Pennsylvania Clinical Payment Policies | Ambetter from PA Health & Wellness

 

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

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

Policy TitlePolicy Number
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157
Acupuncture (PDF)CP.MP.92
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.124
Adopted Clinical Practice and Preventive Health Guidelines (PDF)CPG Grid
Air Ambulance (PDF)CP.MP.175
Allergy Testinng and Therapy (PDF)CP.MP.100
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108
Applied Behavior Analysis (PDF)CP.BH.104
Articular Cartilage Defect Repairs (PDF)CP.MP.26
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.124
Bariatric Surgery (PDF)CP.MP.37
Behavioral Health Treatment Documentation Requirements (PDF)HIM.CP.BH.500
Biofeedback (PDF)CP.MP.168
Biofeedback for Behavioral Health Disorders (PDF)CP.BH.300
Bone-Anchored Hearing Aid (PDF)CP.MP.93
Bronchial Thermoplasty (PDF)CP.MP.110
Burn Surgery (PDF)CP.MP.186
Cardiac Biomarker Testing (PDF)CP.MP.156
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164
Clinical Trials (PDF)CP.MP.94
Cochlear Implant Replacements (PDF)CP.MP.14 
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V2.2024
Concert Genetic Testing: Cardiac Disorders (PDF)V2.2024
Concert Genetic Testing: Dermatologic Conditions (PDF)V2.2024
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V2.2024
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V2.2024
Concert Genetic Testing: Eye Disorders (PDF)V2.2024
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)V2.2024
Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)V2.2024
Concert Genetic Testing: Hearing Loss (PDF)V2.2024
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)V2.2024
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V2.2024
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V2.2024
Concert Genetic Testing: Kidney Disorders (PDF)V2.2024
Concert Genetic Testing: Lung Disorders (PDF)V2.2024
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V2.2024
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V2.2024
Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)V2.2024
Concert Genetic Testing: Pharmacogenetics (PDF)V2.2024
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V2.2024
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V2.2024
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)V2.2024
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V2.2024
Concert Genetics Oncology: Algorithmic Testing (PDF)V2.2024
Concert Genetics Oncology: Cancer Screening (PDF)V2.2024
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF) V2.2024
Concert Genetics Oncology: Cytogenetic Testing (PDF)V2.2024
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V2.2024
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.201
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203
Digital EEG Spike Analysis (PDF)CP.MP.105
Disc Decompression Procedures (PDF)CP.MP.114
Discography (PDF)CP.MP.115
Donor Lymphocyte Infusion (PDF)CP.MP.101
Drugs of Abuse: Definitive Testing (PDF)CP.MP.50
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (DME) (PDF)CP.MP.107
EEG in the Evaluation of Headache (PDF)CP.MP.155
Electric Tumor Treating Fields (Optune)(PDF)CP.MP.145
Endometrial Ablation (PDF)CP.MP.106
Evoked Potential Testing (PDF)CP.MP.134
Experimental Technologies (PDF)CP.MP.36
Facet Joint Interventions (PDF)CP.MP.171
Fecal Incontinence Treatments (PDF)CP.MP.137
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248
Ferriscan R2-MRI (PDF)CP.MP.53
Fertility Preservation (PDF)CP.MP.130
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129
Functional MRI (PDF)CP.MP.43
Gastric Electrical Stimulation (PDF)CP.MP.40
Gender-Affirming Procedures (PDF)CP.MP.95
Heart-Lung Transplant (PDF)CP.MP.132
Holter Monitors (PDF)CP.MP.113
Home Births (PDF)CP.MP.136
Home Ventilators (PDF)CP.MP.184
Homocysteine Testing (PDF)CP.MP.121
Hospice Services (PDF)CP.MP.54
Hyperhidrosis Treatments (PDF)CP.MP.62
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173
Implantable Loop Recorder (PDF)CP.MP.243
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.160
Intensity-Modulated Radiotherapy (PDF)CP.MP.69
Intestinal and Multivisceral Transplant (PDF)CP.MP.58
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.167
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61
Lantidra (donislecel): Allogenic Pancreatic Islet Cellular Therapy (PDF)CP.MP.250
Laser Therapy for Skin Conditions (PDF)CP.MP.123
Liposuction for Lipedema (PDF)CP.MP.244
Long Term Care Placement (PDF)CP.MP.71
Low-Frequency Ultrasound and Noncontact Normothermic Wound (PDF)CP.MP.139
Lung Transplantation (PDF)CP.MP.57
Lysis of Epidural Lesions (PDF)CP.MP.116
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.144
Multiple Sleep Latency Testing (PDF)CP.MP.24
Neonatal Abstinence Syndrome Guidelines (PDF)CP.MP.86
Neonatal Sepsis Management (PDF)CP.MP.85
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.170
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.48
NICU Apnea Bradycardia Guidelines (PDF)CP.MP.82
NICU Discharge Guidelines (PDF)CP.MP.81
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.141
Obstetrical Home Care Programs (PDF)CP.MP.91
Omisirge (omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249
Orthognathic Surgery (PDF)CP.MP.202
Osteogenic Stimulation (PDF)CP.MP.194
Outpatient Cardiac Rehabilitation (PDF)CP.MP.176
Outpatient Oxygen Use (PDF)CP.MP.190
Pancreas Transplantation (PDF)CP.MP.102
Panniculectomy (PDF)CP.MP.109
Pediatric Heart Transplant (PDF)CP.MP.138
Pediatric Kidney Transplant (PDF)CP.MP.246
Pediatric Liver Transplant (PDF)CP.MP.120
Pediatric Oral Function Therapy (PDF)CP.MP.188
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.147
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.150
Physical, Occupational, and Speech Therapy Services (PDF)CP.MP.49
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133
Proton and Neutron Beam Therapies (PDF)CP.MP.70
Pulmonary Function Testing (PDF)CP.MP.242
Reduction Mammaplasty and Gyncomastia Surgery (PDF)CP.MP.51
Repair of Nasal Valve Compromise (PDF)CP.MP.210
Sacroiliac Joint Fusion (PDF)CP.MP.126
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)CP.MP.165
Short Inpatient Hospital Stay (PDF)CP.MP.182
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117
Stereotactic Body Radiation Therapy (PDF)CP.MP.22
Tandem Transplant (PDF)CP.MP.162
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)CP.MP.164
Total Artificial Heart (PDF)CP.MP.127
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163
Transcather Closer of Patent Foramen Ovale (PDF)CP.MP.151
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)CP.MP.200
Transplant Service Documentation Requirements (PDF)CP.MP.247
Trigger Point Injections for Pain Management (PDF)CP.MP.169
Ultrasound in Pregnancy (PDF)CP.MP.38
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142
Urodynamic Testing (PDF)CP.MP.98
Vagus Nerve Stimulation (PDF)CP.MP.12
Ventricular Assist Devices (PDF)CP.MP.46
Wheelchair Seating (PDF)CP.MP.99
Wireless Motility Capsule (PDF)CP.MP.143

