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Policies & Criteria

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

If you have any questions regarding these policies, please contact Provider Services 888-802-7001 (commercial) or 888-445-8913 (Medicare) and ask to be directed to the Medical Management department.

Pharmacy Criteria

Health Net’s goal is to offer the right drug coverage to our members. Trillium Oregon Health Plan (OHP) covers prescription and some over the counter drugs when they are ordered by a licensed prescriber registered with the state of Oregon to provide services to OHP members. The pharmacy program does not cover all drugs. Some drugs need prior approval and some have a limit on the amount of drug that can be given.

Clinical policies are one set of guidelines used to assist in administering health plan benefits. 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. 

The Pharmacy and Therapeutics (P&T) Committee is comprised of community doctors and pharmacists. Together we work to offer drugs used to treat many conditions and illnesses. All clinical policies are reviewed annually by the P&T Committee, which meets quarterly. Approved criteria and revisions made by the P&T Committee go into effect the first day of the month the start of the following quarter. All medications newly approved by the FDA (Food and Drug Administration) require prior approval until reviewed by our P&T Committee.

All policies found in the Health Net Clinical Policy Manual apply to Health Net members. Policies in the Health Net Clinical Policy Manual may have either a Health Net or a “Centene” heading. 

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

Commercial Pharmacy Criteria

April 1, 2019: The criteria listed below are currently under review. For the most up-to-date information, please visit Commercial Rx PA Guidelines.

Be sure to select "Oregon" in the upper right bar.

Amebicides

Amnoglycosides

Antifungals

Antihelmintics

Anti-Infective Agents - Misc.

Antimalarials

Antivirals

Fluoroqunolones

Passive Immunizing and Treatment Agents

Tetracyclines

Alkylating Agents

Antimetabolites

Antineoplastic – Angiogenesis Inhibitors

Antineoplastic – Antibodies

Antineoplastic – BCL-2 Inhibitors

Antineoplastic – Cellular Immunotherapy

Antineoplastic – Hedgehog Pathway Inhibitors

Antineoplastic – Hormonal and Related Agents

Antineoplastic – Immunomodulators

Antineoplastic Antibiotics

Antineoplastic Combinations

Antineoplastic Enzyme Inhibitors

Antineoplastic Enzymes

Antineoplastics Misc.

Chemotherapy Rescue/Antidote Agents

Mitotic Inhibitors

Topoisomerase I Inhibitors

 

Androgens/Anabolic

Antidiabetics

Bone Density Regulators

Contraceptives

Corticosteroids

Corticotropin

Fertility Regulators

GNRH/LHRH Antagonists

Growth Hormone Receptor Antagonists

Growth Hormone Releasing Hormones (GHRH)

Growth Hormones

  • Somatropin (Genotropin, Humatrope, Norditropin, Nutropin, Qmnitrope, Zomacton, Saizen, Serostim, Zorbtive); CP.HNOR.82 (PDF)

Hormone Receptor Modulators

Insulin-Like Growth Factors (Somatomedins)

Metabolic Modifiers

Posterior Pituitary Hormones

Progesterone Receptor Antagonists

Progestins

Somatostatic Agents

Vasopressin Receptor Antagonists

Anti-Diarrheal/Probiotic Agents

Antiemetics

Diuretics

Gastrointestinal Agents – Misc.

Genitourinary Agents – Misc.

Gout Agents

Laxatives

Vaginal Products

Anticoagulants

Hematological Agents – Misc.

Hematopoietic Agents

ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants

Anticonvulsants

Antidepressants

Anti-myasthenic/Cholinergic Agents

Antiparkinson and Related Therapy Agents

Antipsychotics/Antimanic Agents

Hypnotics/Sedatives/Sleep Disorder Agents

Migraine Products

Psychotherapeutic and Neurological Agents – Misc.

 

Medicare Pharmacy Criteria

For the most up-to-date information, please visit Medicare Part D Prior Authorization Criteria (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 Health Net Payment Policy Manual apply with respect to Health Net members. Policies in the Health Net Payment Policy Manual may have either a Health Net or a “Centene” heading.  In addition, Health Net 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 Health Net.     

