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.
CP.MP.12 Vagus Nerve Stimulation (PDF)
CP.MP.14 Cochlear Implant Replacements (PDF)
CP.MP.22 Stereotactic Body Radiation Therapy (PDF)
CP.MP.24 Multiple Sleep Latency Testing (PDF)
CP.MP.26 Articular Cartilage Defect Repairs (PDF)
CP.MP.27 Hyperbaric Oxygen Therapy (PDF)
CP.MP.31 Cosmetic and Reconstructive Surgery (PDF)
CP.MP.34 Hyperemesis Gravidarum Treatment (PDF)
CP.MP.36 Experimental Technologies (PDF)
CP.MP.38 Ultrasound in Pregnancy (PDF)
CP.MP.40 Gastric electrical stimulation (PDF)
CP.MP.43 Functional MRI (PDF)
CP.MP.50 Outpatient testing for drugs of abuse (PDF)
CP.MP.51 Reduction mammoplasty and gynecomastia surgery (PDF)
CP.MP.53 Ferriscan R2 MRI (PDF)
CP.MP.54 Hospice Services (PDF)
CP.MP.56 Ventriculectomy and Cardiomyoplasty (PDF)
CP.MP.57 Lung Transplntation (PDF)
CP.MP.58 Intestinal and multivisceral transplant (PDF)
CP.MP.61 Dental Anesthesia (PDF)
CP.MP.62 HyperhidrosisTreatments (PDF)
CP.MP.68 Medical necessity criteria (PDF)
CP.MP.69 Intensity-Modulated Radiotherapy (PDF)
CP.MP.70 Proton and Neutron Beam Therapy (PDF)
CP.MP.81 NICU discharge guidelines (PDF)
CP.MP.82 NICU Apnea Bradycardia Guidelines (PDF)
CP.MP.83 Carrier Screening in Pregnancy (PDF)
CP.MP.84 Cell-free Fetal DNA Testing (PDF)
CP.MP.85 Neonatal sepsis management (PDF)
CP.MP.86 Neonatal abstinence syndrome guidelines (PDF)
CP.MP.87 Inhaled nitric oxide (PDF)
CP.MP.88 Sickle cell disease observation (PDF)
CP.MP.89 Genetic Testing (PDF)
CP.MP.93 Bone-Anchored Hearing Aid (PDF)
CP.MP.94 Clinical Trials (PDF)
CP.MP.95 Gender Reassignment Surgery (PDF)
CP.MP.96 Ambulatory EEG(PDF)
CP.MP.97 Diagnosis of Vaginitis (PDF)
CP.MP.98 Urodynamic testing (PDF)
CP.MP.99 Wheelchair seating (PDF)
CP.MP.100 Allergy Testing and Therapy (PDF)
CP.MP.101 Donor Lymphocyte Infusion (PDF)
CP.MP.102 Pancreas Transplantation (PDF)
CP.MP.103 Fractional Exhaled Nitric Oxide (PDF)
CP.MP.104 Applied Behavioral Analysis for Autism (PDF)
CP.MP.105 Digital electroencephalography spike analysis (PDF)
CP.MP.106 Endometrial ablation (PDF)
CP.MP.107 Durable Medical Equipment (DME) (PDF)
CP.MP.108 Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF)
CP.MP.109 Panniculectomy (PDF)
CP.MP.110 Bronchial Thermoplasty (PDF)
CP.MP.111 Zika Virus Testing (PDF)
CP.MP.113 Holter Monitors (PDF)
CP.MP.114 Disc Decompression Procedure (PDF)
CP.MP.115 Discography (PDF)
CP.MP.116 Lysis Of Epidural Lesions (PDF)
CP.MP.117 Spinal Cord Stimulation (PDF)
CP.MP.119 Balloon Sinus Ostial Dilation (PDF)
CP.MP.121 Homocysteine testing (PDF)
CP.MP.123 Laser therapy for skin conditions (PDF)
CP.MP.124 ADHD Assessment and Treatment (PDF)
CP.MP.125 DNA analysis of stool to screen for colorectal cancer (PDF)
CP.MP.126 Sacroiliac joint fusion (PDF)
CP.MP.127 Total Artificial Heart (PDF)
CP.MP.128 Optic nerve decompression surgery (PDF)
CP.MP.129 Fetal surgery in utero for prenatally diagnosed malformations (PDF)
CP.MP.130 Fertility preservation (PDF)
CP.MP.131 Essure Removal (PDF)
CP.MP.132 Heart-Lung Transplant (PDF)
CP.MP.133 Posterior tibial nerve stimulation for voiding dysfunction (PDF)
CP.MP.134 Evoked Potential Testing (PDF)
CP.MP.135 Fecal Calprotectin Assay (PDF)
CP.MP.137 Fecal Incontinence Treatments (PDF)
CP.MP.138 Pediatric Heart Transplant (PDF)
CP.MP.139 Low-frequency ultrasound therapy for wound management (PDF)
CP.MP.140 EpiFix Wound Treatment (PDF)
CP.MP.141 Non-myeloablative allogeneic stem cell transplants (PDF)
CP.MP.142 Urinary Incontinence Devices and Treatments (PDF)
CP.MP.143 Wireless Motility Capsule (PDF)
CP.MP.144 Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.145 Electric Tumor Treating Fields (PDF)
CP.MP.146 Sclerotherapy for Vericose Veins (PDF)