A-KL-Z

72 Hour Supply of Medication (PDF)

Effective Date: 06/01/2006


Lost, Stolen, Spilled or Broken Medications (PDF)

Effective Date: 04/01/2007

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

Effective Date: 05/01/2012


Medication Safety Policy (PDF)

Effective Date: 07/01/2017

Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)

Effective Date: 11/01/2001


Pharmaceutical Management (PDF)

Effective Date: 02/01/2003

Dose Escalation of Biologics (PDF)

Effective Date: 09/01/2017


Pharmacy and Therapeutics Committee (PDF)

Effective Date: 08/19/2011

Drug Recall Notification Process (PDF)

Effective Date: 07/01/2008


Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)

Effective Date: 07/09/2010


Drug Utilization Review (PDF)

Effective Date: 04/01/2007

Progesterone (Crinone, Endometrin) (PDF)

Effective Date: 11/16/2016

Filgrastim (Neupogen, Zarxio) (PDF)

Effective Date: 11/16/2016

Somatropin (HGH) (PDF)

Effective Date: 11/16/2016

Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)

Effective Date: 12/01/2016

Lumacaftor-Ivacaftor (Orkambi) (PDF)

Effective Date: 05/01/2016

Ibalizumab-uiyk (Trogarzo) (PDF)

Effective Date: 04/17/2018

Nusinersen (Spinraza®)(PDF)

Effective Date: 11/28/2017

Brentuximab Vedotin (Adcetris) (PDF)

Effective Date: 02/01/2017

Somatropin (Growth Hormone) (PDF)

Effective Date: 03/01/2011

Interferon Gamma- 1b (Actimmune) (PDF)

Effective Date: 06/01/2010

Step Therapy (PDF)

