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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.
| A-K | L-Z |
|---|---|
72 Hour Supply of Medication (PDF) Effective Date: 06/01/2006 |
Effective Date: 04/01/2007 |
Appropriate Use and Safety Edits (PDF) Appropriate Use and Safety Edits: Attachment A (PDF) Effective Date: 05/01/2012 |
Effective Date: 07/01/2017 |
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF) Effective Date: 11/01/2001 |
Effective Date: 02/01/2003 |
Dose Escalation of Biologics (PDF) Effective Date: 09/01/2017 |
Effective Date: 08/19/2011 |
Drug Recall Notification Process (PDF) Effective Date: 07/01/2008 |
Effective Date: 07/09/2010 |
|
Effective Date: 04/01/2007 | Progesterone (Crinone, Endometrin) (PDF) Effective Date: 11/16/2016 |
Filgrastim (Neupogen, Zarxio) (PDF) Effective Date: 11/16/2016 |
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 |
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 |
Effective Date: 08/01/2017 |
Bendamustine (Bendeka®, Treanda®) (PDF) Effective Date: 02/01/2017 |
Effective Date: 03/01/2016 |
|
Effective Date: 10/01/2011 |
Effective Date: 03/01/2016 |
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) Effective Date: 03/01/2016 |
Effective Date: 07/01/2016 |
|
Effective Date: 08/01/2012 | OnabotulinumtoxinA (Botox) (PDF) Effective Date: 07/01/2016 |
|
Effective Date: 02/01/2017 |
Effective Date: 10/01/2011 |
Ibandronate sodium (Boniva®) (PDF) Effective Date: 11/15/2017 |
Effective Date: 05/01/2016 |
|
Effective Date: 10/01/2012 |
Effective Date: 03/01/2014 |
Cerliponase alfa (Brineura) (PDF) Effective Date: 07/01/2017 |
Effective Date: 11/16/2016 |
Carglumic acid (Carbaglu®) (PDF) Effective Date: 05/01/2016 | Taliglucerase Alfa (Elelyso) (PDF) Effective Date: 02/01/2016 |
|
Effective Date: 02/01/2016 |
Effective Date: 02/01/2017 |
|
Effective Date: 08/01/2016 |
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 |
Effective Date: 05/01/2013 |
|
Effective Date: 07/01/2017 |
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 |
|
Effective Date: 11/01/2015 | Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) Effective Date: 03/01/2016 |
|
Effective Date: 05/01/2017 |
Effective Date: 06/01/2011 |
AbobotulinumtoxinA (Dysport) (PDF) Effective Date: 07/01/2016 | RimabotulinumtoxinB (Myobloc) (PDF) Effective Date: 07/01/2016 |
|
Effective Date: 08/01/2016 | Pegfilgrastim (Neulasta) (PDF) Effective Date: 12/01/2016 |
Epoetin Alfa (Epogen® and Procrit) (PDF) Effective Date: 06/01/2016 |
Effective Date: 07/01/2011 |
|
Effective Date: 02/01/2017 |
Effective Date: 04/01/2016 |
|
Effective Date: 12/01/2016 |
Effective Date: 11/01/2016 |
Deferasirox (Exjade Jadenu) (PDF) Effective Date: 11/1/2015 |
Effective Date: 07/01/2015 |
|
Effective Date: 03/01/2016 | Lumacaftor-ivacaftor (Orkambi) (PDF) Effective Date: 05/01/2016 |
Agalsidase Beta (Fabrazyme) (PDF) Effective Date: 02/01/2016 |
Effective Date: 06/01/2016 |
|
Effective Date: 11/01/2015 | Peginterferon beta-1a (Plegridy) (PDF) Effective Date: 08/01/2016 |
Degarelix acetate (Firmagon®) (PDF) Effective Date: 11/09/2017 |
Effective Date: 07/01/2013 |
|
