Updated Payment Policies
Date: 04/11/18
Heritage Health (Medicaid):
Effective June 1, 2018, Nebraska Total Care is implementing additional Payment & Clinical Policies that will guide how claims for certain services are adjudicated and paid. We will be instituting these policies to provide clinically based rule content to evaluate claims against payment and clinical policies to ensure accurate reimbursement. Information and the list of these soon to be effective payment policies can be found below and apply to all Nebraska Total Care products, unless otherwise noted.
Please visit the Clinical and Payment Policies on our website to find and review our payment policies.
| Number | Policy Name | Policy Description | Line of Business |
|---|---|---|---|
| CP.MP.124 (PDF) | ADHD Assessment and Treatment | This policy defines the medically necessary procedures for the diagnosis and treatment of Attention Deficit Hyperactivity disorder (ADHD). | Medicaid |
| CP.MP.110 (PDF) | Bronchial Thermoplasty | This policy provides a statement of medical necessary for bronchial thermoplasty (BT). | Medicaid |
| CP.MP.125 (PDF) | DNA Analysis of Stool | This policy describes the medical necessity requirements for DNA analysis of stool with the Cologuard. | Medicaid |
| CP.MP.140 (PDF) | EpiFix Wound Treatment | This policy describes the medically necessary indications for EpiFix wound treatment.drugs to FDA-labeled and efficacious off-label treatments only. | Medicaid |
| CP.MP.134 (PDF) | Evoked Potentials | This policy describes the medically necessary indications for the neurophysiologic evoked potentials. | Medicaid |
| CP.MP.135 (PDF) | Fecal Calprotectin Assay | The policy provides a statement of medical necessity for FC assay testing. | Medicaid |
| CP.MP.103 (PDF) | FeNo Testing | This policy provides a statement of medical necessity for the testing of FeNO. | Medicaid |
| CP.MP.113 (PDF) | Holter Monitors | This policy defines the medically necessary indications for continuous ambulatory ECG monitoring. | Medicaid |
| CP.MP.123 (PDF) | Laser Skin Treatment | This policy defines the medically necessary indications for excimer laser based targeted phototherapy. | Medicaid |
| CP.MP.139 (PDF) | Low-Frequency Ultrasound Wound Therapy | The policy provides a statement of medical necessity for low-frequency ultrasound wound therapy. | Medicaid |
| CP.MP.144 (PDF) | Mechanical Stretch Devices | This policy describes the medically necessary indications for mechanical stretching devices for joint stiffness and contracture. | Medicaid |
| CC.PP.050 (PDF) | Robotic Surgery | This policy defines payment criteria for robotic surgeries to be used in making payment decisions and administering benefits. | Medicaid |
| CC.PP.035 (PDF) | Sleep Studies Place of Services | The purpose of this policy is to define the appropriate place of service for sleep studies. | Medicaid |
| CC.PP.049 (PDF) | Status P Bundled Services | 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. | Medicaid |
| CP.MP.143 (PDF) | Wireless Motility Capsule | The policy provides a statement of medical necessity for wireless motility capsule (WMC). | Medicaid |
| Medicaid |