Clinical & Payment Policies
Medicaid 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 Magnolia Health Clinical Policy Manual apply to Magnolia Health members. Policies in the Magnolia Health Clinical Policy Manual may have either a Magnolia Health or a “Centene” heading. Magnolia Health utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Magnolia 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 Magnolia Health. In addition, Magnolia 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 Magnolia Health.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- 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 (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and and β-Thalassemia (CP.MP.108) (PDF)
- Ambulatory Surgery Center Optimization (CP.MP.158) (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)
- 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)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Disc Decompression Procedures (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)
- Fecal Incontinence Treatments (CP.MP.137) (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)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) (PDF)
- HyperhidrosisTreatments (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 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)
- 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)
- 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)
- Nutritional Counseling (MS.CP.MP.10.24) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Omisirge (omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (CP.MP.249) (PDF)
- Optic Nerve Decompression Surgery (CP.MP.128) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Osteogenic Stimulation (CP.MP.194) (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)
- Personal Care Services (MS.CP.MP.10.21) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Prescribed Pediatric Extended Care (PPEC) (MS.CP.MP.10.22) (PDF)
- Private Duty Nursing (PDN) (MS.CP.MP.10.20) (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Pulmonary Function Testing (CP.MP.242) (PDF)
- Radial Head Implant (CP.MP.148) (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)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections (CP.MP.165) (PDF)
- Sepsis Diagnosis (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Skin 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)
- Trigger Point Injections for Pain Management (CP.MP.169) (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)
- Abatacept (Orencia) CP.PHAR.241 (PDF)
- Adalimumab (Humira) Humira Biosimilars CP.PHAR.242 (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) CP.PHAR.229 (PDF)
- Aflibercept (Eylea, Eylea HD) CP.PHAR.184 (PDF)
- Alemtuzumab (Lemtrada) CP.PHAR.243 (PDF)
- Alglucosidase Alfa (Lumizyme) CP.PHAR.160 (PDF)
- Anakinra (Kineret) CP.PHAR.184 (PDF)
- Apomorphine (Apokyn) CP.PHAR.244 (PDF)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Abilify Asimtufii, Aristada, Aristada Initio) CP.PHAR.290 (PDF)
