Skip to Main Content

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

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

CLINICAL POLICIES

Clinical Policy NameClinical Policy #
AbobotulinumtoxinA (Dysport)CP.PHAR.230
Aducanumab-avwa (Aduhelm)CP.PHAR.468
Aflibercept (Eylea, Eylea HD), Aflibercept-yszy (Opuviz), Aflibercept-jbvf (Yesafili), Aflibercept-mrbb (Ahzantive), Aflibercept-abzv (Enzeevu), Aflibercept-ayyh (Pavblu) CP.PHAR.184
Agalsidase Beta (Fabrazyme)CP.PHAR.158
Alemtuzumab (Lemtrada)CP.PHAR.243
Alglucosidase Alfa (Lumizyme) CP.PHAR.160
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira)CP.PHAR.94
Anifrolumab-fnia (Saphnelo)CP.PHAR.551
Antithrombin III (ATryn, Thrombate III)CP.PHAR.564
Antithymocyte Globulin (Atgam, Thymoglobulin)CP.PHAR.506
Asciminib (Scemblix) CP.PHAR.565
Belatacept (Nulojix) CP.PHAR.201
Belimumab (Benlysta)CP.PHAR.88
Belzutifan (Welireg) CP.PHAR.553
Beremagene geperpavec-svdt (Vyjuvek)CP.PHAR.592
Bezlotoxumab (Zinplava)CP.PHAR.300
Bimatoprost Implant (Durysta)CP.PHAR.486
Brexanolone (Zulresso)CP.PHAR.417
Brolucizumab-dbll (Beovu)CP.PHAR.445
Burosumab-twza (Crysvita) CP.PHAR.11
Caplacizumab-yhdp (Cablivi)CP.PHAR.416
Casimersen (Amondys 45) CP.PHAR.470
Deferoxamine (Desferal)CP.PHAR.146
Edaravone (Radicava, Radivaca ORS) CP.PHAR.343
Efgartigimod Alfa-fcab, Efgartigimod/Hyaluronidase-qvfc (Vyvgart, Vyvgart Hytrulo)CP.PHAR.555
Elapegademase-lvlr (Revcovi)CP.PHAR.419
Epcoritamab-bysp (Epkinly)CP.PHAR.634
Eptinezumab-jjmr (Vyepti)CP.PHAR.489
Etelcalcetide (Parsabiv)CP.PHAR.379
Eteplirsen (Exondys 51)CP.PHAR.288
Evinacumab-dgnb (Evkeeza)CP.PHAR.511
Faricimab-svoa (Vabysmo)CP.PHAR.581
Fecal Microbiota Spores, Live-brpk (Vowst)CP.PHAR.632
Fecal Microbiota, Live-jslm (Rebyota) CP.PHAR.613
Ferric Pyrophosphate (Triferic, Triferic Avnu) CP.PHAR.624
Furosemide (Furoscix)CP.PHAR.608
Glofitamab-gxbm (Columvi)CP.PHAR.636
Golodirsen (Vyondys 53)CP.PHAR.453
Hyaluronate DerivativesCP.PHAR.05
Ibandronate Injection (Boniva)CP.PHAR.189
Inclisiran (Leqvio)CP.PHAR.568
IncobotulinumtoxinA (Xeomin)CP.PHAR.231
Inebilizumab-cdon (Uplizna)CP.PHAR.458
Lecanemab-irmb (Leqembi)CP.PHAR.596
Lenacapavir (Sunlenca)CP.PHAR.622
Mitapivat (Pyrukynd)CP.PHAR.558
Mitoxantrone CP.PHAR.258
Mobocertinib (Exkivity)CP.PHAR.559
Natalizumab (Tysabri), Natalizumab-sztn (Tyruko)CP.PHAR.259
Nogapendekin alfa inbakicept-pmln (Anktiva) CP.PHAR.684
Nusinersen (Spinraza)CP.PHAR.327
Olipudase Alfa-rpcp (Xenpozyme) CP.PHAR.586
OnabotulinumtoxinA (Botox) CP.PHAR.232
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) CP.PHAR.536
Pacritinib (Vonjo)CP.PHAR.583
Palivizumab (Synagis) OH.PHAR.16
Pasireotide (Signifor, Signifor LAR)CP.PHAR.332
Patisiran (Onpattro)CP.PHAR.395
Pegloticase (Krystexxa) CP.PHAR.115
Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) CP.PHAR.186
Retifanlimab-dlwr (Zynyz)CP.PHAR.629
RimabotulinumtoxinB (Myobloc)CP.PHAR.233
Ropeginterferon Alfa-2b-njft (BESREMi) CP.PHAR.570
Sodium thiosulfate (Pedmark)CP.PHAR.610
Spesolimab-sbzo (Spevigo) CP.PHAR.606
Tarlatamab-dlle (Imdelltra)CP.PHAR.685
Tebentafusp-tebn (Kimmtrak)CP.PHAR.575
Teprotumumab (Tepezza)CP.PHAR.465
Thyrotropin Alfa (Thyrogen) CP.PHAR.95
Tislelizumab-jsgr (Tevimbra)CP.PHAR.687
Tofersen (Qalsody)CP.PHAR.591
Tremelimumab-actl (Imjudo) CP.PHAR.612
Ublituximab-xiiy (Briumvi)CP.PHAR.621
Velmanase Alfa-tycv (Lamzede) CP.PHAR.601
Verteporfin (Visudyne) CP.PHAR.187
Viltolarsen (Viltepso)CP.PHAR.484
Vutrisiran (Amvuttra)CP.PHAR.550

