Diagnosis Cardiovascular (PDF)  
Cosmetic Procedures (PDF)
Effective Date: 1/1/18
Never Paid Events (PDF)
Effective Date: 1/1/18
 
Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18
New Patient (PDF)
Effective Date: 1/1/18
 
Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18
Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 11/1/18
 
EM Bundling Edits (PDF)
Effective Date: 1/1/18
Outpatient Consultation (PDF)
Effective Date: 1/1/18
 
E&M Medical Decision-Making (PDF)
Effective Date: 1/1/18

Physician Consultative Services (PDF)

Effective Date:  1/15/20

 
Global Maternity Billing (PDF)
Effective Date: 1/1/18

Physician Office Lab Testing (POLT) (PDF)

Effective Date:  1/15/20

 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18
 
Inpatient Consultation (PDF)
Effective Date: 1/1/18
Place of Service Mismatch (PDF)
Effective Date: 11/1/18
 
IV Hydration (PDF)
Effective Date: 1/1/18
Post-Operative Visits (PDF)
Effective Date: 1/1/18
 
Inpatient Only Procedures (PDF)
Effective Date: 1/1/18
Pre-Operative Visits (PDF)
Effective Date: 1/1/18
 

Leveling of ER Services (PDF)

Effective Date:  1/15/20

Problem Oriented Visits with Preventive Visits (PDF)

Effective Date:  1/15/20

 

Leveling of Care: Evaluation and Management Overcoding (PDF)

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
 
  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