Clinical & Payment Policies
- Acupuncture (CP.MP.92) (PDF)
- Adopted Clinical Practice and Preventive Health Guidelines (CPG Grid) (PDF)
- Air Ambulance (CP.MP.175) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and B-Thalassemia (CP.MP.108) (PDF)
- Allergy Testing and Therapy (PDF)
- Applied Behavior Analysis (CP.BH.104) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Assisted Reproductive Technology (CP.MP.55) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Biofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF)
- Bronchial Thermoplasty (PDF) Effective Date: 1/1/18
- Burn Surgery (CP.MP.186) (PDF)
- Cardiac Biomarker Testing (PDF)
- Cardiac Biomarket Testing for Acute Myocardial Infarction (PDF) Effective Date: 6/1/18
- Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- Diabetes Prevention Program (MO.CP.MP.503) (PDF)
- Diagnosis of Vaginitis (PDF) Effective Date: 1/1/18
- Diaphragmatic/Phernic Nerve Stimulation (CP.MP.203) (PDF)
- Digital Analysis of EEGS (PDF)
- Disc Decompression Procedures (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101)(PDF)
- Durable Medical Equipment and Orthotics and Prosthetics Guidelines (CP.MP.107) (PDF)
- EEG in the Evaluation of Headache (CP.MP.155) (PDF)
- Electric Tumor Treating Fields (PDF)
- Endometrial Ablation (EA) (PDF)
- Evoked Potentials (PDF)
- Experimental Policy (PDF)
- Experimental Technologies (CP.MP.36)(PDF)
- Facet Joint Interventions (CP.MP.171) (PDF)
- Fecal Incontinence Treatments (PDF)
- Ferriscan R2 MRI (CP.MP.53) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (CP.MP.129) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel (PDF)
- GI Pathogen Nucleic Acid Detection Panel Testing (PDF)
- Grid (PDF)
- H Pylori Serology Testing (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Holter Monitors (PDF)
- Home Births (CP.MP.136) (PDF)
- Home Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Homocysteine Testing (PDF) Effective: 1/1/21
- Hospice Services (CP.MP.54) (PDF)
- Hospice Clinical Coverage (PDF)
- Hyperbaric Oxygen Therapy (PDF)
- Hyperhidrosis Treatments (CP.MP.62)(PDF)
- Implantable Hypoglossal Nerve Stim (PDF)
- Implantable Intrathecal Pain Pump (CP.MP.173) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF)
- Laser Skin Treatment (PDF) Effective Date: 1/1/18
- Laser Therapy for Skin Conditions (PDF)
- Long Term Care Placement (CP.MP.71) (PDF)
- Low-Frequency Ultrasound Wound Therapy (PDF) Effective Date: 1/1/18
- Low-frequency US and NNWT (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Measure Serum 1.25 Vitamin (PDF)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) (PDF)
- Medical Necessity Criteria (PDF)
- Monitored Anesthesia Care (PDF)
- Multiple Sleep Latency Testing (CP.MP.24)(PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Nerve Blocks and Neurolysis for Pain Management (CP.MP.170) (PDF)
- Neurofeedback (PDF)
- Neuromuscular Electrical Stimulation (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Non-Invasive Home Ventilator (CP.MP.184) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Outpatient Testing for DOA (PDF)
- Outpatient Oxygen Use (CP.MP.190) (PDF)
- Pancreas Transplantation (CP.MP.102)(PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138)(PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Pediatric Oral Function Therapy (CP.MP.188) (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (CP.MP.147) (PDF)
- PFO Closure Devices (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Post Acute Care (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Private Duty Nursing (MO.CP.MP.504)(PDF)
- Proton and Neautron Beam Therapies (CP.MP.70) (PDF)
- Pulmonary Function Testing (CP.MP.242)(PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Sacroiliac Joint Fusion (CP.MP.126) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy for Varicose Veins (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Testing Select Genitourinary conditions (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Thyroid Insulin Tests in Pediatrics (PDF)
- Thyroid Testing in Pediatrics (PDF)
- Total Artificial Heart (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcranial Magnetic Stimulation for MDD (PDF)
- Ultrasound in Pregnancy (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Urodynamic Testing (PDF)
