¿NECESITA INSCRIBIRSE? Busque entre nuestros planes
Clinical & Payment Policies | Ambetter de Magnolia Health
Políticas clínicas y de pago
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)
- 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)
- Bronchial Thermoplasty (CP.MP.110) (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)
- Gender-Affirming Procedures (CP.MP.95) (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)
- Homocysteine Testing (CP.MP.121) (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)
- Laser Therapy for Skin Conditions (CP.MP.123) (PDF)
- Long Term Care Placement Criteria (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)
- 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)
- Nonmyeloablative 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)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (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)
- Radial Head Implant (CP.MP.148) (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, Peripheral Nerve, and Percutaneous Electrical Nerve 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)
- Urodynamic Testing (CP.MP.98) (PDF)
- Wheelchair Seating (CP.MP.99) (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.
- 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)
- 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)
- Leveling of Care: Evaluation and Management Overcoding (PDF)
- Leveling of ER (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)
- 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)
- Wireless Motility Capsule (CP.MP.143) (PDF)