- Asfotase Alfa (Strensiq) CP.PHAR.328 (PDF)
- Atezolizumab (Tecentriq) CP.PHAR.235 (PDF)
- Atidarsagene autotemcel (Lenmeldy) CP.PHAR.602 (PDF)
- Avacincaptad Pegol (Izervay) CP.PHAR.641 (PDF)
- Avapritinib (Ayvakit) CP.PHAR.454 (PDF)
- Avelumab (Bavencio) CP.PHAR.333 (PDF)
- Axicabtagene Ciloleucel (Yescarta) CP.PHAR.362 (PDF)
- Aztreonam (Cayston) CP.PHAR.209 (PDF)
- Belimumab (Benlysta) CP.PHAR.088 (PDF)
- Betibeglogene autotemcel (Zynteglo) CP.PHAR.545 (PDF)
- Benralizumab (Fasenra) CP.PHAR.373 (PDF)
- Beremagene geperpavec-svdt (Vyjuvek) CP.PHAR.592 (PDF)
- Bevacizumab (Alymsys, Avastin, Avzivi, Mvasi, Vegzelma,
Zirabev) CP.PHAR.93 (PDF) - Bimekizumab-bkzx (Bimzelx) CP.PHAR.660 (PDF)
- Blinatumomab (Blincyto) CP.PHAR.312 (PDF)
- Brentuximab Vedotin (Adcetris) CP.PHAR.303 (PDF)
- Brexucabtagene Autoleucel (Tecartus) CP.PHAR.472 (PDF)
- Brodalumab (Siliq) CP.PHAR.375 (PDF)
- Burosumab-twza (Crysvita) CP.PHAR.011 (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda,
Ruconest) CP.PHAR.202 (PDF) - Cabazitaxel (Jevtana) CP.PHAR.316 (PDF)
- Casimersen (Amondys 45) CP.PHAR.470 (PDF)
- Cemiplimab-rwlc (Libtayo) CP.PHAR.397 (PDF)
- Cerliponase alfa (Brineura) CP.PHAR.338 (PDF)
- Certolizumab (Cimzia) CP.PHAR.247 (PDF)
- Ciltacabtagene Autoleucel (Carvykti) CP.PHAR.533 (PDF)
- Cipaglucosidase Alfa-atga + Miglustat (Pombiliti + Opfolda)
CP.PHAR.567 (PDF) - Collagenase Clostridium Histolyticum (Xiaflex) CP.PHAR.82 (PDF)
- Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq) CP.PHAR.385 (PDF)
- Crovalimab (PiaSky) CP.PHAR.664 (PDF)
- Cytomegalovirus Immune Globulin (CytoGam) CP.PHAR.277 (PDF)
- Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj
(Darzalex, Darzalex Faspro) CP.PHAR.310 (PDF) - Daunorubicin/Cytarabine (Vyxeos) CP.PHAR.352 (PDF)
- DaxibotulinumtoxinA-lanm (Daxxify) CP.PHAR.651 (PDF)
- Deferoxamine (Desferal) CP.PHAR.146 (PDF)
- Denosumab (Prolia, Xgeva, and biosimilars) CP.PHAR.58 (PDF)
- Donanemab-azbt (Kisunla) CP.PHAR.594 (PDF)
- Dornase Alfa (Pulmozyme) CP.PHAR.212 (PDF)
- Dupilumab (Dupixent) CP.PHAR.336 (PDF)
- Durvalumab (Imfinzi) CP.PHAR.339 (PDF)
- Ecallantide (Kalbitor) CP.PHAR.177
- Eculizumab (Soliris) CP.PHAR.97 (PDF)
- Efgartigimod Alfa-fcab, Efgartigimod/Hyaluronidase-qvfc
(Vyvgart, Vyvgart Hytrulo) CP.PHAR.555 (PDF) - Elevidys (MS.PHAR.593) (PDF)
- Elranatamab-bcmm (Elrexfio) CP.PHAR.652 (PDF)
- Enfuvirtide (Fuzeon) CP.PHAR.41 (PDF)
- Etanercept (Enbrel) CP.PHAR.250 (Pdf)
- Etelcalcetide (Parsabiv) CP.PHAR.379 (PDF)
- Eteplirsen (Exondys 51) CP.PHAR.288 (PDF)
- Etranacogene Dezaparvovec-drlb (Hemgenix) CP.PHAR.580 (PDF)
- Fam-Trastuzumab Deruxtecan-nxki (Enhertu) CP.PHAR.456 (PDF)
- Fecal Microbiota, Live-jslm (Rebyota) CP.PHAR.613 (PDF)
- Ferumoxytol (Feraheme) CP.PHAR.165 (PDF)
- Fibrinogen concentrate (human) (Fibryga, RiaSTAP) CP.PHAR.526 (PDF)
- Fidanacogene Elaparvovec-dzkt (Beqvez) CP.PHAR.643 (PDF)