Effective Date: 08/01/2017

Bendamustine (Bendeka®, Treanda®) (PDF)

Effective Date: 02/01/2017

Riociguat (Adempas®) (PDF)

Effective Date: 03/01/2016

Belimumab (Benlysta) (PDF)

Effective Date: 10/01/2011

Tadalafil (Adcirca®) (PDF)

Effective Date: 03/01/2016

C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF)

Effective Date: 03/01/2016

Tocilizumab (Actemra) (PDF)

Effective Date: 07/01/2016

Immune Globulins (PDF)

Effective Date: 08/01/2012

OnabotulinumtoxinA (Botox) (PDF)

Effective Date: 07/01/2016

Blinatumomab (Blincyto) (PDF)

Effective Date: 02/01/2017

Vandetanib (Caprelsa®) (PDF)

Effective Date: 10/01/2011

Ibandronate sodium (Boniva®) (PDF)

Effective Date: 11/15/2017

Reslizumab (Cinqair) (PDF)

Effective Date: 05/01/2016

Bosutinib (Bosulif) (PDF)

Effective Date: 10/01/2012

Tesamorelin (Egrifta) (PDF)

Effective Date: 03/01/2014

Cerliponase alfa (Brineura) (PDF)

Effective Date: 07/01/2017

Perampanel (Fycompa) (PDF)

Effective Date: 11/16/2016

Carglumic acid (Carbaglu®) (PDF)

Effective Date: 05/01/2016

Taliglucerase Alfa (Elelyso) (PDF)

Effective Date: 02/01/2016

Imiglucerase (Cerezyme) (PDF)

Effective Date: 02/01/2016

Pralatrexate (Folotyn®) (PDF)

Effective Date: 02/01/2017

Certolizumab (Cimzia) (PDF)

Effective Date: 08/01/2016

Teriparatide (Forteo®) (PDF)

Effective Date: 11/15/2017

Cabozantinib (Cometriq®, Cabometyx®) (PDF)

Effective Date: 06/01/2013

Levoleucovorin (Fusilev®) (PDF)

Effective Date: 11/09/2017

Glatiramer (Copaxone, Glatopa) (PDF)

Effective Date: 08/01/2016

Teduglutide (Gattex) (PDF)

Effective Date: 05/01/2013

Daratumumab (Darzalex) (PDF)

Effective Date: 07/01/2017

Obinutuzumab (Gazyva®) (PDF)

Effective Date: 02/01/2017

Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF)

Effective Date: 05/01/2016

Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)

Effective Date: 06/01/2016

Deferoxamine (Desferal) (PDF)

Effective Date: 11/01/2015

Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)

Effective Date: 03/01/2016

Dupilumab (Dupixent) (PDF)

Effective Date: 05/01/2017

Topotecan (Hycamtin)(PDF)

Effective Date: 06/01/2011

AbobotulinumtoxinA (Dysport) (PDF)

Effective Date: 07/01/2016

RimabotulinumtoxinB (Myobloc) (PDF)

Effective Date: 07/01/2016

Etanercept (Enbrel) (PDF)

Effective Date: 08/01/2016

Pegfilgrastim (Neulasta) (PDF)

Effective Date: 12/01/2016

Epoetin Alfa (Epogen® and Procrit) (PDF)

Effective Date: 06/01/2016

sorafenib (Nexavar) (PDF)

Effective Date: 07/01/2011

Cetuximab (Erbitux®) (PDF)

Effective Date: 02/01/2017

Mepolizumab (Nucala) (PDF)

Effective Date: 04/01/2016

Eteplirsen (PDF)

Effective Date: 12/01/2016

Obeticholic (Ocaliva) (PDF)

Effective Date: 11/01/2016

Deferasirox (Exjade Jadenu) (PDF)

Effective Date: 11/1/2015

Nivolumab (Opdivo) (PDF)

Effective Date: 07/01/2015

Aflibercept (Eylea®) (PDF)

Effective Date: 03/01/2016

Lumacaftor-ivacaftor (Orkambi) (PDF)

Effective Date: 05/01/2016

Agalsidase Beta (Fabrazyme) (PDF)

Effective Date: 02/01/2016

Pertuzumab (Perjeta) (PDF)

Effective Date: 06/01/2016

Deferiprone (Ferriprox) (PDF)

Effective Date: 11/01/2015

Peginterferon beta-1a (Plegridy) (PDF)