- US in Pregnancy (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (PDF)
- Vitamin D Testing in Children (PDF)
- Wheelchair Seating (PDF)
- Wireless Motility Capsule (PDF)
- Acupuncture (CP.MP.92) (PDF)
- Allergy Testing and Therapy (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and B-Thalassemia (CP.MP.108) (PDF)
- Applied Behavior Analysis (CP.BH.104) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Assisted Reproductive Technology (CP.MP.55) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Biofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18 - Burn Surgery (CP.MP.186) (PDF)
- Cardiac Biomarker Testing (PDF)
- Caudal or Interlaminar ESI (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- CPG Grid (PDF)
- Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18 - Diaphragmatic/Phrenic Nerve Simulation (CP.MP.203) (PDF)
- Digital Analysis of EEGS (PDF)
- Disc Decompression Procedures (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lumphocyte Infusion (CP.MP.101) (PDF)
- Durable Medical Equipment and Orthotics and Prosthetics Guidelines (CP.MP.107) (PDF)
- EEG in the Evaluation of Headache (CP.MP.155) (PDF)
- Electric Tumor Treating Fields (PDF)
- Endometrial Ablation EA (PDF)
Effective Date: 1/1/18 - Evoked Potentials (PDF)
- Facet Joint Interventions (PDF)
- Fecal Incontinence Treatments (PDF)
- Ferriscan R2-MRI (CP.MP.53) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery in Utero (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gender Affirming Procedures (PDF)
- H Pylori Serology Testing (PDF)
- Holter Monitors (PDF)
- Home Births (CP.MP.136) (PDF)
- Home Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Homosysteine Testing (PDF)
Effective Date: 1/1/21 - Hospice (PDF)
- Hyperhidrosis Treatments (PDF)
- Implantable Hypoglossal Nerve Stim (PDF)
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF)
- Laser Skin Treatment (PDF)
Effective Date: 1/1/18 - Low-frequency US and NNWT (PDF)
- Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18 - Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Measure Serum 1.25 Vitamin (PDF)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) (PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Nerve Blocks for Pain Management (CP.MP.170) (PDF)
- Neuromuscular Electrical Stimulation (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- Noninvasive Home Ventilators (CP.MP.184) (PDF)
- Optic nerve decompression surgery (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Outpatient Oxygen Use (CP.MP.190) (PDF)
- Outpatient Testing for DOA (PDF)
- Pancreas Transplantation (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Pediatric Oral Function Therapy (CP.MP.188) (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (CP.MP.147) (PDF)
- Post Acute Care (PDF)
- Private Duty Nursing (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Pulmonary Function Testing (CP.MP.242) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (PDF)
- Testing Select Genitourinary conditions (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Thyroid Testing in Pediatrics (PDF)
- Thyroid Insulin Tests in Pediatrics (PDF)
- Total Artificial Heart (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Urodynamic Testing (PDF)
- Ventricular Assist Devices (PDF)
- Vitamin D Testing in Children (PDF)
- Wheelchair Seating (PDF)
- Wireless Motility Capsule (PDF)
For Medicare information, please visit our Medicare Prior Authorization website.
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.
- 30-Day Readmission (PDF) Effective Date: 1/1/18
- Assistant Surgeon (PDF) Effective 1/2014
- BH Services for Children with Severe Trauma (PDF) Effective 7/2020
- Bilateral Procedures (PDF) Effective 1/2014
- Biopsychosocial Treatment of Obesity (PDF) Effective 7/2022
- Cerumen Removal (PDF) Effective 1/2024
- Clean Claims (PDF) Effective 11/2012
- Clinical Validation of Modifier 25 (PDF)
- Coding Overview (PDF) Effective 1/2013
- Cosmetic Procedures (PDF) Effective 1/2014
- Cost to Charge Adjustments on Clean Claim Reviews (PDF) Effective 1/2013
- Distinct Procedural Modifiers (PDF) Effective 1/2014
- Duplicate Primary Code Billing (PDF) Effective 1/2014
- E&M Medical Decision-Making (PDF) Effective 6/2017
- EM Bundling Edits (PDF) Effective 1/2013
- Extended Ophthalmoscopy (PDF) Effective Date: 1/1/18
- External Ocular Photography (PDF) Effective Date: 1/1/18
