Skip to Main Content

Clinical & Payment Policies

Clinical Policies

Heritage Health - Nebraska Total Care 

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

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

 

Clinical Policies
Policy TitlePolicy Number
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157
Acupuncture (PDF)CP.MP.92
Adopted Clinical Practice and Preventive Health Guidelines (PDF)CPG Grid
Air Ambulance (PDF)CP.MP.175
Allergy Testing and Therapy (PDF)CP.MP.100
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108
Ambulatory Surgery Center Optimization (PDF)CP.MP.158
Applied Behavior Analysis (PDF)CP.BH.104
Articular Cartilage Defect Repairs (PDF)CP.MP.26
Assisted Reproductive Technology (PDF)CP.MP.55
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.124
Bariatric Surgery (PDF)CP.MP.37
Biofeedback (PDF)CP.MP.168
Bone-Anchored Hearing Aid (PDF)CP.MP.93
Bronchial Thermoplasty (PDF)CP.MP.110
Burn Surgery (PDF)CP.MP.186
Cardiac Biomarker Testing (PDF)CP.MP.156
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164
Clinical Trials (PDF)CP.MP.94
Cochlear Implant Replacements (PDF)CP.MP.14
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V1.2024
Concert Genetic Testing: Cardiac Disorders (PDF)V1.2024
Concert Genetic Testing: Dermatologic Conditions (PDF)V1.2024
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V1.2024
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V1.2024
Concert Genetic Testing: Eye Disorders (PDF)V1.2024
Concert Genetic Testing: Gastroenterologic Disorders (Non-Cancerous) (PDF)V1.2024
Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)V1.2024
Concert Genetic Testing: Hearing Loss (PDF)V1.2024
Concert Genetic Testing: Hematologic Conditions (Non-Cancerous) (PDF)V1.2024
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V1.2024
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V1.2024
Concert Genetic Testing: Kidney Disorders (PDF)V1.2024
Concert Genetic Testing: Lung Disorders (PDF)V1.2024
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V1.2024
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V1.2024
Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)V1.2024
Concert Genetic Testing: Pharmacogenetics (PDF)V1.2024
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V1.2024
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V1.2024
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)V1.2024
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V1.2024
Concert Genetics Oncology: Algorithmic Testing (PDF)V1.2024
Concert Genetics Oncology: Cancer Screening (PDF)V1.2024
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)V1.2024
Concert Genetics Oncology: Cytogenetic Testing (PDF)V1.2024
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V1.2024
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.201
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203
Digital EEG Spike Analysis (PDF)CP.MP.105
Discography (PDF)CP.MP.115
Donor Lymphocyte Infusion (PDF)CP.MP.101
Drugs of Abuse: Definitive Testing (PDF)CP.MP.50
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)CP.MP.107
EEG in the Evaluation of Headache (PDF)CP.MP.155
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.145
Endometrial Ablation (PDF)CP.MP.106
Evoked Potential Testing (PDF)CP.MP.134
Experimental Technologies (PDF)CP.MP.36
Facet Joint Interventions (PDF)CP.MP.171
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248