Effective Date: 08/01/2016

Degarelix acetate (Firmagon®) (PDF)

Effective Date: 11/09/2017

Pomalidomide (Pomalyst) (PDF)

Effective Date: 07/01/2013

Dalteparin (Fragmin) (PDF)

Effective Date: 05/01/2016

Necitumumab (Portrazza®) (PDF)

Effective Date: 03/01/2017

Enfuvirtide (Fuzeon) (PDF)

Effective Date: 06/01/2010

Palbociclib (Ibrance®) (PDF)

Effective Date: 10/01/2015

Fingolimod (Gilenya) (PDF)

Effective Date: 08/01/2016

Ponatinib (Iclusig) (PDF)

Effective Date: 06/01/2013

Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF)

Effective Date: 03/01/2012

Ibrutinib (Imbruvica) (PDF)

Effective Date: 10/01/2015

Imatinib (Gleevec) (PDF)

Effective Date: 06/01/2011

 

Eribulin Mesylate (Halaven®) (PDF)

Effective Date: 03/01/2017

 

Adalimumab (Humira) (PDF)

Effective Date: 08/01/2016

 

Hydroxyprogesterone Caproate (Makena®) (PDF)

Effective Date: 11/20/2017

 

Galsulfase (Naglazyme) (PDF)

Effective Date: 02/01/2016

 

Ixazomib (Ninlaro) (PDF)

Effective Date: 02/01/2017

 

belatacept (Nulojix®) (PDF)

Effective Date: 11/09/2017

 

abatacept (Orencia) (PDF)

Effective Date: 08/01/2016

 

irinotecan Liposome (Onivyde®) (PDF)

Effective Date: 02/01/2017

 

Apremilast (Otezla) (PDF)

Effective Date: 08/01/2016

 

Buprenorphine implant (Probuphine) (PDF)

Effective Date: 11/16/2016

 

Alirocumab (Praluent) (PDF)

Effective Date: 10/01/2015

 

Cysteamine oral (Cystagon, Procysbi) (PDF)

Effective Date: 02/01/2016

 

Denosumab (Prolia, Xgeva) (PDF)

Effective Date: 03/01/2011

 

Eltrombopag (Promacta®) (PDF)

Effective Date: 03/01/2016

 

Canakinumab (Ilaris) (PDF)

Effective Date: 08/01/2016

 

 

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 PA Health & Wellness Payment Policy Manual apply with respect to PA Health & Wellness members. Policies in the PA Health & Wellness Payment Policy Manual may have either a PA Health & Wellness or a “Centene” heading.  In addition, PA Health & Wellness 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 PA Health & Wellness.     

