Clinical & Payment Policies
Clinical Policies (CP.MP.XX)
Clinical policies are 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 for plans that cover outpatient medications.
Clinical policies 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 this Clinical Policy site are listed by Line of Business – Medicaid, Marketplace (Ambetter) and Medicare (Wellcare and WellCare by Allwell).
- 25 Hydroxyvitamin D Testing in Children and Adolescents (CP.MP.157) (PDF)
- Acupuncture (CP.MP.92) (PDF)
- Adopted Clinical Practice and Preventive Health Guidelines (CPG Grid) (PDF)
- Air Ambulance (CP.MP.175) (PDF)
- Allergy Testing and Therapy (MO.CP.MP.100) (PDF) Effective 1/1/2024
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-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)
- Bariatric Surgery (CP.MP.37) (PDF)
- Behavioral Health Treatment Documentation Requirements (CP.BH.500) (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 (CP.MP.110) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Cardiac Biomarker Testing (CP.MP.156) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Cardiac Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Dermatologic Conditions (V2.2024) (PDF)
- Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (V2.2024) (PDF)
- Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Eye Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (V2.2024) (PDF)
- Concert Genetic Testing: General Approach to Genetic and Molecular Testing (V2.2024) (PDF)
- Concert Genetic Testing: Hearing Loss (V2.2024) (PDF)
- Concert Genetic Testing: Hematologic Conditions (non-cancerous) (V2.2024) (PDF)
- Concert Genetic Testing: Hereditary Cancer Susceptibility (V2.2024) (PDF)
- Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Kidney Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Lung Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (V2.2024) (PDF)
- Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (V2.2024) (PDF)
- Concert Genetic Testing: Pharmacogenetics (V2.2024) (PDF)
- Concert Genetic Testing: Preimplantation Genetic Testing (V2.2024) (PDF)
- Concert Genetic Testing: Prenatal and Preconception Carrier Screening (V2.2024) (PDF)
- Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (V2.2024) (PDF)
- Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (V2.2024) (PDF)
- Concert Genetic Oncology: Algorithmic Testing (V2.2024) (PDF)
- Concert Genetic Oncology: Cancer Screening (V2.2024) (PDF)
- Concert Genetic Oncology: Circulating Tumor Cells (Liquid Biopsy) (V2.2024) (PDF)
- Concert Genetic Oncology: Cytogenetic Testing (V2.2024) (PDF)
- Concert Genetic Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (V2.2024) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (CP.BH.201) (PDF)
- Diabetes Prevention Program (DPP) (MO.CP.MP.503) (PDF)
- Diaphragmatic/Phernic Nerve Stimulation (CP.MP.203) (PDF)
- Digital EEG Spike Analysis (CP.MP.105) (PDF)
- Disc Decompression Procedures (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101)(PDF)
- Drugs of Abuse: Definitive Testing (CP.MP.50) (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 (Optune)(CP.MP.145) (PDF)
- Endometrial Ablation (CP.MP.106) (PDF)
- Evoked Potential Testing (CP.MP.134) (PDF)
- Experimental Technologies (CP.MP.36)(PDF)
- Facet Joint Interventions (CP.MP.171) (PDF)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (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)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Helicobacter Pylori Serology Testing (CP.MP.153) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Home Births (CP.MP.136) (PDF)
- Home Ventilators (CP.MP.184) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperhidrosis Treatments (CP.MP.62)(PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal or Epidural Pain Pump (CP.MP.173) (PDF)
- Implantable Loop Recorder (CP.MP.243) (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)
- Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (CP.MP.250) (PDF)
- Laser Therapy for Skin Conditions (CP.MP.123) (PDF)
- Liposuction for Lipedema (CP.MP.244) (PDF)
- Long Term Care Placement (CP.MP.71) (PDF)
- Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (CP.MP.139) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Measurement of Serum 1,25-dihydroxyvitamin D (CP.MP.152) (PDF)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) (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)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (CP.MP.48) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Nonmyeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Omisirge (omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (CP.MP.249) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (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 Kidney Transplant (CP.MP.246) (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)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (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)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