Fecal Incontinence Treatments (PDF)CP.MP.137
Ferriscan R2-MRI (PDF)CP.MP.53
Fertility Preservation (PDF)CP.MP.130
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129
Functional MRI (PDF)CP.MP.43
Gastric Electrical Stimulation (PDF)CP.MP.40
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)CP.MP.209
Gender-Affirming Procedures (PDF)CP.MP.95
Helicobacter Pylori Serology Testing (PDF)CP.MP.153
Heart-Lung Transplant (PDF)CP.MP.132
Holter Monitors (PDF)CP.MP.113
Home Births (PDF)CP.MP.136
Home Ventilators (PDF)CP.MP.184
Homocysteine Testing (PDF)CP.MP.121
Hospice Services (PDF)CP.MP.54
Hyperhidrosis Treatments (PDF)CP.MP.62
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173
Implantable Loop Recorder (PDF)CP.MP.243
Intensity-Modulated Radiotherapy (PDF)CP.MP.69
Intestinal and Multivisceral Transplant (PDF)CP.MP.58
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.167
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61
Lantidra (Donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)CP.MP.250
Laser Therapy for Skin Conditions (PDF)CP.MP.123
Long Term Care Placement (PDF)CP.MP.71
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.139
Lung Transplantation (PDF)CP.MP.57
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.144
Neonatal Abstinence Syndrome Guidelines (PDF)CP.MP.86
Neonatal Sepsis Management (PDF)CP.MP.85
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.170
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.48
NICU Apnea Bradycardia Guidelines (PDF)CP.MP.82
NICU Discharge Guidelines (PDF)CP.MP.81
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.141
Obstetrical Home Care Programs (PDF)CP.MP.91
Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249
Orthognathic Surgery (PDF)CP.MP.202
Osteogenic Stimulation (PDF)CP.MP.194
Outpatient Oxygen Use (PDF)CP.MP.190
Pancreas Transplantation (PDF)CP.MP.102
Panniculectomy (PDF)CP.MP.109
Pediatric Heart Transplant (PDF)CP.MP.138
Pediatric Kidney Transplant (PDF)CP.MP.246
Pediatric Liver Transplant (PDF)CP.MP.120
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.150
Physical, Occupational, and Speech Therapy Services (PDF)CP.MP.49
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)CP.MP.181
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133
Proton and Neutron Beam Therapies (PDF)CP.MP.70
Pulmonary Function Testing (PDF)CP.MP.242
Reduction Mammoplasty and Gynecomastia Surgery (PDF)CP.MP.51
Sacroiliac Joint Fusion (PDF)CP.MP.126
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165
Short Inpatient Hospital Stay (PDF)CP.MP.182
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117
Stereotactic Body Radiation Therapy (PDF)CP.MP.22
Tandem Transplant (PDF)CP.MP.162
Testing for Select Genitourinary Conditions (PDF)NE.CP.MP.97
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)CP.MP.154
Total Artificial Heart (PDF)CP.MP.127
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163
Transcatheter Closure of Patent Foramen Ovale (PDF)CP.MP.151
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)CP.BH.200 
Transplant Service Documentation Requirements (PDF)CP.MP.247
Trigger Point Injections for Pain Management (PDF)CP.MP.169
Ultrasound in Pregnancy (PDF)CP.MP.38
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142
Urodynamic Testing (PDF)CP.MP.98
Vagus Nerve Stimulation (PDF)CP.MP.12
Ventricular Assist Devices (PDF)CP.MP.46
Wheelchair Seating (PDF) CP.MP.99
Wireless Motility Capsule (PDF)CP.MP.143

