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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.
- 25-Hydroxyvitamin D Testing in Children and Adolescents (PDF)
- ADHD Assessment and Treatment (PDF)
- Allergy Testing and Therapy (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF)
- Ambulatory EEG(PDF)
- Ambulatory Surgery Center Optimization (PDF)
- Applied Behavioral Analysis for Autism (PDF)
- Articular Cartilage Defect Repairs (PDF)
- Balloon Sinus Ostial Dilation (PDF)
- Biofeedback (PDF)
- Bone-Anchored Hearing Aid (PDF)
- Bronchial Thermoplasty (PDF)
- Cardiac Biomarker Testing (PDF)
- Carrier Screening in Pregnancy (PDF)
- Cell-free Fetal DNA Testing (PDF)
- Clinical Trials (PDF)
- Cochlear Implant Replacements (PDF)
- Cosmetic and Reconstructive Surgery (PDF)
- Dental Anesthesia (PDF)
- Diagnosis of Vaginitis (PDF)
- Digital Electroencephalography Spike Analysis (PDF)
- Disc Decompression Procedure (PDF)
- Discography (PDF)
- Donor Lymphocyte Infusion (PDF)
- Durable Medical Equipment (DME) (PDF)
- EEG in the Evaluation of Headache (PDF)
- Electric Tumor Treating Fields (PDF)
- Elective Deliveries Before 39 Weeks Gestational Age (PDF)
- Endometrial Ablation (PDF)
- EpiFix Wound Treatment (PDF)
- Essure Removal (PDF)
- Evoked Potential Testing (PDF)
- Experimental Technologies (PDF)
- Fecal Calprotectin Assay (PDF)
- Fecal Incontinence Treatments (PDF)
- Ferriscan R2 MRI (PDF)
- Fertility Preservation (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)
- Functional MRI (PDF)
- Gender Reassignment Surgery (PDF)
- Gastric Electrical Stimulation (PDF)
- Genetic Testing (PDF)
- Heart-Lung Transplant (PDF)
- Homocysteine Testing (PDF)
- H. Pylori serology testing (PDF)
- Holter Monitors (PDF)
- Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)
- Hospice Services (PDF)
- Hyperbaric Oxygen Therapy (PDF)
- Hyperemesis Gravidarum Treatment (PDF)
- HyperhidrosisTreatments (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
- Inhaled Nitric Oxide (PDF)
- Intensity-Modulated Radiotherapy (PDF)
- Intestinal and multivisceral transplant (PDF)
- Laser Therapy for Skin Conditions (PDF)
- Low-Frequency Ultrasound Therapy for Wound Management (PDF)
- Lung Transplntation (PDF)
- Lysis Of Epidural Lesions (PDF)
- Measurement of Serum 1,25-Dihydroxyvitamin D (PDF)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
- Medical Necessity Criteria (PDF)
- Multiple Sleep Latency Testing (PDF)
- Neonatal Abstinence Syndrome Guidelines (PDF)
- Neonatal Sepsis Management (PDF)
- NICU Apnea Bradycardia Guidelines (PDF)
- NICU Discharge Guidelines (PDF)
- Non-Myeloablative Allogeneic Stem Cell Transplants (PDF)
- Non-OB & OB Transabdominal and Transvaginal Ultrasounds (PDF)
- Nutritional Counseling (PDF)
- Optic Nerve Decompression Surgery (PDF)
- Outpatient Testing for Drugs of Abuse (PDF)
- Pancreas Transplantation (PDF)
- Panniculectomy (PDF)
- Pediatric Heart Transplant (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
- Prescribed Pediatric Extended Care (PPEC) (PDF)
- Private Duty Nursing (PDF)
- Proton and Neutron Beam Therapy (PDF)