- Sacroiliac Joint Fusion (CP.MP.126) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Skin and Soft Tissue Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (CP.MP.154) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF)
- Transcranial Magnetic Stimulation for the Treatment of Major Depressive Disorder (MO.CP.BH.202) (PDF)
- Transplant Service Documentation Requirements (CP.MP.247) (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Urodynamic Testing (CP.MP.98) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46)(PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
- 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 β-Thalassemia (CP.MP.108) (PDF)
- Applied Behavior Analysis (CP.BH.104) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Behavioral Health Treatment Documentation Requirements (HIM.CP.BH.500) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Biofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (V2.204) (PDF)
- Concert Genetic Testing: Cardiac Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Dermatologic Conditions (V2.2024) (PDF)
- Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (V2.2024) (PDF)
- Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Eye Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (V2.2024) (PDF)
- Concert Genetic Testing: General Approach to Genetic and Molecular Testing (V2.2024) (PDF)
- Concert Genetic Testing: Hearing Loss (V2.2024) (PDF)
- Concert Genetic Testing: Hematologic Conditions (non-cancerous) (V2.2024) (PDF)
- Concert Genetic Testing: Hereditary Cancer Susceptibility (V2.2024) (PDF)
- Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Kidney Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Lung Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (V2.2024) (PDF)
- Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (V2.2024) (PDF)
- Concert Genetic Testing: Pharmacogenetics (V2.2024) (PDF)
- Concert Genetic Testing: Preimplantation Genetic Testing (V2.2024) (PDF)
- Concert Genetic Testing: Prenatal and Preconception Carrier Screening (V2.2024) (PDF)
- Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (V2.2024) (PDF)
- Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (V2.2024) (PDF)
- Concert Genetic Oncology: Algorithmic Testing (V2.2024) (PDF)
- Concert Genetic Oncology: Cancer Screening (V2.2024) (PDF)
- Concert Genetic Oncology: Circulating Tumor Cells (Liquid Biopsy) (V2.2024) (PDF)
- Concert Genetic Oncology: Cytogenetic Testing (V2.2024) (PDF)
- Concert Genetic Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (V2.2024) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (CP.BH.201) (PDF)
- Diaphragmatic/Phrenic Nerve Simulation (CP.MP.203) (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)
- Electric Tumor Treating Fields (Optune) (CP.MP.145) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171) (PDF)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (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)
- Gender Affirming Procedures (CP.MP.95) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Home Births (CP.MP.136) (PDF)
- Home Ventilators (CP.MP.184) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperhidrosis Treatments (CP.MP.62)(PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal or Epidural Pain Pump (CP.MP.173) (PDF)
- Implantable Loop Recorder (CP.MP.243) (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)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF)
- Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (CP.MP.250) (PDF)
- Liposuction for Lipedema (CP.MP.244) (PDF)
- Long Term Care Placement (CP.MP.71) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) (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)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (CP.MP.48) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Nonmyeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Omisirge (omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (CP.MP.249) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (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 Kidney Transplant (CP.MP.246) (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)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Private Duty Nursing (MO.CP.MP.504)(PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
- Sacroiliac Joint Fusion (CP.MP.126) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Skin and Soft Tissue Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF)
- Transplant Service Documentation Requirements (CP.MP.247) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
We are committed to providing appropriate, high-quality, and cost-effective drug therapy to all Ambetter Health members.
Use our Preferred Drug List to find more information on the drugs that Ambetter Health covers.
Pharmacy Resources for Providers | Ambetter from Home State Health
For Medicare information, please visit our Medicare Prior Authorization website.