 

For Medicare information, please visit our Medicare Prior Authorization website.

 

Pharmacy Policies A-E
Rx Policy TitlePolicy NumberEffective Date
Abametapir (Xeglyze) (PDF)CP.PMN.25311/01/2020
AbobotulinumtoxinA (Dysport) (PDF)CP.PHAR.23005/16/2019
ACEI ARB Duplicate Therapy (PDF)CP.PMN.6105/17/2019
Acitretin (Soriatane) (PDF)CP.PMN.4005/06/2020
adamts13, recombinant krhn (Adzynma) (PDF)CP.PHAR.63505/01/2024
Ado-Trastuzumab Emtansine (Kadcyla) (PDF)CP.PHAR.22908/13/2019
Aducanumab (Aduhelm) (PDF)CP.PHAR.46807/01/2021
aflibercept (Eylea) (PDF)CP.PHAR.18402/13/2019
agalsidase beta (Fabrazyme) (PDF)CP.PHAR.15805/16/2019
Alemtuzumab (Lemtrada) (PDF)CP.PHAR.24305/14/2019
alglucosidase alfa (Lumizyme) (PDF)CP.PHAR.16005/16/2019
Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft) (PDF)CP.PHAR.56203/01/2022
Allogenic processed thymus tissue-agdc (Rethymic) (PDF)CP.PHAR.56303/01/2022
Alpha-1 Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF)CP.PHAR.9406/26/2019
Amifampridine (Firdapse) (PDF)CP.PHAR.41109/13/2019
Amisulpride (Barhemsys) (PDF)CP.PMN.23605/06/2020
Amivantamab-vmjw (Rybrevant) (PDF)CP.PHAR.54409/01/2021
anifrolumab-fnia (Saphnelo) (PDF)CP.PHAR.55112/01/2021
Antithrombin III (ATryn, Thrombate III) (PDF)CP.PHAR.56403/01/2022
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)CP.PHAR.50611/01/2020
asenapine (Saphris) (PDF)CP.PMN.1502/15/2019
asfotase alfa (Strensiq) (PDF)CP.PHAR.32811/20/2018
atezolizumab (Tecentriq) (PDF)CP.PHAR.23505/20/2019
Atidarsagene Autotemcel (Lenmeldy) (PDF)CP.PHAR.60205/01/2024
Avacincaptad pegol (Izervay) (PDF)CP.PHAR.64110/01/2023
Avalglucosidase Alfa (NeoGAA) (PDF)CP.PHAR.52106/01/2021
avelumab (Bacencio) (PDF)CP.PHAR.33306/26/2019
axicabtagene ciloleucel (Yescarta) (PDF)CP.PHAR.36208/16/2019
azacitidine (Onureg, Vidaza) (PDF)CP.PHAR.38711/20/2018
Baclofen (Gablofen, Lioresal, Lyvispah, Ozobax) (PDF)CP.PHAR.14911/14/2018
Bedaquiline (Sirturo) (PDF)CP.PMN.21205/06/2020
Belantamab mafodotin (Blenrep) (PDF)CP.PHAR.46906/01/2021
belatacept (Nulojix) (PDF)CP.PHAR.20111/14/2018
belimumab (Benlysta) (PDF)CP.PHAR.8808/10/2019
belinostat (Beleodaq) (PDF)CP.PHAR.31111/17/2018
bendamustine (Bendeka, Treanda) (PDF)CP.PHAR.30711/14/2018
Benznidazole (PDF)CP.PMN.9002/18/2019
Benzyl alcohol (Ulesfia) (PDF)CP.PMN.20208/17/2019
Berdazimer (Zelsuvmi) (PDF)CP.PMN.29304/01/2024
Beremagene Geperpavec (Vyjuvek) (PDF)CP.PHAR.59203/01/2023
betaine (Cystadane) (PDF)CP.PHAR.14311/20/2018
Betibeglogene Autotemcel (Zynteglo) (PDF)CP.PHAR.54512/01/2022
bevacizumab (Avastin, Mvasi) (PDF)CP.PHAR.9306/26/2019
Bexarotene (Targretin) (PDF)CP.PHAR.7505/16/2019