CP.MP.147 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
CP.MP.148 Radial Head Implant (PDF)
CP.MP.149 Testing for rupture of fetal membranes (PDF)
CP.MP.150 Home phototherapy for neonatal hyperbilirubinemia (PDF)
CP.MP.151 Transcatheter closure of patent foramen ovale (PDF)
CP.MP.152 Measurement of serum 1,25-dihydroxyvitamin D (PDF)
CP.MP.153 H. Pylori serology testing (PDF)
CP.MP.154 Thyroid hormones and insulin testing in pediatrics (PDF)
CP.MP.155 Electroencephalography in the evaluation of headaches (PDF)
CP.MP.156 Cardiac Biomarker Testing (PDF)
CP.MP.157 25-hydroxyvitamin D testing in children and adolescents (PDF)
CP.MP.158 Ambulatory Surgery Center Optimization (PDF)
CP.MP.160 Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
CP.MP.161 Monitored Anesthesia Care for Gastroinestinal Endoscopy (PDF)
CP.MP.163 TPN IDPN (PDF)
CP.MP.168 Biofeedback (PDF)
MS.CP.MP.17 Elective Deliveries Before 39 Weeks Gestational Age (PDF)
MS.CP.MP.10.20 Private Duty Nursing (PDF)
MS.CP.MP.10.22 Prescribed Pediatric Extended Care (PPEC) (PDF)
CC.PHAR.01 72 Hour Emergency Supply of Medication (PDF)
CC.PHAR.04 Drug Utilization Review (PDF)
CC.PHAR.05 Lost, Stolen, Spilled or Broken Medication (PDF)
CC.PHAR.09 Pharmacy Program (PDF)
MS.PHAR.15 Pharmacy Lock-In Program (PDF)
MS.PHAR.28 340 B (PDF)
MS.PHAR.30 Drug Recall Notification Process (PDF)
MS.PHAR.17 Care Management Referral Process (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.
CC.PP.007 Maximum Units CC (PDF)
PP.008 Cerumen Removal (PDF)
CC.PP.009 Unlisted Procedure Codes (PDF)
CC.PP.010 EM Bundling Edits (PDF)
CC.PP.011 Coding Overview (PDF)
CC.PP.012 IV Hydration (PDF)
CC.PP.013 Modifier -25 clinical validation (PDF)
CC.PP.014 Modifier -59 clinical validation (PDF)
CC.PP.015 Moderate Conscious Sedation (PDF)
CC.PP.016 Global Maternity Billing (PDF)
CC.PP.017 Never Paid Events (PDF)
CC.PP.018 Inpatient Only Procedures (PDF)
CC.PP.019 Physician Visit Codes Billed with Labs (PDF)
CC.PP.020 Distinct Procedural Modifiers (PDF)
CC.PP.021 Clean Claims (PDF)
CC.PP.022 CLIA Number (PDF)
CC.PP.023 Hospital Visit Codes Billed with Labs (PDF)
CC.PP.024 Cosmetic Procedures (PDF)
CC.PP.025 Pulse Oximetry (PDF)
CC.PP.027 Professional Component (PDF)
CC.PP.028 Modifier to Procedure Code Validation (PDF)
CC.PP.029 Assistant Surgeon (PDF)
CC.PP.030 Add on Code Billed Without Primary Code (PDF)
CC.PP.031 NCCI Unbundling (PDF)
CC.PP.032 Supplies Billed on Same Day As Surgery (PDF)
CC.PP.033 Multiple CPT Code Replacement (PDF)
CC.PP.034 Modifier DOS Validation (PDF)
CC.PP.035 Sleep Studies Place of Services (PDF)
CC.PP.036 New Patient (PDF)
CC.PP.037 Bilateral Procedures (PDF)
CC.PP.038 Inpatient Consultation (PDF)
CC.PP.039 Outpatient Consultation (PDF)
CC.PP.040 Same Day Visits (PDF)
CC.PP.041 Pre-Operative Visits (PDF)
CC.PP.042 Post-Operative Visits (PDF)
CC.PP.043 Unbundled Professional Services (PDF)
CC.PP.044 Duplicate Primary Code Billing (PDF)
CC.PP.045 Unbundled Surgical Procedures (PDF)
CC.PP.046 Status "B" Bundled Services (PDF)
CC.PP.047 Transgender Related Services (PDF)
CC.PP.049 Status P Bundled Services (PDF)
CC.PP.051 E&M Medical Decision-Making (PDF)
CC.PP.056 Urine Specimen Validity Testing (PDF)
CC.PP.060 Not Medically Necessary Inpatient Services (PDF)
CC.PP.061 Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
CC.PP.063 Place of Service Mismatch (PDF)
CC.PP.500 3-Day Payment Window (PDF)
CC.PP.501 30-Day Readmission (PDF) (*Effective for Ambetter Only)
MS.FINC.09_ Encounter Submission (PDF)
MS.FINC.08 Eligibility Capitation (PDF)
MS_FINC 10 Rate Reconciliation (PDF)
MS.CLMS.11 Encounter Business Ops
Prompt Payment Rule for Claims (PDF)
Policies and Procedures - MLR Calculation (PDF)