- Adjacent-Tissue-Transfer-Grafts-involving-Eyelid (PDF)
- Age-Related-Macular-Degeneration (PDF)
- Amblyopia (PDF)
- Amniotic-Membrane-Placement-on-Ocular-Surface (PDF)
- Anterior-Segment-Photography-with-Fluorescein-Angiography (PDF)
- Aqueous-Shunt (PDF)
- Blepharoplasty-Ptosis-Repair-and-Canthoplasty (PDF)
- Canthotomy (PDF)
- Cataract-Extraction (PDF)
- Chemodenervation (PDF)
- Complex-Cataract-Extraction (PDF)
- Corneal-Erosion-and-Photo-Keratectomy (PDF)
- Corneal-Hysteresis (PDF)
- Corneal-Pachymetry (PDF)
- Corneal-Topography (PDF)
- Dark-Adaption-and-Color-Vision-Examinations (PDF)
- Destruction-of-Localized-Lesion-of-Choroid (PDF)
- Destruction-of-Localized-Lesion-of-the-Retina (PDF)
- Destruction-of-Retinopathy (PDF)
- Ectropion-Entropion-Repair (PDF)
- Electroretinography (PDF)
- Eyelid-Reanimation (PDF)
- Examination-Guidelines-for-Diabetic-Patients (PDF)
- External-Ocular-Photography (PDF)
- Extended Ophthalmoscopy (CP.VP.26) (PDF)
- Fluorescein Angiography (CP.VP.28) (PDF)
- Fundus Photography (CP.VP.29) (PDF)
- Glaucoma (PDF)
- Glaucoma-Screening (PDF)
- Gonioscopy (CP.VP.31) (PDF) Medicaid and Ambetter Only
- Guidelines-for-Dilation-Protocol-during-Examination-of-the-Eye (PDF)
- Indocyanine-Green-(ICG)-Angiography (PDF)
- Infracture-of-the-Inferior-Turbinate (PDF)
- Iris-Coloboma (PDF)
- Keratoplasty (PDF)
- Laser-Iridotomy-and-Iridectomy for Glaucoma (PDF)
- Laser-Trabeculoplasty (PDF)
- Low-Vision-Evaluations-and-Aids (PDF)
- Ocular-Prosthesis (PDF)
- Ocular-Surface-Reconstruction (PDF)
- Ophthalmic-B-scans (PDF)
- Ophthalmic-Biometry (PDF)
- Pediatric-Eye-Examinations (PDF)
- Photodynamic-and-Intravitreal-Therapies-and-Pharmaceuticals (PDF)
- Probing-and-Closure-of-the-Lacrimal-Duct-System (PDF)
- Prophylaxis-of-Retinal-Detachment (PDF)
- Refractive-Surgery (PDF)
- Refraction (PDF)
- Repair-of-Retinal-Detachment (PDF)
- Scanning Computerized Ophthalmic Diagnostic Imaging (CP.VP.14) (PDF) Medicaid and Ambetter Only
- Secondary-Intraocular-Lens-(IOL) (PDF)
- Sensorimotor-Examination (PDF)
- Serial-Tonometry (PDF)
- Specular-Microscopy (PDF)
- Surgical-Excision-of-Eyelid-Lesions (PDF)
- Surgical-Strabismus-Repair (PDF)
- Teleretinal-Screening-for-Diabetic-Retinopathy (PDF)
- Trabeculectomy-Ab-Externo (PDF)
- Visual-Therapy (PDF)
- Visual Field Testing (CP.VP.63) (PDF)
- Vitrectomy (PDF)
- Yttrium-Aluminium-Garnet-(YAG)-Laser-Capsulotomy (PDF)
Payment Policies (CC.PP.XX)
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).
Policies in this site 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 guidance (e.g., MO HealthNet’s managed care policy statements) or provider contract terms may further determine whether a technology, procedure or treatment not addressed in a policy, one of our Provider Manuals or other posted information is payable.