- Fluorescein Angiography (PDF) Effective Date: 1/1/18
- Fundus Photography (PDF) Effective Date: 1/1/18
- Global Maternity Billing (PDF} Effective 1/2013
- Gonioscopy (PDF) Effective Date: 1/1/18
- Hospital Visit Codes Billed with Labs (PDF)
- Inpatient Consultation (PDF)
- Inpatient Only Procedures (PDF)
- IV Hydration (PDF)
- Leveling of Care: Evaluation and Management Overcoding (PDF)
- Leveling of ER Services (PDF) Effective Date: 1/1/19
- Leveling of ER Services (Hospitals) (PDF)
- Maximum Units (PDF)
- Moderate Conscious Sedation (PDF)
- Modifer 59 Clinical Validation (PDF)
- Modifer DOS Validation (PDF)
- Modifer to Procedure Code Validation (PDF)
- MPPR for Ophthalmology (PDF) Effective 01/01/2021
- Multiple CPT Code Replacement (PDF)
- Multiple Diagnosis Cardiovascular (PDF)
- Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
- NCCI Unbundling (PDF)
- Never Paid Events (PDF)
- New Patient (PDF)
- Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF) Effective 01/01/2021
- Optum Comprehensive Payment Integrity (CPI) (PDF)
- Outpatient Consultation (PDF)
- Physician Visit Codes Billed with Labs (PDF)
- Physician's Office Lab Testing (PDF)
- Place of Service Mismatch (PDF) Effective Date: 11/1/18
- Post-Operative Visits (PDF)s
- Pre-Operative Visits (PDF)
- Problem Oriented Visits with Preventative Visits (PDF)
- Professional Component (PDF)
- Pulse Oximetry (PDF)
- Renal Hemodialysis (PDF) Effective: 1/1/21
- Robotic Surgery (PDF) Effective Date: 1/1/18
- Same Day Visits (PDF)
- Scanning Computerized Ophthalmic Diagnostic Imaging (PDF) Effective Date: 1/1/18
- Sleep Studies Place of Service (PDF) Effective Date: 1/1/18
- Status "B" Bundled Services (PDF)
- Status "P" Bundled Services (PDF) Effective Date: 1/1/18
- Supplies Billed on Same Day As Surgery (PDF)
- Transcranial Magnetic Stimulation for MDD (PDF)
- Transgender Related Services (PDF)
- Unbundled Professional Services (PDF)
- Unbundled Surgical Procedures (PDF)
- Unbundling Adjustments on Clean Claim Reviews (PDF)
- Unlisted Procedure Codes (PDF)
- Urine Specimen Validity Testing (PDF)
- Visual Field Testing (PDF) Effective Date: 1/1/18
- Wheelchair Seating (PDF) Effective Date: 10/1/2018
- 3 Day Payment Window (PDF) - Effective Date: 1/1/18
- 30-Day Readmission (PDF) - Effective Date: 1/1/18
- Assistant Surgeon (PDF) - Effective Date: 1/1/18
- Add on Code Billed Without Primary Code - Effective Date: 1/1/18
- Bilateral Procedures (PDF) - Effective Date: 1/1/18
- MPPR for Ophthalmology (PDF) - Effective 01/01/2021
- Cerumen Removal (PDF) - Effective Date: 1/1/18
- Clean Claims (PDF)
- Clinical Validation of Modifier 25 (PDF)
- Coding Overview (PDF) - Effective Date: 1/1/18
- Concert Laboratory Payment Policy (CG.CC.PP.01) (PDF) - Effective Date: 6/15/24
- Cosmetic Procedures (PDF) - Effective Date: 1/1/18
- Cost to Charge Adjustments on Clean Claim Reviews (PDF)
- Distinct Procedural Modifiers (PDF) - Effective Date: 1/1/18
- Duplicate Primary Code Billing (PDF) - Effective Date: 1/1/18
- EM Bundling Edits (PDF) - Effective Date: 1/1/18
- E&M Medical Decision-Making (PDF) - Effective Date: 1/1/18
- Evaluation and Management Services Billed with Treatment Rooms (PDF) - Effective 6/18/2022
- Genetic and Molecular Testing Services (VersionC) (CG.CC.PP.511) (PDF) - Effective Date: 6/15/24
- Global Maternity Billing (PDF) - Effective Date: 1/1/18
- Hospital Visit Codes Billed with Labs (PDF) - Effective Date: 1/1/18
- Infectious Disease: Dermatologic Lab Testing (CG.CP.MP.03) (PDF) - Effective Date: 6/15/24
- Infectious Disease: Gastroenterologic Lab Testing (CG.CP.MP.04) (PDF) - Effective Date: 6/15/24
- Infectious Disease: Genitourinary Lab Testing (CG.CP.MP.07) (PDF) - Effective Date: 6/15/24
- Infectious Disease: Multisystem Lab Testing (CG.CP.MP.02) (PDF) - Effective Date: 6/15/24
- Infectious Disease: Primary Care & Preventive Lab Screening (CG.CP.MP.05) (PDF) - Effective Date: 6/15/24
- Infectious Disease: Respiratory Lab Testing (CG.CP.MP.01) (PDF) - Effective Date: 6/15/24
- Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (CG.CMP.MP.06) (PDF) - Effective Date: 6/15/24
- Inpatient Consultation (PDF) - Effective Date: 1/1/18
- IV Hydration (PDF)
- Inpatient Only Procedures (PDF) - Effective Date: 1/1/18
- Leveling of ER Services (PDF) - Effective Date: 1/15/20
- Leveling of ER Services (Hospitals) (PDF)
