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 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)
- Air Ambulance (CP.MP.175) (PDF)
- Allergy Testing and Therapy (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (CP.MP.108) (PDF)
- Ambulatory Surgery Center Optimization (CP.MP.158) (PDF)
- Applied Behavioral 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)
- 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)
- Cosmetic and Reconstructive Surgery (CP.MP.31) (PDF)
- CPG Grid (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Disc Decompression Procedure (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Durable Medical Equipment (DME) (CP.MP.107) (PDF)
- Electric Tumor Treating Fields (CP.MP.145) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171) (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)
- Gender Reassignment Surgery (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Genetic Testing Aortopathies and Connective Tissue Disorders (CP.MP.215) (PDF)
- Genetic Testing Cardiac Disorders (CP.MP.216) (PDF)
- Genetic Testing Dermatologic Conditions (CP.MP.217) (PDF)
- Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Disorders (CP.MP.218) (PDF)
- Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (CP.MP.219) (PDF)
- Genetic Testing Eye Disorders (CP.MP.220) (PDF)
- Genetic Testing Gastroenterologic Disorders (non-cancerous) (CP.MP.221) (PDF)
- Genetic Testing General Approach to Genetic Testing (CP.MP.222) (PDF)
- Genetic Testing Hearing Loss (CP.MP.223) (PDF)
- Genetic Testing Hematologic Condition (non-cancerous) (CP.MP.224) (PDF)
- Genetic Testing Hereditary Cancer Susceptibility (CP.MP.225) (PDF)
- Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders (CP.MP.226) (PDF)
- Genetic Testing Kidney Disorders (CP.MP.227) (PDF)
- Genetic Testing Lung Disorders (CP.MP.228) (PDF)
- Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (CP.MP.229) (PDF)
- Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (CP.MP.230) (PDF)
- Genetic Testing Pharmacogenetics (CP.MP.232) (PDF)
- Genetic Testing Preimplantation Genetic Testing (CP.MP.233) (PDF)
- Genetic Testing Prenatal and Preconception Carrier Screening (CP.MP.234) (PDF)
- Genetic Testing Prenatal Diagnosis (CP.MP.235) (PDF)
- Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (CP.MP.236) (PDF)
- Home Births (CP.MP.136) 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)
- Inhaled Nitric Oxide (CP.MP.87) (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)
- Long Term Care Placement Criteria (CP.MP.71) (PDF)
- Lung Transplntation (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 Electrical Stimulation (NMES) (CP.MP.48) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Non-Myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Health Care Programs (CP.MP.91) (PDF)
- Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (CP.MP.239) (PDF)
- Optic Nerve Decompression Surgery (CP.MP.128) (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 (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)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Radial Head Implant (CP.MP.148) (PDF)
- Radiofrequency Ablation of Uterine Fibroids (CP.MP.187) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
- Sacroiliac Joint Fusion (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy for Vericose Veins (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)
- Skilled Nursing Facility Leveling (CP.MP.206) (PDF)
- Skin Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Tandem Transplant (CP.MP.162) (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.MP142) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
- 340 B (PDF)
- 72 Hour Emergency Supply of Medication (PDF)
- Care Management Referral Process (PDF)
- Continous Glucose Monitors CP.PMN.214 (PDF)
- Drug Recall Notification Process (PDF)
- Drug Utilization Review (PDF)
- Lost, Stolen, Spilled or Broken Medication (PDF)
- No Coverage Criteria (PDF)
- Non-FDA Approved Use (PDF)
- Pharmacy Lock-In Program (PDF)
- Pharmacy Program (PDF)
- Abiraterone (Zytiga, Yonsa) (PDF)
- Adalimumab (Humira) (PDF)
- Allogenic Processed Thymus Tissue-Agdc (Rethymic) (PDF)
- Amivantamab-vmjw (Rybrevant) (PDF)
- Anakinra (Kineret) (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)
- Apomorphine (Apokyn, Kynmobi) (PDF)
- Apremilast (Otezla) (PDF)
- Asfotase Alfa (Strensiq) (PDF)
- Betibeglogene autotemcel (Zynteglo) (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) (PDF)