bezlotoxumab (Zinplava) (PDF)CP.PHAR.30002/15/2019
Bimatoprost (Durysta) (PDF)CP.PHAR.48611/01/2020
Bimekizumab-bkzx (Bimzelx) (PDF)CP.PHAR.66002/01/2024
Birch triterpenes (Filsuvez) (PDF)CP.PHAR.66902/01/2024
blinatumomab (Blincyto) (PDF)CP.PHAR.31208/13/2019
Bortezomib (Velcade) (PDF)CP.PHAR.41002/19/2019
Brand Name Override (PDF)CP.PMN.2202/19/2019
Bremelanotide (Vyleesi) (PDF)CP.PHAR.43405/06/2020
brentuximab Vedotin (Adcetris) (PDF)CP.PHAR.30308/13/2019
Brexanolone (Zulresso) (PDF)CP.PHAR.41705/13/2019
Brexpiprazole (Rexulti) (PDF)CP.PMN.6805/06/2020
Brexucabtagene Autoleucel (Tecartus) (PDF)CP.PHAR.47209/01/2020
Brimonidine (Mirvaso) (PDF)CP.PMN.19205/13/2019
Brolucizumab (Beovu) (PDF)CP.PHAR.44504/01/2021
buprenorphine implant (Sublocade) (PDF)CP.PHAR.28906/01/2023
Burosumab-twza (Crysvita) (PDF)CP.PHAR.1108/10/2019
cabazitaxel (Jevtana) (PDF)CP.PHAR.31609/13/2019
Cabotegravir, Cabotegravir-Rilpivirine (Apretude, Cabenuva) (PDF)CP.PHAR.57306/01/2022
calcifediol (Rayaldee) (PDF)CP.PMN.7608/16/2019
canakinumab (Ilaris) (PDF)CP.PHAR.24605/16/2019
Cannabidiol (Epidiolex) (PDF)CP.PMN.16408/17/2019
Caplacizumab-yhdp (Cablivi) (PDF)CP.PHAR.41605/13/2019
Carbamazepine ER (Equetro) (PDF)CP.PMN.13705/17/2019
carfilzomib (Kyprolis) (PDF)CP.PHAR.30911/14/2018
carglumic acid (Carbaglu) (PDF)CP.PHAR.20602/14/2019
Cariprazine (Vraylar) (PDF)CP.PMN.9106/26/2019
Casimersen (Amondys) (PDF)CP.PHAR.47006/01/2021
Cemiplimab-rwlc (Libtayo) (PDF)CP.PHAR.39711/26/2018
Cenegermin-bkbj (Oxervate (PDF)CP.PMN.18608/14/2019
Cenobamate (Xcopri) (PDF)CP.PMN.23111/01/2020
Cerliponase alfa (Brineura) (PDF)CP.PHAR.33808/15/2019
cetuximab (Erbitux) (PDF)CP.PHAR.31711/17/2018
Chloramphenicol (PDF)CP.PHAR.38802/15/2019
Chronic Use of Opioid Analgesics (PDF)NE.PMN.9712/06/2018
Ciltacabtagene Autoleucel (Carvykti) (PDF)CP.PHAR.533 05/01/2021
cinacalcet (Sensipar) (PDF)CP.PHAR.6108/10/2019
Cipaglucosidase alfa-miglustat (Pombiliti) PDF)CP.PHAR.56711/01/2023
clobazam (Onfi) (PDF)CP.PMN.5406/26/2019
collagenase clostridium histolyticum (Xiaflex) (PDF)CP.PHAR.8208/15/2019
Compounded Medications (PDF)CP.PMN.28008/01/2022
Conjugated estrogens-bazedoxifene (Duavee) (PDF)CP.PMN.25803/01/2021
Continuous Glucose Monitors (PDF)NE.PMN.21401/01/2023
copanlisib (Aliqopa) (PDF)CP.PHAR.35711/20/2018
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF)CP.PHAR.38509/13/2019
cosyntropin (Cortrosyn) (PDF)CP.PHAR.20302/13/2019
Crizanlizumab-tmca (Adakveo) (PDF)CP.PHAR.44906/01/2021
cysteamine (Cystagon, Procysbi) (PDF)CP.PHAR.15505/16/2019
Cysteamine ophthalmic (Cystaran) (PDF)CP.PMN.13005/17/2019