  • For Medicaid Pharmacy Prior Authorization policies and forms, please go to Gainwell’s website.
  • For biopharmacy injectable drugs payable through Gainwell Technologies, the Single Pharmacy Benefit Manager, please visit Gainwell's website and utilize the UPDL clinical coverage criteria outlined.

For Evolent clinical policies, please visit Evolent’s website.

   

MEDICARE CLINICAL POLICIES

OH MA PartB Step Therapy (PDF)

For Medicare information, please visit our Medicare Prior Authorization website.

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

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

Policy NamePolicy NumberEffective Date
3-Day Payment Window (PDF)CC.PP.5003/1/2018
30-Day Readmission (PDF)OH.PP.5012/20/2018
Add on Code Billed Without Primary Code (PDF)CC.PP.0302/24/2018
Assistant Surgeon (PDF)CC.PP.0293/1/2018
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.1248/19/2024
Bilateral Procedures (PDF)CC.PP.0373/1/2018
Cerumen Removal (PDF)CC.PP.0082/28/2018
Clean Claims (PDF)CC.PP.0216/9/2018
Clinic Facility Change (PDF)CC.PP.0595/8/2018
Clinical Labatory Improvement Amendments (CLIA) (PDF)CC.PP.0222/27/2018
Clinical Validation of Modifer 25 (PDF)CC.PP.0132/24/2018
Clinical Validation of Modifier 59 (PDF)CC.PP.0142/24/2018
Coding Overview (PDF)CC.PP.0116/9/2018
Concert Laboratory Payment Policy (PDF)CG.CC.PP.016/1/2024
Cosmetic Procedures (PDF)CC.PP.0246/20/2018
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)CC.PP.0203/10/2018
Duplicate Primary Code Billing (PDF)CC.PP.0443/10/2018
E&M Bundling with Labs and Radiology (PDF)CC.PP.0102/24/2018
E&M Medical Decision-Making (PDF)CC.PP.0518/7/2017
Emergency Department E&M Leveling for Professional Services (PDF)OH.PP.076  
Extended Ophthalmoscopy (PDF)CP.VP.268/19/2024
Fluorescein Angiography (PDF)CP.VP.288/19/2024
Fundus Photography (PDF)CP.VP.298/19/2024
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)CP.MP.2098/19/2024
Global Maternity Package (PDF)CC.PP.0163/1/2018
Gonioscopy (PDF)CP.VP.318/19/2024
Hospital Visit Codes Billed with Labs (PDF)CC.PP.0236/20/2018
Infectious Disease: Dermatologic Lab Testing (PDF)CG.CP.MP.036/1/2024
Infectious Disease: Gastroenterologic Lab Testing (PDF)CG.CP.MP.046/1/2024
Infectious Disease: Genitourinary Lab Testing (PDF)CG.CP.MP.076/1/2024
Infectious Disease: Multisystem Lab Testing (PDF)CG.CP.MP.026/1/2024