- Filgrastim (Neupogen, Zarxio, Granix, Nivestym, Releuko, Nypozi) CP.PHAR.297 (PDF)
- Golimumab (Simponi, Simponi Aria) CP.PHAR.253 (PDF)
- Golodirsen (Vyondys 53) CP.PHAR.453 (PDF)
- Guselkumab (Tremfya) CP.PHAR.364 (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) CP.PHAR.172 (PDF)
- Human Growth Hormone (Somapacitan, Somatrogon, Somatropin, Lonapegsomatropin-tcgd) CP.PHAR.517 (PDF)
- Icatibant (Firazyr) CP.PHAR.178 (PDF)
- Ibalizumab-uiyk (Trogarzo) CP.PHAR.378 (PDF)
- Idecabtagene Vicleucel (Abecma) CP.PHAR.481 (PDF)
- Idursulfase (Elaprase) CP.PHAR.156 (PDF)
- Imetelstat (Rytelo) CP.PHAR.690 (PDF)
- Imiglucerase (Cerezyme) CP.PHAR.154 (PDF)
- Immune Globulin Injections CP.PHAR.103 (PDF)
- IncobotulinumtoxinA (Xeomin) CP.PHAR.231 (PDF)
- Inebilizumab-cdon (Uplizna) CP.PHAR.458 (PDF)
- Infliximab (Remicade), Infliximab-axxq (Avsola),
Infliximab-dyyb (Inflectra, Zymfentra), and Infliximab-abda (Renflexis) CP.PHAR.254
(PDF) - Inotuzumab Ozogamicin (Besponsa) CP.PHAR.359 (PDF)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) CP.PHAR.534 (PDF)
- Ipilimumab (Yervoy) CP.PHAR.319 (PDF)
- Ixekizumab (Taltz) CP.PHAR.257 (PDF)
- Lanadelumab-fylo (Takhzyro) CP.PHAR.396 (PDF)
- Lanreotide (Somatuline Depot and Unbranded) CP.PHAR.391
(PDF) - Laronidase (Aldurazyme) CP.PHAR.152 (PDF)
- Lecanemab-irmb (Leqembi) CP.PHAR.596 (PDF)
- Lisocabtagene Maraleucel (Breyanzi) CP.PHAR.483 (PDF)
- Lovotibeglogene autotemcel (Lyfgenia) CP.PHAR.627 (PDF)
- Lurbinectedin (Zepzelca) CP.PHAR.500 (PDF)
- Lutetium Lu 177 Dotatate (Lutathera) CP.PHAR.384 (PDF)
- Mecasermin (Increlex) CP.PHAR.150 (PDF)
- Mepolizumab (Nucala) CP.PHAR.200 (PDF)
- Metreleptin (Myalept) CP.PHAR.425 (PDF)
- Mirikizumab-mrkz (Omvoh) CP.PHAR.662 (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) CP.PHAR.495 (PDF)
- Mogamulizumab-kpkc (Poteligeo) CP.PHAR.139 (PDF)
- Mometasone Furoate (Sinuva) CP.PHAR.448 (PDF)
- Motixafortide (Aphexda) CP.PHAR.655 (PDF)
- Natalizumab (Tysabri), Natalizumab-sztn (Tyruko) CP.PHAR.259
(PDF) - Nivolumab (Opdivo) CP.PHAR.121 (PDF)
- Nogapendekin alfa inbakicept-pmln (Anktiva) CP.PHAR.684 (PDF)
- No Coverage Criteria MS.PMN.255 (PDF)
- Non FDA Approved MS.PMN.53 (PDF)
- Nusinersen (Spinraza) CP.PHAR.327 (PDF)
- Obinutuzumab (Gazyva) CP.PHAR.305 (PDF)
- Ocrelizumab (Ocrevus) CP.PHAR.335 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Mycapssa) CP.PHAR.40 (PDF)
- Olanzapine la inj (Zyprexa Relprev) CP.PHAR.292 (PDF)
- Omalizumab (Xolair) CP.PHAR.01 (PDF)
- OnabotulinumtoxinA (Botox) CP.PHAR.232 (PDF)
- Paliperidone inj (Invega Sustenna, Invega Trinza, Invega Hafyera, Erzofri) CP.PHAR.291 (PDF)
- Paricalcitol Injection (Zemplar) CP.PHAR.270 (PDF)
- Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas)
CP.PHAR.353 (PDF) - Pegcetacoplan (Empaveli, Syfovre) CP.PHAR.524 (PDF)
- Pegfilgrastim (Neulasta, Neulasta Onpro),
Pegfilgrastim-jmdb, Pegfilgrastim-pbbk, Pegfilgrastim-apgf, Eflapegrastim-xnst,
Efbemalenograstim alfa-vuxw, Pegfilgrastim-fpgk, Pegfilgrastim-cbqv,