Cytomegalovirus Immune Globulin (CytoGam) (PDF)CP.PHAR.27708/15/2019
daptomycin (Cubicin, Cubicin RF) (PDF)CP.PHAR.35108/15/2019
daratumumab (Darzalex) (PDF)CP.PHAR.31008/13/2019
daunorubicin/cytarabine (Vyxeos) (PDF)CP.PHAR.35211/20/2018
DaxibotulinumtoxinA-lanm (Daxxify) (PDF)CP.PHAR.65110/01/2023
deferasirox (Jadenu) (PDF)CP.PHAR.14508/10/2019
deferiprone (Ferriprox) (PDF)CP.PHAR.14708/17/2019
deferoxamine (Desferal) (PDF)CP.PHAR.14608/15/2019
degarelix acetate (Firmagon) (PDF)CP.PHAR.17011/17/2018
Delandistrogene Moxeparvovec (Elevidys) (PDF)CP.PHAR.59309/01/2023
Denosumab (Prolia, Xgeva) (PDF)CP.PHAR.5805/16/2019
Desmopressin acetate (DDAVP Injection, Stimate, Noctiva) (PDF)CP.PHAR.21402/13/2019
Dexrazoxane (Zinecard Totect) (PDF)CP.PHAR.41805/13/2019
Dextromethorphan/Bupropion (Auvelity) (PDF)CP.PMN.28401/01/2023
Dextromethorphan-Quinidine (Nuedexta) (PDF)CP.PMN.9302/18/2019
Diazepam Nasal Spray (Valtoco) (PDF)CP.PMN.21612/01/2019
Dichlorphenamide (Keveyis) (PDF)CP.PMN.26103/01/2021
Dostarlimab-gxly (Jemperli) (PDF)CP.PHAR.54007/01/2021
droxidopa (Northera) (PDF)CP.PMN.1711/13/2018
Duplicate SSRI/SNRI Therapy (PDF)CP.PMN.6008/15/2019
Durvalumab (Imfinzi) (PDF)CP.PHAR.33907/19/2019
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF)CP.PMN.23410/01/2022
ecallantide (Kalbitor) (PDF)CP.PHAR.17709/01/2021
eculizumab (Soliris) (PDF)CP.PHAR.9705/14/2019
Edaravone (Radicava) (PDF)CP.PHAR.34305/16/2019
Efgartigimod (Vyvgart, Vyvgart Hytrulo) (PDF)CP.PHAR.55503/01/2022
Elapegademase-lvlr (Revcovi) (PDF)CP.PHAR.41905/13/2019
Elivaldogene autotemcel (Skysona) (PDF)CP.PHAR.55612/01/2022
elosulfase alfa (Vimizim) (PDF)CP.PHAR.16205/16/2019
elotuzumab (Empliciti) (PDF)CP.PHAR.30805/14/2019
Elranatamab-bcmm (Elrexfio) (PDF)CP.PHAR.65210/01/2023
Emapalumab-lzsg (Gamifant) (PDF)CP.PHAR.40205/30/2019
Enfortumab Vedotin-ejfv (Padcev) (PDF)CP.PHAR.45509/01/2021
Epcoritamab-bysp (Epkinly) (PDF)CP.PHAR.63411/01/2023
Eplontersen (Wainua) (PDF)CP.PHAR.63302/01/2024
epoprostenol (Flolan), Veletri) (PDF)CP.PHAR.19204/02/2019
Eptinezumab (Vyepti) (PDF)CP.PHAR.48905/06/2020
eribulin Mesylate (Halaven) (PDF)CP.PHAR.31811/17/2018
erwina asparaginase (Erwinaze) (PDF)CP.PHAR.30102/15/2019
Esketamine (Spravato) (PDF)CP.PMN.19909/13/2019
Estradiol Vaginal Ring (Femring) (PDF)CP.PMN.26301/01/2022
etelcalcetide (Parsabiv) (PDF)CP.PHAR.37908/13/2019
eteplirsen (Exondys 51) (PDF)CP.PHAR.28802/15/2019
Etranacogene Dezaparvovec (Hemgenix) (PDF)CP.PHAR.58003/01/2023
Evinacumab (Evkeeza) (PDF)CP.PHAR.51106/01/2021
Exagamglogene Autotemcel (Casgevy) (PDF)CP.PHAR.60302/01/2024

