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
- 25-Hydroxyvitamin D Testing in Children and Adolescents (CP.MP.157) (PDF)
- Acupuncture (CP.MP.92) (PDF)
- Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.MP.124) (PDF)
- Air Ambulance (CP.MP.175) (PDF)
- Allergy Testing and Therapy (CP.MP.100) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (CP.MP.108) (PDF)
- Ambulatory Electroencephalography (CP.MP.96) (PDF)
- Ambulatory Surgery Center Optimization (CP.MP.158) (PDF)
- Applied Behavioral Analysis (CP.BH.104) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Assertive Community Treatment (ACT) (OH.CP.BH.501) (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)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Cardiac Biomarker Testing (CP.MP.156) (PDF)
- Cardiac Rehabilitation (CP.MP.176) (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)
- Dental Anesthesia (CP.MP.61) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (OH.CP.MP.203) (PDF)
- Digital Electroencephalography Spike Analysis (CP.MP.105) (PDF)
- Disc Decompression Procedures (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Drugs of Abuse: Definitive Testing (CP.MP.50) (PDF)
- Durable Medical Equipment and Orthotics and Prosthetics Guidelines (DME) (OH.CP.MP.107) (PDF)
- Electric Tumor Treating Fields (CP.MP.145) (PDF)
- Electroencephalography in the Evaluation of Headache (CP.MP.155) (PDF)
- Endometrial Ablation (CP.MP.106) (PDF)
- Evoked Potential Testing (CP.MP.134) (PDF)
- Experimental Technologies (CP.MP.36 ) (PDF)
- Facet Joint Interventions for Pain Management (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 (OH.CP.MP.129) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- Helicobacter Pylori Serology Testing (CP.MP.153) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Home Births (CP.MP.136) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (OH.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)
- Laser Therapy for Skin Conditions (OH.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)
- Measurement of Serum 1,25-Dihydroxyvitamin D (CP.MP.152) (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 (OH.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)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Osteogenic Stimulation (OH.CP.MP.194) (PDF)
- Pancreas Transplantation (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (CP.MP.147) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (OH.CP.MP.150) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Pulmonary Function Testing (CP.MP.242) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Repair of Nasal Valve Compromise (OH.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 Nerve Root Blocks and Transforaminal Epidural Steroid Injections (CP.MP.165) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Substance Use Disorders Treatment and Services (OH.CP.BH.100) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (CP.MP.154) (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)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (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)
- Video Electroencephalograhic (VEEG) Monitoring (CP.MP.177) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
- Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Cardiac Disorders (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Dermatologic Conditions (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Eye Disorders (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Hearing Loss (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Hematologic Conditions (non-cancerous) (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Hereditary Cancer Susceptibility (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (V2.2023)(PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Kidney Disorders (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Lung Disorders (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (V2.2023)(PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS) (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Pharmacogenetics (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Preimplantation Genetic Testing (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Prenatal and Preconception Carrier Screening (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetics Oncology: Algorithmic Testing (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetics Oncology: Cancer Screening (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetics Oncology: Cytogenetic Testing (V2.2023) (PDF) - Effective Date: 8/15/2023
- Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (V2.2023) (PDF) - Effective Date: 8/15/2023
For Medicaid Pharmacy Prior Authorization policies and forms, please go to Gainwell’s 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 Name | Policy Number | Review Date |
---|---|---|
Biologic and Non-biologic DMARDs (PDF) | HIM.PA.SP60 | Aug-23 |
Brand Name Override and Non-Formulary Medications (PDF) | HIM.PA.103 | Aug-23 |
Ferric Carboxymaltose (Injectafer) (PDF) | CP.PHAR.234 | Aug-23 |
Human Growth Hormone (Somapacitan, Somatrogon, Somatropin) (PDF) | HIM.PA.161 | Aug-23 |
Immune Globulins (PDF) | CP.PHAR.103 | Aug-23 |
Letermovir (Prevymis) (PDF) | CP.PHAR.367 | Aug-23 |
No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update (PDF) | HIM.PA.33 | Aug-23 |
Odevixibat (Bylvay) (PDF) | CP.PHAR.528 | Aug-23 |
Olaparib (Lynparza) (PDF) | CP.PHAR.360 | Aug-23 |
Talazoparib (Talzenna) (PDF) | CP.PHAR.409 | Aug-23 |