- Radial Head Implant (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF)
- Sacroiliac Joint Fusion (PDF)
- Sclerotherapy for Vericose Veins (PDF)
- Sepsis Diagnosis (PDF)
- Short Inpatient Hospital Stay (PDF)
- Sickle Cell Disease Observation (PDF)
- Spinal Cord Stimulation (PDF)
- Stereotactic Body Radiation Therapy (PDF)
- Testing for Rupture of Fetal Membranes (PDF)
- Testing of Select Genitourinary Conditions (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
- Total Artificial Heart (PDF)
- TPN IDPN (PDF)
- Transcatheter Closure of Patent Foramen Ovale (PDF)
- Ultrasound in Pregnancy (PDF)
- Urinary Incontinence Devices and Treatments (PDF)
- Urodynamic Testing (PDF)
- Vagus Nerve Stimulation (PDF)
- Ventriculectomy and Cardiomyoplasty (PDF)
- Wheelchair Seating (PDF)
- Wireless Motility Capsule (PDF)
- Zika Virus Testing (PDF)
- 340 B (PDF)
- 72 Hour Emergency Supply of Medication (PDF)
- Care Management Referral Process (PDF)
- Drug Recall Notification Process (PDF)
- Drug Utilization Review (PDF)
- Lost, Stolen, Spilled or Broken Medication (PDF)
- No Coverage Criteria (PDF)
- Non-FDA Approved Use (PDF)
- Pharmacy Lock-In Program (PDF)
- Pharmacy Program (PDF)
- Abiraterone (Zytiga, Yonsa) (PDF)
- Adalimumab (Humira) (PDF)
- Allogenic Processed Thymus Tissue-Agdc (Rethymic) (PDF)
- Amivantamab-vmjw (Rybrevant) (PDF)
- Anakinra (Kineret) (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)
- Apomorphine (Apokyn, Kynmobi) (PDF)
- Apremilast (Otezla) (PDF)
- Asfotase Alfa (Strensiq) (PDF)
- Betibeglogene autotemcel (Zynteglo) (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) (PDF)
- Bimatoprost Implant (Durysta) (PDF)
- Bortezomib (Velcade) (PDF)
- Brexucabtagene Autoleucel (Tecartus) (PDF)
- Brolucizumab (Beovu) (PDF)
- Buprenorphine Implant (Probuphine) (PDF)
- Casimersen (Amondys 45) (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda) (PDF)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF)
- Canakinumab (Ilaris) (PDF)
- Certolizumab (Cimzia) (PDF)
- Ciltacabtagene Autoleucel (Carvykti) (PDF)
- Corticotropin (H.P. Acthar Gel) (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF)
- Dalfampridine (Ampyra) (PDF)
- Darbepoetin alfa (Aranesp) (PDF)
- Dimethyl fumarate (Tecfidera) (PDF)
- Edaravone (Radicava) (PDF)
- Efgartigimod (Vyvgart) (PDF)
- Elivaldogene autotemcel (Skysona) (PDF)
- Elosulfase Alfa (Vimizim) (PDF)
- Eptinezumab (Vyepti) (PDF)
- Etanercept (Enbrel) (PDF)
- Faricimab (Vabysmo) (PDF)
- Ferric Derisomaltose (Monoferric) (PDF)
- Fibrinogen Concentrate (Human) (Fibryga, RiaSTAP) (PDF)
- Filgrastim (Neupogen), filgrastim-sndz (Zarxio), tbo-filgrastim (Granix) (PDF)
- Fingolimod (Gilenya) (PDF)
- Glatiramer (Copaxone, Glatopa) (PDF)
- Golimumab (Simponi, Simponi Aria) (PDF)
- Idecabtagene vicleucel (Abecma) (PDF)
- Immune Globulin Injections (PDF)
- Infliximab (Remicade, Inflectra, Renflexis) (PDF)
- Interferon beta-1b (Betaseron, Extavia) (PDF)
- Isatuximab-irfc (Sarclisa) (PDF)
- Ixekizumab (Taltz) (PDF)
- Lisocabtagene maraleucel (Breyanzi) (PDF)
- Loncastuximab Tesirine-Lpyl (Zynlonta) (PDF)
- Lurbinectedin (Zepzelca) (PDF)