 

 

Pharmacy Policies F-N
Rx Policy TitlePolicy NumberEffective Date
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF)CP.PHAR.45607/01/2022
faricimab-svoa (Vabysmo) (PDF)CP.PHAR.58106/01/2022
Fecal Microbiota, Live-jslm (Rebyota) (PDF)CP.PHAR.61303/01/2023
Fenfluramine (Fintepla) (PDF)CP.PMN.24601/21/2021
ferric carboxymaltose (Injectafer) (PDF)CP.PHAR.23402/14/2019
Ferric Derisomaltose (Monoferric) (PDF)CP.PHAR.48005/31/2020
Ferric Pyrophosphate Citrate (Triferic, Triferic Avnu) (PDF)CP.PHAR.62406/01/2023
Ferric maltol (Accrufer) (PDF)CP.PMN.21305/06/2020
ferumoxytol (Feraheme) (PDF)CP.PHAR.16502/14/2019
Fezolinetant (Veozah) (PDF)CP.PMN.28909/01/2023
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF)CP.PHAR.52606/01/2021
Flibanserin (Addyi) (PDF)CP.PHAR.4463/1/2020
Fluorouracil Cream (Tolak) (PDF)CP.PMN.16511/21/2018
Fosdenopterin (Nulibry) (PDF)CP.PHAR.47106/01/2021
Fulvestrant (Faslodex Injection) (PDF)CP.PHAR.42408/12/2019
furosemide (Furoscix) (PDF)CP.PHAR.60803/01/2023
Gabapentin ER (Gralise, Horizant) (PDF)CP.PMN.24005/06/2020
galsulfase (Naglazyme) (PDF)CP.PHAR.16105/16/2019
Ganaxolone (Ztalmy) (PDF)CP.PMN.27808/01/2022
gemtuzumab ozogamicin (Mylotarg) (PDF)CP.PHAR.35811/14/2018
gepirone (Exxua) (PDF)CP.PMN.29202/01/2024
Givinostat (Duvyzat) (PDF)CP.PHAR.64405/01/2024
Givosiran (Givlaari) (PDF)CP.PHAR.45711/01/2020
Glofitamab-gxbm (Columvi) (PDF)CP.PHAR.63609/01/2023
glycerol phenylbutyrate (Ravicti) (PDF)CP.PHAR.20703/13/2019
Glycopyrronium (Qbrexza) (PDF)CP.PMN.17711/21/2018
goserelin acetate (Zoladex) (PDF)CP.PHAR.17111/17/2018
hemin (Panhematin) (PDF)CP.PHAR.18102/13/2019
histrelin acetate (Vantas, Supprelin LA) (PDF)CP.PHAR.17211/17/2018
Hyaluronate Derivatives (PDF)CP.PHAR.0509/27/2019
ibalizumab-uiyk (Trogarzo) (PDF)CP.PHAR.37805/17/2019
Idecabtagene Vicleucel (Abecma) (PDF)CP.PHAR.48106/01/2021
idursulfase (Elaprase) (PDF)CP.PHAR.15605/17/2019
iloperidone (Fanapt) (PDF)CP.PMN.3202/15/2019
imiglucerase (Cerezyme) (PDF)CP.PHAR.15405/16/2019
Immune Globulin Injections (PDF)CP.PHAR.10308/10/2019
Immunization Coverage (PDF)CP.PHAR.2808/01/2022
Inclisiran (Leqvio) (PDF)CP.PHAR.56806/01/2022
IncobotulinumtoxinA (Xeomin) (PDF)CP.PHAR.23105/16/2019
Inebilizumab-cdon (Uplizna) (PDF)CP.PHAR.45811/01/2020
Infliximab (Avsola, Inflectra, Remicade, Renflexis) (PDF)CP.PHAR.25409/13/2019
Inotersen (Tegsedi) (PDF)CP.PHAR.40505/30/2019
inotuzumab ozogamicin (Besponsa) (PDF)CP.PHAR.35911/20/2018
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)CP.PHAR.53406/01/2021
interferon gamma- 1b (Actimmune) (PDF)CP.PHAR.5202/13/2019
ipilimumab (Yervoy) (PDF)CP.PHAR.31905/14/2019
iptacopan-lnpo (Fabhalta) (PDF)CP.PHAR.65602/01/2024
irinotecan Liposome (Onivyde) (PDF)CP.PHAR.30411/14/2018
Isatuximab-irfc (Sarclisa) (PDF)CP.PHAR.48206/01/2021
isotretinoin (PDF)CP.PMN.14311/14/2018
Itraconazole (Sporanox ,Onmel, Tolsura) (PDF)CP.PMN.12405/06/2020
lacosamide (Vimpat) (PDF)CP.PMN.15508/17/2019
Lactic acid-citric acid-potassium bitartrate (Phexxi) (PDF)CP.PMN.25111/01/2020
Lanreotide (Somatuline Depot) (PDF)CP.PHAR.39111/20/2018
laronidase (Aldurazyme) (PDF)CP.PHAR.15205/16/2019
Lecanemab (Leqembi) (PDF)CP.PHAR.59603/01/2023
leniolisib (Joenja) (PDF)CP.PHAR.59703/24/2023