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

Policy Reference Number

Policy Name

Description

CC.PP.501 (PDF)

30 Day Readmission

This policy is based, in part, on the methodology set forth in the Quality Improvement Organization Manual, CMS Publication 100-10, Chapter 4, Section 4240, for determining an inappropriate readmission.

For a readmission that is determined to have been inappropriate or preventable according to the clinical review guidelines set forth below, Health Net will deny payment or reimbursement.

CC.PP.500 (PDF)

3-day Payment Window

The purpose of this policy is to serve as one component of the guidelines used to assist in making coverage decisions and administering benefits. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), and to applicable law.

CP.MP.100 (PDF) Allergy Testing (effective 10/1/19)

Allergy testing is performed to determine immunologic sensitivity or reaction to antigens for the purpose of identifying the cause of the allergic state.  This policy addresses immediate (IgE-mediated) hypersensitivity and delayed (cell-mediated) hypersensitivity.  Allergen immunotherapy is the repeated administration of specific allergens to patients with IgE-mediated conditions, for the purpose of providing protection against the allergic symptoms and inflammatory reactions associated with exposure to these allergens.

Please note: unit limitations for allergy testing and treatment are based on state specific guidelines (defined in the provider fee schedule).  In the absence of state-specific rules, the CMS Medicaid/Medicare NCCI MUE limitations are applied.

CP.MP.140 (PDF) EpiFix Wound Treatment (effective 10/1/19) EpiFix® (MiMedx Group) is dehydrated human amniotic tissue that is used as an allograft material (or tissue graft) to treat nonhealing wounds.   It is the policy of health plans affiliated with Centene Corporation® that Epifix is medically necessary for the treatment of chronic foot ulcers when all criteria are met. It is the policy of health plans affiliated with Centene Corporation that continued treatment with EpiFix is not medically necessary when the ulcer fails to heal by ≥ 50% within the first 6 weeks of treatment.  Treatment beyond 12 weeks is considered not medically necessary regardless of wound status.

CC.PI.04 (PDF)

Equian for Clean Claims Reviews

The purpose of this policy is to define the referral criteria, review components, and guidelines used to support the inpatient clean claim reviews.

Criteria for high-dollar clean claim review includes, but is not limited to, pre-payment, inpatient claims greater than $50,000 payable for Medicare for inpatient claims that hit DRG outlier. These reviews will also be applied to claims paying on a percentage of billed charges methodology, payable greater than $50,000.

CC.PP.053 (PDF) Leveling of ED Services (Effective Date: 10/1/2019)

This policy outlines enhancement of the claims review process for emergency department (ED) facility and professional claims.

Prepayment policy to down-grade non-emergent, high-level billings to a more appropriate level of payment based on primary diagnosis code.

CC.MP.161 (PDF)

Monitored Anesthesia Care for Gastrointestinal Endoscopy

This policy outlines the indications for when Monitored Anesthesia Care is considered medically necessary Gastrointestinal Endoscopy.

CP.MP.149 (PDF)

Non-invasive Testing for Rupture of Fetal Membranes

The purpose of this policy is to define medical necessity criteria for the non-invasive testing for rupture of fetal membranes testing (e.g. AmniSure®, Actim®PROM and the ROM Plus Fetal Membranes Rupture Test) for the diagnostic evaluation of premature rupture of membranes.

CC.PP.061 (PDF)

Non-obstetrical Pelvic and Transvaginal Ultrasounds

The purpose of this policy is to define payment criteria for multiple non-obstetrical ultrasound images in a single session.

CC.PP.055 (PDF)

Physician’s Office Lab Testing (Effective Date: 10/1/19)

To ensure higher quality laboratory tests are performed in the correct setting, the health plan will limit the performance of in-office laboratory testing to the CPT® and HCPCS codes listed in the Short Turnaround Time (STAT) laboratory (lab) code list included in this policy.

The purpose of this policy is to define payment criteria for in-office laboratory procedures to be used in making payment decisions and administering benefits.  Furthermore to encourage the specialization of independent labs to ensure higher quality laboratory tests are performed in the appropriate setting.

CC.PP.063 (PDF)

Place of Service Mismatch

The purpose of this policy is to identify instances in which a procedure code is billed with an inappropriate place of service per CPT/HCPCS guidelines.

CC.PP.057 (PDF)

Problem Oriented Visits with Preventive Visits

The purpose of this policy is to define payment criteria for problem-oriented visits when billed with preventive visits to be used in making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for both a preventive E&M service and a problem-oriented E&M service during the same patient encounter.