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

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
3 Day Payment Window (PDF)CC.PP.500Effective Date: 07/01/2014
30 Day Readmission (PDF)CC.PP.501Effective Date: 01/01/2015
Add On Policy (PDF)CC.PP.030Effective Date: 01/01/2013
Assistant Surgeon (PDF)CC.PP.029Effective Date: 01/01/2014
Bilateral Procedures (PDF)CC.PP.037Effective Date: 01/01/2014
Cerumen Removal Policy (PDF)CC.PP.008Effective Date: 01/01/2014
Clean Claims Policy (PDF)CC.PP.021Effective Date: 01/01/2013
Clinical Validation of Modifier 25 (PDF)CC.PP.013Effective Date: 01/01/201
Clinical Validation of Modifier 59 (PDF)CC.PP.014Effective Date: 01/01/2013
Code Editing Overview (PDF)CC.PP.011Effective Date: 01/01/2013
Concert Laboratory Payment Policy (PDF)CG.CC.PP.01Effective Date: 06/01/2024
Cosmetic Procedures (PDF)CC.PP.024Effective Date: 01/01/2014
Distinct Procedure Modifiers Policy (PDF)CC.PP.020Effective Date: 01/01/2013
Duplicate Primary Code Billing (PDF)CC.PP.044Effective Date: 01/01/2014
EM Medical Decision Making (PDF)CC.PP.051Effective Date: 06/01/2017
E&M Bundling with Labs and Radiology (PDF)CC.PP.010Effective Date: 01/01/2013
Hospital Visit Codes Billed with Labs (PDF)CC.PP.023Effective Date: 01/01/2016
Infectious Disease: Dermatologic Lab Testing (PDF)CG.CP.MP.03Effective Date: 06/01/2024
Infectious Disease: Gastroenterologic Lab Testing (PDF)CG.CP.MP.04Effective Date: 06/01/2024
Infectious Disease: Genitourinary Lab Testing (PDF)CG.CP.MP.07Effective Date: 06/01/2024
Infectious Disease: Multisystem Lab Testing (PDF)CG.CP.MP.02Effective Date: 06/01/2024
Infectious Disease: Primary Care & Preventive Lab Screening (PDF)CG.CP.MP.05Effective Date: 06/01/2024
Infectious Disease: Respiratory Lab Testing (PDF)CG.CP.MP.01Effective Date: 06/01/2024
Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (PDF)CG.CP.MP.06Effective Date: 06/01/2024
Inpatient Only Procedures Policy (PDF)CC.PP.018Effective Date: 01/01/2018
IV Hydration Policy (PDF)CC.PP.012Effective Date: 01/01/2013
Inpatient Consultation (PDF)CC.PP.038Effective Date: 01/01/2014
Moderate Conscious Sedation (PDF)CC.PP.015Effective Date: 01/01/2013
Max Units Payment Policy (PDF)CC.PP.007Effective Date: 01/01/2013
Max Units Payment Policy (PDF)CC.PP.007Effective Date: 01/01/2013
Modifier DOS Validation (PDF)CC.PP.034Effective Date: 01/01/2015
Multiple CPT Code Replace (PDF)CC.PP.033Effective Date: 01/01/2013
Modifier to Procedure Code Validation (PDF)CC.PP.028Effective Date: 01/01/2013
NCCI Unbundling (PDF)CC.PP.031Effective Date: 01/01/2013
New Patient (PDF)CC.PP.036Effective Date: 01/01/2014
Never Paid Events (PDF)CC.PP.017Effective Date: 01/01/2013
Outpatient Consultation (PDF)CC.PP.039Effective Date: 01/01/2014
Physician Visit Codes Billed with Labs (PDF)CC.PP.055Effective Date: 01/01/2013
Physicians Consultation Services (PDF)CC.PP.054Effective Date: 10/01/2017
Postoperative Visits (PDF)CC.PP.042Effective Date: 01/01/2014
Preoperative Visits (PDF)CC.PP.041Effective Date: 01/01/2014
Problem Oriented Visits with Preventative Services (PDF)CC.PP.057Effective Date: 10/01/2017
Problem Oriented Visits with Surgical Procedures (PDF)CC.PP.052Effective Date: 10/01/2017
Professional Component Modifier (PDF)CC.PP.027Effective Date: 01/01/2013
Pulse Oximetry w Office Visits (PDF)CC.PP.025Effective Date: 01/01/2013
Place of Service Mismatch (PDF)CC.PP.063Effective Date: 09/01/2018
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF)CC.PP.061Effective Date: 06/01/2018 
Not Medically Necessary Inpatient Service (PDF)CC.PP.060Effective Date: 06/01/2018
Reporting the Global Maternity Package (PDF)CC.PP.016Effective Date: 01/01/2013
Robotic Surgeries (PDF)CC.PP.050Effective Date: 08/01/2017
Same Day Visits (PDF)CC.PP.040Effective Date: 01/01/2014
Skilled Nursing Facility Leveling (PDF)CC.PP.206Effective Date 07/01/2024
Status B Bundled Services (PDF)CC.PP.046Effective Date: 01/01/2014
Status B Bundled Services (PDF)CC.PP.046Effective Date: 01/01/2014
Status P Bundled Services (PDF)CC.PP.049Effective Date: 01/01/2014
Supplies Same Day as Surgery (PDF)CC.PP.032Effective Date: 01/01/2013
Transgender Related Services (PDF)CC.PP.047Effective Date: 01/01/2017
Unbundled Professional Services (PDF)CC.PP.043Effective Date: 03/15/2017
Unbundled Surgical Procedures (PDF)CC.PP.045Effective Date: 03/15/2017
Unlisted Procedure Codes Policy (PDF)CC.PP.009Effective Date: 01/01/2013
Urine Specimen Validity Testing (PDF)CC.PP.056Effective Date: 10/01/2017
Visual Field Testing (PDF)OC.UM.CP.0063Effective Date: 01/01/2017
Wheelchairs and Accessories (PDF)CC.PP.502Effective Date: 10/01/2015
Ultrasound in Pregnancy (PDF)CP.MP.38Effective Date: 01/31/2011