Effective Date: 05/01/2016 | Necitumumab (Portrazza®) (PDF) Effective Date: 03/01/2017 |
|
Effective Date: 06/01/2010 |
Effective Date: 10/01/2015 |
|
Effective Date: 08/01/2016 |
Effective Date: 06/01/2013 |
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) Effective Date: 03/01/2012 |
Effective Date: 10/01/2015 |
|
Effective Date: 06/01/2011 | |
Eribulin Mesylate (Halaven®) (PDF) Effective Date: 03/01/2017 | |
|
Effective Date: 08/01/2016 | |
Hydroxyprogesterone Caproate (Makena®) (PDF) Effective Date: 11/20/2017 | |
|
Effective Date: 02/01/2016 | |
|
Effective Date: 02/01/2017 | |
|
Effective Date: 11/09/2017 | |
|
Effective Date: 08/01/2016 | |
irinotecan Liposome (Onivyde®) (PDF) Effective Date: 02/01/2017 | |
|
Effective Date: 08/01/2016 | |
Buprenorphine implant (Probuphine) (PDF) Effective Date: 11/16/2016 | |
|
Effective Date: 10/01/2015 | |
Cysteamine oral (Cystagon, Procysbi) (PDF) Effective Date: 02/01/2016 | |
Denosumab (Prolia, Xgeva) (PDF) Effective Date: 03/01/2011 | |
|
Effective Date: 03/01/2016 | |
|
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 TITLE | POLICY NUMBER | EFFECTIVE DATE |
|---|---|---|
| 3 Day Payment Window (PDF) | CC.PP.500 | Effective Date: 07/01/2014 |
| 30 Day Readmission (PDF) | CC.PP.501 | Effective Date: 01/01/2015 |
| Add On Policy (PDF) | CC.PP.030 | Effective Date: 01/01/2013 |
| Assistant Surgeon (PDF) | CC.PP.029 | Effective Date: 01/01/2014 |
| Bilateral Procedures (PDF) | CC.PP.037 | Effective Date: 01/01/2014 |
| Cerumen Removal Policy (PDF) | CC.PP.008 | Effective Date: 01/01/2014 |
| Clean Claims Policy (PDF) | CC.PP.021 | Effective Date: 01/01/2013 |
| Clinical Validation of Modifier 25 (PDF) | CC.PP.013 | Effective Date: 01/01/201 |
| Clinical Validation of Modifier 59 (PDF) | CC.PP.014 | Effective Date: 01/01/2013 |
| Code Editing Overview (PDF) | CC.PP.011 | Effective Date: 01/01/2013 |
| Concert Laboratory Payment Policy (PDF) | CG.CC.PP.01 | Effective Date: 06/01/2024 |
| Cosmetic Procedures (PDF) | CC.PP.024 | Effective Date: 01/01/2014 |
| Distinct Procedure Modifiers Policy (PDF) | CC.PP.020 | Effective Date: 01/01/2013 |
| Duplicate Primary Code Billing (PDF) | CC.PP.044 | Effective Date: 01/01/2014 |
| EM Medical Decision Making (PDF) | CC.PP.051 | Effective Date: 06/01/2017 |
| E&M Bundling with Labs and Radiology (PDF) | CC.PP.010 | Effective Date: 01/01/2013 |
| Hospital Visit Codes Billed with Labs (PDF) | CC.PP.023 | Effective Date: 01/01/2016 |
| Infectious Disease: Dermatologic Lab Testing (PDF) | CG.CP.MP.03 | Effective Date: 06/01/2024 |
| Infectious Disease: Gastroenterologic Lab Testing (PDF) | CG.CP.MP.04 | Effective Date: 06/01/2024 |
| Infectious Disease: Genitourinary Lab Testing (PDF) | CG.CP.MP.07 | Effective Date: 06/01/2024 |
| Infectious Disease: Multisystem Lab Testing (PDF) | CG.CP.MP.02 | Effective Date: 06/01/2024 |
| Infectious Disease: Primary Care & Preventive Lab Screening (PDF) | CG.CP.MP.05 | Effective Date: 06/01/2024 |
| Infectious Disease: Respiratory Lab Testing (PDF) | CG.CP.MP.01 | Effective Date: 06/01/2024 |
| Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (PDF) | CG.CP.MP.06 | Effective Date: 06/01/2024 |