- 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
- Global Maternity Billing (PDF} Effective 1/2013
- 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 (CC.PP.055) (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)
- 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)
- 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)
- 3 Day Payment Window (PDF)
- Assistant Surgeon (PDF)
- Add on Code Billed Without Primary Code
- Bilateral Procedures (PDF)
- Cerumen Removal (PDF)
- Clean Claims (PDF)
- Clinical Validation of Modifier 25 (PDF)
- Coding Overview (PDF)
- Concert Laboratory Payment Policy (CG.CC.PP.01) (PDF) - Effective Date: 6/15/24
- Cosmetic Procedures (PDF)
- Cost to Charge Adjustments on Clean Claim Reviews (PDF)
- Distinct Procedural Modifiers (PDF)
- Duplicate Primary Code Billing (PDF)
- EM Bundling Edits (PDF)
- E&M Medical Decision-Making (PDF)
- Evaluation and Management Services Billed with Treatment Rooms (PDF)
- Genetic and Molecular Testing Services (VersionC) (CG.CC.PP.511) (PDF) - Effective Date: 6/15/24
- Global Maternity Billing (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospital Visit Codes Billed with Labs (PDF)
- 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)
- IV Hydration (PDF)
- Inpatient Only Procedures (PDF)
- Leveling of ER Services (PDF)
- Leveling of ER Services (Hospitals) (PDF)
- Leveling of Care: Evaluation and Management Overcoding (PDF)
- Maximum Units (PDF)
- Moderate Conscious Sedation (PDF)
- Modifier-59 Clinical Validation (PDF)
- Modifier DOS Validation (PDF)
- Modifier to Procedure Code Validation (PDF)
- MPPR for Ophthalmology (PDF)
- 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)
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
- Optum Comprehensive Payment Integrity (CPI) (PDF)
- Outpatient Consultation (PDF)
- Physician Consultative Services (PDF)
- Physician's Office Lab Testing (CC.PP.055) (PDF)
- Physician Visit Codes Billed with Labs (PDF)
- Place of Service Mismatch (PDF)
- Post-Operative Visits (PDF)
- Pre-Operative Visits (PDF)
- Problem Oriented Visits with Preventive Visits (PDF)
- Problem Oriented Visits with Surgical Procedures (PDF)
- Professional Component (PDF)
- Pulse Oximetry (PDF)
- Renal Hemodialysis (PDF)
- Robotic Surgery (PDF)
- Same Day Visits (PDF)
- Sepsis Diagnosis (CC.PP.073) (PDF)
- Severe Malnutrition (CC.PP.145) (PDF)
- Status "B" Bundled Services (PDF)
- Status "P" Bundled Services (PDF)
- Supplies Billed on Same Day As Surgery (PDF)
- Transgender Related Services (PDF)
- Unbundling Adjustments on Clean Claim Reviews (PDF)
- Unbundled Professional Services (PDF)
- Unbundled Surgical Procedures (PDF)
- Unlisted Procedure Codes (PDF)
- 30 Day Readmission (PDF)
- Bevacizumab (PDF)
- 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)
- Endometrial Ablation (CP.MP.106) (PDF)
- Evaluation and Management Services Billed with Treatment Rooms (PDF)
- 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)
- Multiple Diagnosis Cardiovascular (PDF)
- Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
- Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF)
- NCCI Unbundling (PDF)
- Optum Comprehensive Payment Integrity (CPI) (PDF)
- Physician's Office Lab Testing (CC.PP.055) (PDF)
- Professional Component (PDF)
- Problem Orriented Visits with Preventative Visits (PDF)
- Problem Oriented Visits with Surgical Procedures (PDF)
- Renal Hemodialysis (PDF)
- Robotic Surgery (PDF)
- Same Day Visits (PDF)
- Sepsis Diagnosis (PDF)
- Skilled Nursing Facility Leveling (CC.PP.206) (PDF)
- Status "B" Bundled Services (PDF)
- Status "P" Bundled Services (PDF)
- Unbundling Adjustments on Clean Claim Reviews (PDF)
- Unbundled Professional Services (PDF)
- Urine Specimen Visits with Surgical Procedures (PDF)