Providers do not incur duplicate indirect expenses with the original E&M (preventive service) when there is a problem-oriented visit on the same date of service. For example, obtaining vital signs, scheduling the visits, staffing, lighting, and supplying the examination room costs are not incurred twice by the provider. Health Net will reimburse the preventive medicine code plus 50 percent of the problem-oriented E&M code.

CP.PP.052 (PDF)

Problem Oriented Visits with Surgical Procedures

The purpose of this policy is to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure to be used in making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for a problem-oriented evaluation and management (E&M) service on the same day of a procedure with a 0-, 10- or 90- day global surgical period if the physician indicates that the service is a significant and separately identifiable E&M service that is above and beyond the usual pre- and post-operative work associated with the procedure. 

The purpose of this policy is to prevent duplicate payments that occur when a provider is reimbursed for resources not directly consumed during the provision of a service.  Furthermore, to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure with a 0-, 10- or 90- day global period when making payment decisions and administering benefits.

CC.PP.049 (PDF) Status "P" Bundled Services (Effective Date: 10/1/19)

The Centers for Medicare and Medicaid Services (CMS) classifies certain procedure codes as always bundled when billed on the same claim or a historical claim containing another procedure code or codes to which the bundled code shares an incidental relationship.  

The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another physician’s procedure or service to be used in making payment decisions and administering benefits.

CC.PP.056 (PDF)

Urine Specimen Validity Testing

The purpose of this policy is to define payment criteria for urine specimen validity testing to be used in making payment decisions and administering benefits.

Health Net will disallow separate reimbursement for testing to confirm that a urine drug specimen is unadulterated. Validity testing in an internal control process that is not separately reportable.

CP.MP.98 (PDF)

Urodynamic Testing

Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction. The clinician must exercise clinical judgment in the appropriate selection of urodynamic tests following an appropriate evaluation and symptom characterization. The purpose of this policy is to define medical necessity criteria for commonly used urodynamic studies.

Policy Reference Number

Policy Name

Description

CC.PP.501 (PDF)

30 Day Readmission

This policy is based, in part, on the methodology set forth in the Quality Improvement Organization Manual, CMS Publication 100-10, Chapter 4, Section 4240, for determining an inappropriate readmission.

For a readmission that is determined to have been inappropriate or preventable according to the clinical review guidelines set forth below, Health Net will deny payment or reimbursement.

CC.PP.500 (PDF)

3-day Payment Window

The purpose of this policy is to serve as one component of the guidelines used to assist in making coverage decisions and administering benefits. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), and to applicable law.

CP.MP.100 (PDF) Allergy Testing (effective 10/1/19)

Allergy testing is performed to determine immunologic sensitivity or reaction to antigens for the purpose of identifying the cause of the allergic state.  This policy addresses immediate (IgE-mediated) hypersensitivity and delayed (cell-mediated) hypersensitivity.  Allergen immunotherapy is the repeated administration of specific allergens to patients with IgE-mediated conditions, for the purpose of providing protection against the allergic symptoms and inflammatory reactions associated with exposure to these allergens.

Please note: unit limitations for allergy testing and treatment are based on state specific guidelines (defined in the provider fee schedule).  In the absence of state-specific rules, the CMS Medicaid/Medicare NCCI MUE limitations are applied.

CP.MP.140 (PDF) EpiFix Wound Treatment (effective 10/1/19) EpiFix® (MiMedx Group) is dehydrated human amniotic tissue that is used as an allograft material (or tissue graft) to treat nonhealing wounds.   It is the policy of health plans affiliated with Centene Corporation® that Epifix is medically necessary for the treatment of chronic foot ulcers when all criteria are met. It is the policy of health plans affiliated with Centene Corporation that continued treatment with EpiFix is not medically necessary when the ulcer fails to heal by ≥ 50% within the first 6 weeks of treatment.  Treatment beyond 12 weeks is considered not medically necessary regardless of wound status.

CC.PI.04 (PDF)

Equian for Clean Claims Reviews

The purpose of this policy is to define the referral criteria, review components, and guidelines used to support the inpatient clean claim reviews.