Pegfilgrastim-bmez CP.PHAR.296(PDF) - Peginterferon alfa-2b (Pegasys) CP.PHAR.089 (PDF)
- Pegloticase (Krystexxa) CP.PHAR.115 (PDF)
- Pegunigalsidase Alfa-iwxj (Elfabrio) CP.PHAR.512 (PDF)
- Pembrolizumab (Keytruda) CP.PHAR.322 (PDF)
- Pemetrexed (Alimta, Pemfexy) CP.PHAR.368 (PDF)
- Pertuzumab (Perjeta) CP.PHAR.227 (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) CP.PHAR.501
(PDF) - Plerixafor (Mozobil) CP.PHAR.323 (PDF)
- Polatuzuman vedotin – piiq (Polivy) CP.PHAR.433 (PDF)
- Pralatrexate (Folotyn) CP.PHAR.313 (PDF)
- Ramucirumab (Cyramza) CP.PHAR.119 (PDF)
- Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars CP.PHAR.186 (PDF)
- Ravulizumab-cwvz (Ultomiris) CP.PHAR.415 (PDF)
- Reslizumab (Cinqair) CP.PHAR.223 (PDF)
- Retifanlimab-dlwr (Zynyz) CP.PHAR.629 (PDF)
- Risperidone la inj (Risperdal Consta) CP.PHAR.293 (PDF)
- Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr
(Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela)
CP.PHAR.260 (PDF) - Rozanolixizumab-noli (Rystiggo) CP.PHAR.648 (PDF)
- Sacituzumab Govitecan-hziy (Trodelvy) CP.PHAR.475 (PDF)
- Sargramostim (Leukine) CP.PHAR.295 (PDF)
- Sarilumab (Kevzara) CP.PHAR.346 (PDF)
- Secukinumab (Cosentyx) CP.PHAR.261 (PDF)
- Sodium thiosulfate (Pedmark) CP.PHAR.610 (PDF)
- Tafasitamab-cxix (Monjuvi) CP.PHAR.508 (PDF)
- Talimogene laherparepvec (Imlygic) CP.PHAR.542 (PDF)
- Talquetamab-tgvs (Talvey) CP.PHAR.649 (PDF)
- Tarlatamab-dlle (Imdelltra) CP.PHAR.685 (PDF)
- Temasmorelin (Egrifta) CP.PHAR.109 (PDF)
- Teplizumab-mzwv (Tzield) CP.PHAR.492 (PDF)
- Teprotumumab (Tepezza) CP.PHAR.465 (PDF)
- Thyrotropin Alfa (Thyrogen) CP.PHAR.95 (PDF)
- Tildrakizumab-asmn (Ilumya) CP.PHAR.386 (PDF)
- Tisagenlecleucel (Kymriah) CP.PHAR.361 (PDF)
- Tislelizumab-jsgr (Tevimbra) CP.PHAR.687 (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) CP.PHAR.211 (PDF)
- Tocilizumab (Actemra), Tocilizumab-bavi (Tofidence), Tocilizumab-aazg (Tyenne) CP.PHAR.263 (PDF)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase CP.PHAR.228
(PDF) - Travoprost Implant (iDose TR) CP.PHAR.672 (PDF)
- Ustekinumab (Stelara), Ustekinumab-ttwe (Pyzchiva), Ustekinumab-aekn (Selarsdi), Ustekinumab-auub (Wezlana) CP.PHAR.264 (PDF)
- Valoctocogene Roxaparvovec-rvox (Roctavian) CP.PHAR.466
(PDF) - Vedolizumab (Entyvio) CP.PHAR.265 (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) CP.PHAR.372 (PDF)
- Zolgensma (MS.PHAR.421) (PDF)
Medicaid 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 Magnolia Health Payment Policy Manual apply with respect to Magnolia Health members. Policies in the Magnolia Health Payment Policy Manual may have either a Magnolia Health or a “Centene” heading. In addition, Magnolia 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 Magnolia Health.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- 3-Day Payment Window (PDF)
- 25-hydroxyvitamin D Testing in Children and Adolescents (CP.MP.157) (PDF)
- Add on Code Billed Without Primary Code (PDF)
- Assistant Surgeon (PDF)
- Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.MP.124) (PDF)
- Bilateral Procedures (PDF)
- Cardiac Biomarker Testing (CP.MP.156) (PDF)
- Cerumen Removal (PDF)
- Clean Claims (PDF)
- Clean Claim Reviews (PDF)
- Coding Overview (PDF)
- Concert Laboratory Payment Policy (CG.CC.PP.01) (PDF)
- Cosmetic Procedures (PDF)
- Cost to Charge Adjustments on Clean Claim Reviews (PDF)
- Digital Electroencephalography Spike Analysis (CP.MP.105) (PDF)
- Distinct Procedural Modifiers (PDF)
- Drugs of Abuse: Definitive Testing (CP.MP.50) (PDF)
- Duplicate Primary Code Billing (PDF)
- Electroencephalography in the Evaluation of Headache (CP.MP.155) (PDF)
- EM Bundling Edits (PDF)
- E&M Medical Decision-Making (PDF)
- Endometrial Ablation (CP.MP.106) (PDF)
- Evoked Potential Testing (CP.MP.134) (PDF)
- Global Maternity Billing (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Hospital Visit Codes Billed with Labs (PDF)
- Infectious Disease: Dermatologic Lab Testing (CG.CP.MP.03) (PDF)
- Infectious Disease: Gastroenterologic Lab Testing (CG.CP.MP.04) (PDF)
- Infectious Disease: Genitourinary Lab Testing (CG.CP.MP.07) (PDF)
- Infectious Disease: Multisystem Lab Testing (CG.CP.MP.02) (PDF)
- Infectious Disease: Primary Care & Preventive Lab Screening (CG.CP.MP.05) (PDF)
- Infectious Disease: Respiratory Lab Testing (CG.CP.MP.01) (PDF)
- Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (CG.CP.MP.06) (PDF)
- Inpatient Consultation (PDF)
- Inpatient Only Procedures (PDF)
- IV Hydration (PDF)
- Maximum Units CC (PDF)
- Measurement of Serum 1,25-dihydroxyvitamin D (CP.MP.152) (PDF)
- Moderate Conscious Sedation (PDF)
- Modifier-25 Clinical Validation (PDF)
- Modifier-59 Clinical Validation (PDF)
- Modifier DOS Validation (PDF)
- Modifier to Procedure Code Validation (PDF)
- Multiple CPT Code Replacement (PDF)
- Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)
- Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
- Multiple Procedure Reduction: Ophthalmology (PDF)
- NCCI Unbundling (PDF)
- Never Paid Events (PDF)
- New Patient (PDF)
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
- Not Medically Necessary Inpatient Services (PDF)
- Outpatient Consultation (PDF)
- Physician Visit Codes Billed with Labs (PDF)
- Place of Service Mismatch (PDF)
- Post-Operative Visits (PDF)
- Pre-Operative Visits (PDF)
- Professional Component (PDF)
- Prompt Payment Rule for Claims (PDF)
- Pulse Oximetry (PDF)
- Renal Hemodialysis (PDF)
- Same Day Visits (PDF)
- Sepsis Diagnosis (CC.PP.073) (PDF)
- Skilled Nursing Facility Leveling (CC.PP.206) (PDF)
- Sleep Studies Place of Services (PDF)
- Status "B" Bundled Services (PDF)
- Status P Bundled Services (PDF)
- Supplies Billed on Same Day As Surgery (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (CP.MP.154) (PDF)
- Transgender Related Services (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (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)
- Wireless Motility Capsule (CP.MP.143) (PDF)