letermovir (Prevymis) (PDF)CP.PHAR.36702/15/2019
Leucovorin Injection (PDF)CP.PHAR.39311/20/2018
leuprolide acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF)CP.PHAR.17308/16/2019
Levoketoconazole (Recorlev) (PDF)CP.PMN.27506/01/2022
levoleucovorin (Fusilev) (PDF)CP.PHAR.15111/14/2018
Lidocaine transdermal (Lidoderm, ZTlido) (PDF)CP.PMN.0807/01/2023
Lifileucel (Amtagvi) (PDF)CP.PHAR.59805/01/2024
Lisocabtagene maraleucel (Breyanzi) (PDF)CP.PHAR.48306/01/2021
Lonafarnib (Zokinvy) (PDF)CP.PHAR.49903/01/2021
Loncastuximab tesirine-lpyl (Zynlonta) (PDF)CP.PHAR.53907/01/2021
Lotilaner (Xdemvy) (PDF)CP.PMN.29110/01/2023
Lovotibeglogene Autotemcel (Lyfgenia) (PDF)CP.PHAR.62702/01/2024
Lumasiran (Oxlumo) (PDF)CP.PHAR.47303/01/2021
Lumateperone (Caplyta) (PDF)CP.PMN.23206/01/2022
Lurbinectedin (Zepzelca) (PDF)CP.PHAR.50009/01/2020
Luspatercept-aamt (Reblozyl) (PDF)CP.PHAR.45005/06/2020
lutetium Lu 177 dotatate (Lutathera) (PDF)CP.PHAR.38408/16/2019
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF)CP.PHAR.582 06/01/2022
Margetuximab-cmkb (Margenza) (PDF)CP.PHAR.52203/01/2021
Maribavir (Livtencity) (PDF)CP.PMN.27103/01/2022
mavacamten (Camzyos) (PDF)CP.PMN.27206/03/2022
Mecamylamine (Vecamyl) (PDF)CP.PMN.13605/17/2019
mecasermin (Increlex) (PDF)CP.PHAR.15008/15/2019
mechlorethamine (Valchlor) (PDF)CP.PHAR.38108/13/2019
megestrol Acetate Oral Suspension (Megace ES) (PDF)CP.PMN.17911/21/2018
Melphalan (Hepzato) (PDF)CP.PHAR.65310/01/2023
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF)CP.PHAR.23805/16/2019
Metreleptin (Myalept) (PDF)CP.PHAR.42508/12/2019
Midazolam (Nayzilam) (PDF)CP.PMN.21108/16/2019
mifepristone (Korlym) (PDF)CP.PHAR.10102/13/2019
Migalastat (Galafold) (PDF)CP.PHAR.39402/01/2019
Milnacipran (Savella) (PDF)CP.PMN.12505/17/2019
minocycline (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF)CP.PMN.8011/01/2020
mirvetuximab soravatansine-gynx (Elahere) (PDF)CP.PHAR.61703/01/2023
Mitapivat (Pyrukynd) (PDF)CP.PHAR.55806/01/2022
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)CP.PHAR.49509/01/2020
Mitoxantrone (Novantrone) (PDF)CP.PHAR.25805/14/2019
Mixed pollens allergen extract (Oralair) (PDF)CP.PMN.8508/16/2019
Mogamulizumab-kpkc (Poteligeo) (PDF)CP.PHAR.13911/20/2018
mosunetuzumab-axgb (Lunsumio) (PDF)CP.PHAR.61803/01/2023
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)CP.PHAR.39811/26/2018
motixafortide (Aphexda) (PDF)CP.PHAR.65502/01/2024
Nadofaragene firadenovec-vncg (Adstiladrin) (PDF)CP.PHAR.46106/01/2023
nafarelin acetate (Synarel) (PDF)CP.PHAR.17411/17/2018
Natalizumab (Tysabri) (PDF)CP.PHAR.25905/14/2019
Naxitamab-gqgk (Danyelza) (PDF)CP.PHAR.52303/01/2021
necitumumab (Portrazza) (PDF)CP.PHAR.32011/17/2018
Nedosiran (Rivfloza) (PDF)CP.PHAR.61911/01/2023
Neomycin-fluocinolone cream (Neo-Synalar) (PDF)CP.PMN.16711/21/2018
Nifurtimox (Lampit) (PDF)CP.PMN.25611/01/2020
Nirsevimab (Beyfortus) (PDF)CP.PHAR.61410/01/2023
nitisinone (Orfadin, Nityr) (PDF)CP.PHAR.13211/20/2018
nivolumab (Opdivo) (PDF)CP.PHAR.12102/14/2019
Nivolumab and Relatlimab (Opdualag) (PDF)CP.PHAR.58808/01/2022
No Coverage Criteria (PDF)CP.PMN.25503/01/2022
Non-preferred blood glucose monitors and test strips (PDF)CP.PMN.21505/06/2020
nusinersen (Spinraza) (PDF)CP.PHAR.32708/13/2019