Infectious Disease: Primary Care & Preventive Lab Screening (PDF)CG.CP.MP.056/1/2024
Infectious Disease: Respiratory Lab Testing (PDF)CG.CP.MP.016/1/2024
Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (PDF)CG.CP.MP.066/1/2024
Inpatient Consultation (PDF)CC.PP.0383/10/2018
Inpatient Only Procedures (PDF)CC.PP.0183/10/2018
Intravenous Hydration (PDF)CC.PP.0122/25/2018
Leveling of ER Services (PDF)CC.PP.0535/17/2018
Level of Care Office-Based Evaluation and Management Overcoding (PDF)OH.PP.066 
Maximum Units (PDF)CC.PP.0075/11/2018
Moderate Conscious Sedation (PDF)CC.PP.0153/5/2018
Modifier DOS Validation (PDF)CC.PP.0342/24/2018
Modifier to Procedure Code Validation (PDF)CC.PP.0282/23/2018
Multiple CPT Code Replacement (PDF)CC.PP.0332/28/2018
NCCI Unbundling (PDF)CC.PP.0319/9/2016
Never Paid Events (PDF)CC.PP.0173/5/2018
New Patient (PDF)CC.PP.0363/10/2018
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)CC.PP.0616/1/2018
Not Medically Necessary IP Serv (PDF)CC.PP.0606/1/2018
Optum Newborn Inpatient Stays (PDF)CC.PP.075 05/2024
Outpatient Consultations (PDF)CC.PP.0393/13/2018
Physician's Consultation Services (PDF)CC.PP.05411/25/2017
Physician's Office Lab Testing (PDF)CC.PP.0555/14/2021
Place of Service Mismatch (PDF)CC.PP.0639/1/2018
Post-operative Visits (PDF)CC.PP.0423/1/2018
Problem Oriented Visits Billed with Surgical Procedures (PDF)CC.PP.052 
Professional Component (PDF)CC.PP.0276/28/2018
Professional Services (Visit Codes) Billed With Labs (PDF)CC.PP.0193/10/2018
Pulse Oximetry (PDF)CC.PP.0252/13/2018
Renal Hemodialysis (PDF)CC.PP.067 
Robotic Surgery (PDF)CC.PP.0504/21/2017
Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)CP.VP.148/19/2024
Sepsis Diagnosis (PDF)CP.PP.0731/10/2025
Severe Malnutrition (PDF)CC.PP.1451/10/2025
Sleep Studies Place of Service (PDF)CC.PP.0355/1/2017
Status "B" Bundled Services (PDF)CC.PP.0463/10/2018
Status "P" Bundled Services (PDF)CC.PP.0494/27/2017
Supplies Billed on Same Day as Surgery (PDF)CC.PP.0322/28/2018
Transgender Related Services (PDF)CC.PP.0472/15/2018
Unbundled Professional Services (PDF)CC.PP.0433/1/2018
Unbundled Surgical Procedures (PDF)CC.PP.0453/1/2018
Unlisted Procedure Codes (PDF)CC.PP.0092/24/2018
Urine Specimen Validity Testing (PDF)CC.PP.0568/13/2017
Visits On Same Day As Surgery (PDF)CC.PP.0403/1/2018
Visual Field Testing (PDF)CP.VP.638/19/2024
Wheelchairs and Accessories (PDF)OH.PP.5021/13/2017