- Bimatoprost Implant (Durysta) (PDF)
- Bortezomib (Velcade) (PDF)
- Brexucabtagene Autoleucel (Tecartus) (PDF)
- Brolucizumab (Beovu) (PDF)
- Buprenorphine Implant (Probuphine) (PDF)
- Casimersen (Amondys 45) (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda) (PDF)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF)
- Canakinumab (Ilaris) (PDF)
- Certolizumab (Cimzia) (PDF)
- Ciltacabtagene Autoleucel (Carvykti) (PDF)
- Corticotropin (H.P. Acthar Gel) (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF)
- Dalfampridine (Ampyra) (PDF)
- Darbepoetin alfa (Aranesp) (PDF)
- Dimethyl fumarate (Tecfidera) (PDF)
- Edaravone (Radicava) (PDF)
- Efgartigimod (Vyvgart) (PDF)
- Elivaldogene autotemcel (Skysona) (PDF)
- Elosulfase Alfa (Vimizim) (PDF)
- Eptinezumab (Vyepti) (PDF)
- Etanercept (Enbrel) (PDF)
- Faricimab (Vabysmo) (PDF)
- Ferric Derisomaltose (Monoferric) (PDF)
- Fibrinogen Concentrate (Human) (Fibryga, RiaSTAP) (PDF)
- Filgrastim (Neupogen), filgrastim-sndz (Zarxio), tbo-filgrastim (Granix) (PDF)
- Fingolimod (Gilenya) (PDF)
- Glatiramer (Copaxone, Glatopa) (PDF)
- Golimumab (Simponi, Simponi Aria) (PDF)
- Idecabtagene vicleucel (Abecma) (PDF)
- Immune Globulin Injections (PDF)
- Infliximab (Remicade, Inflectra, Renflexis) (PDF)
Insulin Delivery Systems (V-Go, Omnipod, InPen) CP.PHAR.534 (PDF)
- Interferon beta-1b (Betaseron, Extavia) (PDF)
- Isatuximab-irfc (Sarclisa) (PDF)
- Ixekizumab (Taltz) (PDF)
- Lecanemab-irmb (Leqembi) CP.PHAR.596 (PDF)
- Lisocabtagene maraleucel (Breyanzi) (PDF)
- Loncastuximab Tesirine-Lpyl (Zynlonta) (PDF)
- Lurbinectedin (Zepzelca) (PDF)
- Margetuximab-cmkb (Margenza) (PDF)
- Melphalan Flufenamide (Pepaxto) (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)
- Mitoxantrone (Novantrone) (PDF)
- Naxitamab-Gqgk (Danyelza) (PDF)
- Omalizumab (Xolair) (PDF)
- Paciltaxel Protein Bound (PDF)
- Pegfilgrastim (Neulasta) (PDF)
- Plasminogen (Ryplazim) (PDF)
- Ranibizumab (Lucentis) (PDF)
- Secukinumab (Cosentyx) (PDF)
- Sirolimus Protein-Bound Particles (Fyarro) (PDF)
- Spesolimab-sbzo (Spevigo) CP.PHAR.606 (PDF)
- Sutimlimab (Enjaymo) (PDF)
- Tafasitamab-cxix (Monjuvi) (PDF)
- Talimogene Laherparepvec (Imlygic) (PDF)
- Tebentafusp-tebn (Kimmtrak) (PDF)
- Teriflunomide (Aubagio) (PDF)
- Tocilizumab (Actemra) (PDF)
- Tofacitinib (Xeljanz, Xeljanz XR) (PDF)
- Tralokinumab-ldrm (Adbry) (PDF)
- Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)
- Vedolizumab (Entyvio) (PDF)
- Acupuncture (CP.MP.92) (PDF)
- Air Ambulance (CP.MP.175) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (CP.MP.108) (PDF)
- Ambulatory Surgery Center Optimization (CP.MP.158) (PDF)
- Applied Behavioral 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)
- 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)
- Cosmetic and Reconstructive Surgery (CP.MP.31) (PDF)
- CPG Grid (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Durable Medical Equipment (DME) (CP.MP.107) (PDF)
- Electric Tumor Treating Fields (CP.MP.145) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171) (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)
- Genetic Testing Aortopathies and Connective Tissue Disorders (CP.MP.215) (PDF)
- Genetic Testing Cardiac Disorders (CP.MP.216) (PDF)
- Genetic Testing Dermatologic Conditions (CP.MP.217) (PDF)
- Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Disorders (CP.MP.218) (PDF)
- Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (CP.MP.219) (PDF)
- Genetic Testing Eye Disorders (CP.MP.220) (PDF)
- Genetic Testing Gastroenterologic Disorders (non-cancerous) (CP.MP.221) (PDF)
- Genetic Testing General Approach to Genetic Testing (CP.MP.222) (PDF)
- Genetic Testing Hearing Loss (CP.MP.223) (PDF)
- Genetic Testing Hematologic Condition (non-cancerous) (CP.MP.224) (PDF)
- Genetic Testing Hereditary Cancer Susceptibility (CP.MP.225) (PDF)
- Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders (CP.MP.226) (PDF)
- Genetic Testing Kidney Disorders (CP.MP.227) (PDF)
- Genetic Testing Lung Disorders (CP.MP.228) (PDF)
- Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (CP.MP.229) (PDF)
- Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (CP.MP.230) (PDF)
- Genetic Testing Pharmacogenetics (CP.MP.232) (PDF)
- Genetic Testing Preimplantation Genetic Testing (CP.MP.233) (PDF)
- Genetic Testing Prenatal and Preconception Carrier Screening (CP.MP.234) (PDF)