- Leveling of Care: Evaluation and Management Overcoding (PDF)
- Maximum Units (PDF) - Effective Date: 1/1/18
- Moderate Conscious Sedation (PDF) - Effective Date: 1/1/18
- Modifier-59 Clinical Validation (PDF) - Effective Date: 1/1/18
- Modifier DOS Validation (PDF) - Effective Date: 1/1/18
- Modifier to Procedure Code Validation (PDF) - Effective Date: 1/1/18
- MPPR for Ophthalmology (PDF) - Effective 01/01/2021
- Multiple CPT Code Replacement (PDF) - Effective Date: 1/1/18
- Multiple Diagnosis Cardiovascular (PDF)
- Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF) - Effective 01/01/2021
- NCCI Unbundling (PDF) - Effective Date: 1/1/18
- Never Paid Events (PDF) - Effective Date: 1/1/18
- New Patient (PDF) - Effective Date: 1/1/18
- Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF) - Effective 01/01/2021
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF) - Effective Date: 11/1/18
- Optum Comprehensive Payment Integrity (CPI) (PDF)
- Outpatient Consultation (PDF) - Effective Date: 1/1/18
- Physician Consultative Services (PDF) - Effective Date: 1/15/20
- Physician's Office Lab Testing (PDF)
- Physician Visit Codes Billed with Labs (PDF) - Effective Date: 1/1/18
- Place of Service Mismatch (PDF) - Effective Date: 11/1/18
- 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
- Sepsis Diagnosis (PDF)
- 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
- Unbundling Adjustments on Clean Claim Reviews (PDF)
- Unbundled Professional Services (PDF) - Effective Date: 1/1/18
- Unbundled Surgical Procedures (PDF) - Effective Date: 1/1/18
- Unlisted Procedure Codes (PDF) - Effective Date: 1/1/18
- Wheelchair Seating (PDF) - Effective Date: 10/1/2018
- 30 Day Readmission (PDF)
- Bevacizumab (PDF) - Effective Date: 1/1/18
- Bilateral Procedures (PDF)
- Clean Claims (PDF)
- Clinical Validation (PDF)
- Concert Genetics Lab Testing Clinical Criteria Support (PDF) - Effective 5/6/24
- Concert Laboratory Payment Policy (CG.CC.PP.01) (PDF) – Effective 6/15/24
- Cosmetic Procedures (PDF)
- Cost to Charge Adjustments on Clean Claim Reviews (PDF)
- E&M Medical Decision-Making (PDF)
- Evaluation and Management Services Billed with Treatment Rooms (PDF) - Effective 6/18/2022
- Genetic and Molecular Testing Services (Version C) (CG.CC.PP.511) (PDF) – Effective 6/15/24
- Infectious Disease: Dermatologic Lab Testing (CG.CP.MP.03) (PDF) – Effective 6/15/24
- Infectious Disease: Gastroenterologic Lab Testing (CG.CP.MP.04) (PDF) – Effective 6/15/24
- Infectious Disease: Genitourinary Lab Testing (CG.CP.MP.07) (PDF) – Effective 6/15/24
- Infectious Disease: Multisystem Lab Testing (CG.CP.MP.02) (PDF) – Effective 6/15/24
- Infectious Disease: Primary Care & Preventive Lab Screening (CG.CP.MP.05) (PDF) – Effective 6/15/24
- Infectious Disease: Respiratory Lab Testing (CG.CP.MP.01) (PDF) – Effective 6/15/24
- Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (CG.CP.MP.06) (PDF) – Effective 6/15/24
- IV Hydration (PDF)
- Leveling of Care: Evaluation and Management Overcoding (PDF)
- Leveling of ER Services (Hospitals) (PDF)
- Modifer DOS Validation (PDF)
- MPPR for Ophthalmology (PDF) - Effective 01/01/2021
- Multiple Diagnosis Cardiovascular (PDF)
- Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF) - Effective 01/01/2021
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF) - Effective Date: 11/1/18
- Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF) - Effective 01/01/2021
- NCCI Unbundling (PDF)
- Optum Comprehensive Payment Integrity (CPI) (PDF)
- Physician's Office Lab Testing (PDF)
- Professional Component (PDF)
- Problem Orriented Visits with Preventative Visits (PDF) - Effective: 1/1/18
- Problem Oriented Visits with Surgical Procedures (PDF) - Effective Date: 1/1/19
- Place of Service Mismatch (PDF) - Effective Date: 11/1/18
- Renal Hemodialysis (PDF) - Effective: 1/1/21
- Robotic Surgery (PDF) - Effective Date: 1/1/18
- Same Day Visits (PDF)
- Sepsis Diagnosis (PDF)
- Status "B" Bundled Services (PDF) - Effective Date: 1/1/18
- Status "P" Bundled Services (PDF) - Effective Date: 1/1/18
- Unbundling Adjustments on Clean Claim Reviews (PDF)
- Unbundled Professional Services (PDF)
- Urine Specimen Visits with Surgical Procedures (PDF) - Effective Date: 1/1/18
- Skilled Nursing Facility Leveling (CC.PP.206) (PDF) - Effective Date: January 1, 2024