Criteria for high-dollar clean claim review includes, but is not limited to, pre-payment, inpatient claims greater than $50,000 payable for Medicare for inpatient claims that hit DRG outlier. These reviews will also be applied to claims paying on a percentage of billed charges methodology, payable greater than $50,000.

CC.PP.053 (PDF) Leveling of ED Services (Effective Date: 10/1/2019)

This policy outlines enhancement of the claims review process for emergency department (ED) facility and professional claims.

Prepayment policy to down-grade non-emergent, high-level billings to a more appropriate level of payment based on primary diagnosis code.

CC.MP.161 (PDF)

Monitored Anesthesia Care for Gastrointestinal Endoscopy

This policy outlines the indications for when Monitored Anesthesia Care is considered medically necessary Gastrointestinal Endoscopy.

CP.MP.149 (PDF)

Non-invasive Testing for Rupture of Fetal Membranes

The purpose of this policy is to define medical necessity criteria for the non-invasive testing for rupture of fetal membranes testing (e.g. AmniSure®, Actim®PROM and the ROM Plus Fetal Membranes Rupture Test) for the diagnostic evaluation of premature rupture of membranes.

CC.PP.061 (PDF)

Non-obstetrical Pelvic and Transvaginal Ultrasounds

The purpose of this policy is to define payment criteria for multiple non-obstetrical ultrasound images in a single session.

CC.PP.055 (PDF)

Physician’s Office Lab Testing (Effective Date: 10/1/19)

To ensure higher quality laboratory tests are performed in the correct setting, the health plan will limit the performance of in-office laboratory testing to the CPT® and HCPCS codes listed in the Short Turnaround Time (STAT) laboratory (lab) code list included in this policy.

The purpose of this policy is to define payment criteria for in-office laboratory procedures to be used in making payment decisions and administering benefits.  Furthermore to encourage the specialization of independent labs to ensure higher quality laboratory tests are performed in the appropriate setting.

CC.PP.063 (PDF)

Place of Service Mismatch

The purpose of this policy is to identify instances in which a procedure code is billed with an inappropriate place of service per CPT/HCPCS guidelines.

CC.PP.057 (PDF)

Problem Oriented Visits with Preventive Visits

The purpose of this policy is to define payment criteria for problem-oriented visits when billed with preventive visits to be used in making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for both a preventive E&M service and a problem-oriented E&M service during the same patient encounter.

Providers do not incur duplicate indirect expenses with the original E&M (preventive service) when there is a problem-oriented visit on the same date of service. For example, obtaining vital signs, scheduling the visits, staffing, lighting, and supplying the examination room costs are not incurred twice by the provider. Health Net will reimburse the preventive medicine code plus 50 percent of the problem-oriented E&M code.

CP.PP.052 (PDF)

Problem Oriented Visits with Surgical Procedures

The purpose of this policy is to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure to be used in making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for a problem-oriented evaluation and management (E&M) service on the same day of a procedure with a 0-, 10- or 90- day global surgical period if the physician indicates that the service is a significant and separately identifiable E&M service that is above and beyond the usual pre- and post-operative work associated with the procedure. 

The purpose of this policy is to prevent duplicate payments that occur when a provider is reimbursed for resources not directly consumed during the provision of a service.  Furthermore, to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure with a 0-, 10- or 90- day global period when making payment decisions and administering benefits.

CC.PP.049 (PDF) Status "P" Bundled Services (Effective Date: 10/1/19)

The Centers for Medicare and Medicaid Services (CMS) classifies certain procedure codes as always bundled when billed on the same claim or a historical claim containing another procedure code or codes to which the bundled code shares an incidental relationship.  

The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another physician’s procedure or service to be used in making payment decisions and administering benefits.

CC.PP.056 (PDF)

Urine Specimen Validity Testing

The purpose of this policy is to define payment criteria for urine specimen validity testing to be used in making payment decisions and administering benefits.

Health Net will disallow separate reimbursement for testing to confirm that a urine drug specimen is unadulterated. Validity testing in an internal control process that is not separately reportable.

CP.MP.98 (PDF)

Urodynamic Testing

Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction. The clinician must exercise clinical judgment in the appropriate selection of urodynamic tests following an appropriate evaluation and symptom characterization. The purpose of this policy is to define medical necessity criteria for commonly used urodynamic studies.