- Genetic Testing Prenatal Diagnosis (Via Amniocentises, CVS, or PUBS) and Pregnancy Loss (CP.MP.235) (PDF)
- Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (CP.MP.236) (PDF)
- Home Births (CP.MP.136) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) (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 Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (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)
- Long Term Care Placement Criteria (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 Electrical Stimulation (NMES) (CP.MP.48) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Non-Myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (CP.MP.239) (PDF)
- Optic Nerve Decompression Surgery (CP.MP.128) (PDF)
- Osteogenic Stimulation (CP.MP.194) (PDF)
- Outpatient Oxygen Use (CP.MP.190) (PDF)
- Pancreas Transplant (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)
- 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)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Radial Head Implant (CP.MP.148) (PDF)
- Radiofrequency Ablation of Uterine Fibroids (CP.MP.187) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (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)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Skilled Nursing Facility Leveling (CP.MP.206) (PDF)
- Skin Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Tandem Transplant (CP.MP.162) (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)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
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)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Cardiac Biomarker Testing (CP.MP.156) (PDF)
- Cerumen Removal (PDF)
- Clean Claims (PDF)
- Clean Claim Reviews (PDF)
- Coding Overview (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)
- GI Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- Global Maternity Billing (PDF)
- H. Pylori Serology Testing (CP.MP.153) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospital Visit Codes Billed with Labs (PDF)
- Inpatient Consultation (PDF)
- Inpatient Only Procedures (PDF)
- IV Hydration (PDF)
- Laser Therapy for Skin Conditions (CP.MP.123) (PDF)
- Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (CP.MP.139) (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)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (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)
- Sleep Studies Place of Services (PDF)
- Status "B" Bundled Services (PDF)
- Status P Bundled Services (PDF)
- Supplies Billed on Same Day As Surgery (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (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)
- Urodynamic Testing (CP.MP.98) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
- 25-hydroxyvitamin D Testing in Children and Adolescents (CP.MP.157) (PDF)
- 30-Day Readmission (PDF)
- 340B Drug Payment Reduction (PDF)
- ADHD Assessment and Treatment (CP.MP.124) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Cardiac Biomarker Testing (CP.MP.156) (PDF)
- Digital Electroencephalography Spike Analysis (CP.MP.105) (PDF)
- Drugs of Abuse: Definitive Testing (CP.MP.50) (PDF)
- Electroencephalography in the Evaluation of Headache (CP.MP.155) (PDF)
- E&M Services Billed with Treatment Room Revenue Codes (CC.PP.071) (PDF)
- Endometrial Ablation (CP.MP.106) (PDF)
- Evoked Potential Testing (CP.MP.134) (PDF)
- GI Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- H. Pylori Serology Testing (CP.MP.153) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Laser Therapy for Skin Conditions (CP.MP.123) (PDF)
- Leveling of Care: Evaluation and Management Overcoding (PDF)
- Leveling of ER (PDF)
- Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (CP.MP.139) (PDF)
- Measurement of Serum 1,25-dihydroxyvitamin D (CP.MP.152) (PDF)
- Non-Emergent ER Services (PDF)
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
- Optum Comprehensive Payment Integrity (CPI) (CC.PP.074) (PDF)
- Physician's Consultation Services (PDF)
- Place of Service Mismatch (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (PDF)
- Problem Oriented Visits and Prentative Visits (PDF)
- Problem Oriented Visits with Surgical Procedures (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (CP.MP.154) (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (PDF)
- Urine Specimen Validity Testing (PDF)
- Urodynamic Testing (CP.MP.98) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)