- Margetuximab-cmkb (Margenza) (PDF)
- Melphalan Flufenamide (Pepaxto) (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)
- Mitoxantrone (Novantrone) (PDF)
- Naxitamab-Gqgk (Danyelza) (PDF)
- Omalizumab (Xolair) (PDF)
- Paciltaxel Protein Bound (PDF)
- Pegfilgrastim (Neulasta) (PDF)
- Plasminogen (Ryplazim) (PDF)
- Ranibizumab (Lucentis) (PDF)
- Secukinumab (Cosentyx) (PDF)
- Sirolimus Protein-Bound Particles (Fyarro) (PDF)
- Sutimlimab (Enjaymo) (PDF)
- Tafasitamab-cxix (Monjuvi) (PDF)
- Talimogene Laherparepvec (Imlygic) (PDF)
- Tebentafusp-tebn (Kimmtrak) (PDF)
- Teriflunomide (Aubagio) (PDF)
- Tocilizumab (Actemra) (PDF)
- Tofacitinib (Xeljanz, Xeljanz XR) (PDF)
- Tralokinumab-ldrm (Adbry) (PDF)
- Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)
- Vedolizumab (Entyvio) (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.
- 3-Day Payment Window (PDF)
- Add on Code Billed Without Primary Code (PDF)
- Assistant Surgeon (PDF)
- Bilateral Procedures (PDF)
- Cerumen Removal (PDF)
- Clean Claims (PDF)
- Clean Claim Reviews (PDF)
- Coding Overview (PDF)
- Cosmetic Procedures (PDF)
- Cost to Charge Adjustments on Clean Claim Reviews (PDF)
- Distinct Procedural Modifiers (PDF)
- Duplicate Primary Code Billing (PDF)
- EM Bundling Edits (PDF)
- E&M Medical Decision-Making (PDF)
- Global Maternity Billing (PDF)
- Hospital Visit Codes Billed with Labs (PDF)
- Inpatient Consultation (PDF)
- Inpatient Only Procedures (PDF)
- IV Hydration (PDF)
- Maximum Units CC (PDF)
- Moderate Conscious Sedation (PDF)
- Modifier-25 Clinical Validation (PDF)
- Modifier-59 Clinical Validation (PDF)
- Modifier DOS Validation (PDF)
- Modifier to Procedure Code Validation (PDF)
- Multiple CPT Code Replacement (PDF)
- Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)
- Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
- Multiple Procedure Reduction: Ophthalmology (PDF)
- NCCI Unbundling (PDF)
- Never Paid Events (PDF)
- New Patient (PDF)
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
- Not Medically Necessary Inpatient Services (PDF)
- Outpatient Consultation (PDF)
- Physician Visit Codes Billed with Labs (PDF)
- Place of Service Mismatch (PDF)
- Post-Operative Visits (PDF)
- Pre-Operative Visits (PDF)
- Professional Component (PDF)
- Prompt Payment Rule for Claims (PDF)
- Pulse Oximetry (PDF)
- Renal Hemodialysis (PDF)
- Same Day Visits (PDF)
- Sleep Studies Place of Services (PDF)
- Status "B" Bundled Services (PDF)
- Status P Bundled Services (PDF)
- Supplies Billed on Same Day As Surgery (PDF)
- Transgender Related Services (PDF)
- Unbundled Professional Services (PDF)
- Unbundled Surgical Procedures (PDF)
- Unbundling Adjustments on Clean Claim Reviews (PDF)
- Unlisted Procedure Codes (PDF)
- Urine Specimen Validity Testing (PDF)
- 30-Day Readmission (PDF)
- 340B Drug Payment Reduction (PDF)
- Leveling of Care: Evaluation and Management Overcoding (PDF)
- Leveling of ER (PDF)
- Non-Emergent ER Services (PDF)
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (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)
- Urine Specimen Validity Testing (PDF)