| Inpatient Only Procedures Policy (PDF) | CC.PP.018 | Effective Date: 01/01/2018 |
| IV Hydration Policy (PDF) | CC.PP.012 | Effective Date: 01/01/2013 |
| Inpatient Consultation (PDF) | CC.PP.038 | Effective Date: 01/01/2014 |
| Moderate Conscious Sedation (PDF) | CC.PP.015 | Effective Date: 01/01/2013 |
| Max Units Payment Policy (PDF) | CC.PP.007 | Effective Date: 01/01/2013 |
| Max Units Payment Policy (PDF) | CC.PP.007 | Effective Date: 01/01/2013 |
| Modifier DOS Validation (PDF) | CC.PP.034 | Effective Date: 01/01/2015 |
| Multiple CPT Code Replace (PDF) | CC.PP.033 | Effective Date: 01/01/2013 |
| Modifier to Procedure Code Validation (PDF) | CC.PP.028 | Effective Date: 01/01/2013 |
| NCCI Unbundling (PDF) | CC.PP.031 | Effective Date: 01/01/2013 |
| New Patient (PDF) | CC.PP.036 | Effective Date: 01/01/2014 |
| Never Paid Events (PDF) | CC.PP.017 | Effective Date: 01/01/2013 |
| Outpatient Consultation (PDF) | CC.PP.039 | Effective Date: 01/01/2014 |
| Physician Visit Codes Billed with Labs (PDF) | CC.PP.055 | Effective Date: 01/01/2013 |
| Physicians Consultation Services (PDF) | CC.PP.054 | Effective Date: 10/01/2017 |
| Postoperative Visits (PDF) | CC.PP.042 | Effective Date: 01/01/2014 |
| Preoperative Visits (PDF) | CC.PP.041 | Effective Date: 01/01/2014 |
| Problem Oriented Visits with Preventative Services (PDF) | CC.PP.057 | Effective Date: 10/01/2017 |
| Problem Oriented Visits with Surgical Procedures (PDF) | CC.PP.052 | Effective Date: 10/01/2017 |
| Professional Component Modifier (PDF) | CC.PP.027 | Effective Date: 01/01/2013 |
| Pulse Oximetry w Office Visits (PDF) | CC.PP.025 | Effective Date: 01/01/2013 |
| Place of Service Mismatch (PDF) | CC.PP.063 | Effective Date: 09/01/2018 |
| Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF) | CC.PP.061 | Effective Date: 06/01/2018 |
| Not Medically Necessary Inpatient Service (PDF) | CC.PP.060 | Effective Date: 06/01/2018 |
| Reporting the Global Maternity Package (PDF) | CC.PP.016 | Effective Date: 01/01/2013 |
| Robotic Surgeries (PDF) | CC.PP.050 | Effective Date: 08/01/2017 |
| Same Day Visits (PDF) | CC.PP.040 | Effective Date: 01/01/2014 |
| Skilled Nursing Facility Leveling (PDF) | CC.PP.206 | Effective Date 11/01/2024 |
| Status B Bundled Services (PDF) | CC.PP.046 | Effective Date: 01/01/2014 |
| Status B Bundled Services (PDF) | CC.PP.046 | Effective Date: 01/01/2014 |
| Status P Bundled Services (PDF) | CC.PP.049 | Effective Date: 01/01/2014 |
| Supplies Same Day as Surgery (PDF) | CC.PP.032 | Effective Date: 01/01/2013 |
| Transgender Related Services (PDF) | CC.PP.047 | Effective Date: 01/01/2017 |
| Unbundled Professional Services (PDF) | CC.PP.043 | Effective Date: 03/15/2017 |
| Unbundled Surgical Procedures (PDF) | CC.PP.045 | Effective Date: 03/15/2017 |
| Unlisted Procedure Codes Policy (PDF) | CC.PP.009 | Effective Date: 01/01/2013 |
| Urine Specimen Validity Testing (PDF) | CC.PP.056 | Effective Date: 10/01/2017 |
| Visual Field Testing (PDF) | OC.UM.CP.0063 | Effective Date: 01/01/2017 |
| Wheelchairs and Accessories (PDF) | CC.PP.502 | Effective Date: 10/01/2015 |
| Ultrasound in Pregnancy (PDF) | CP.MP.38 | Effective Date: 01/31/2011 |