 

 

Pharmacy Policies O-Z
Rx Policy TitlePolicy NumberEffective Date
obinutuzumab (Gazyva) (PDF)CP.PHAR.30511/14/2018
Ocrelizumab (Ocrevus) (PDF)CP.PHAR.33505/16/2019
octreotide acetate (Sandostatin, Sandostatin LAR) (PDF)CP.PHAR.4002/14/2019
ofatumumab (Arzerra) (PDF)CP.PHAR.30611/17/2018
Off Label Use Policy (PDF)CP.PMN.5303/01/2022
Olanzapine-samidorphan (Lybalvi) (PDF)CP.PMN.26507/01/2021
Olipudase alfa (XENPOZYME) (PDF)CP.PHAR.58601/01/2023
omacetaxine (Synribo) (PDF)CP.PHAR.10805/14/2019
Omaveloxolone (Skyclarys) (PDF)CP.PHAR.59006/01/2023
OnabotulinumtoxinA (Botox) (PDF)CP.PHAR.23209/13/2019
Onasemnogene abeparvovec (Zolgensma) (PDF)CP.PHAR.42108/12/2019
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)CP.PHAR.53606/01/2021
Osilodrostat (Isturisa) (PDF)CP.PHAR.48705/06/2020
Ospemifene (Osphena) (PDF)CP.PMN.16805/15/2019
oxymetazoline (Rhofade) (PDF)CP.PMN.865/15/2019
Ozenoxacin (Xepi) (PDF)CP.PMN.11906/01/2021
Paclitaxel, Protein Bound (Abraxane) (PDF)CP.PHAR.17607/18/2020
palivizumab (Synagis) (PDF)CP.PHAR.1611/01/2020
Palovarotene (Sohonos) (PDF)CP.PHAR.54811/01/2023
panitumumab (Vectibix) (PDF)CP.PHAR.32111/17/2018
Parathyroid hormone (Natpara) (PDF)CP.PHAR.28208/15/2019
Paricalcitol (Zemplar) (PDF)CP.PHAR.27008/10/2019
pasireotide (Signifor LAR) (PDF)CP.PHAR.33211/14/2018
Patiromer (Veltassa) (PDF)CP.PMN.20508/12/2019
pegaspargase (Oncaspar) (PDF)CP.PHAR.35311/14/2018
Pegcetacoplan (Empaveli,Skyfovre) (PDF)CP.PHAR.52407/01/2021
peginterferon alfa-2b (Sylatron) (PDF)CP.PHAR.8908/17/2019
pegloticase (Krystexxa) (PDF)CP.PHAR.11502/14/2019
Pegunigalsidase Alfa (Elfabrio) (PDF)CP.PHAR.51209/01/2023
Pegvaliase-pqpz (Palynziq) (PDF)CP.PHAR.14002/01/2019
pegvisomant (Somavert) (PDF)CP.PHAR.38911/20/2018
pembrolizumab (Keytruda) (PDF)CP.PHAR.32208/16/2019
pemetrexed (Alimta) (PDF)CP.PHAR.36804/02/2019
Pentosan polysulfate sodium (Elmiron) (PDF)CP.PMN.27606/01/2022
Pertuzumab (Perjeta) (PDF)CP.PHAR.22705/17/2019
Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF)CP.PHAR.50109/01/2020
Plasminogen (Ryplazim) (PDF)CP.PHAR.513 10/01/2021
plerixafor (Mozobil) (PDF)CP.PHAR.32308/13/2019
Polatuzuman vedotin – piiq (Polivy) (PDF)CP.PHAR.43308/16/2019
Pozelimab-bbfg (Veopoz) (PDF)CP.PHAR.62611/01/2023
pralatrexate (Folotyn) (PDF)CP.PHAR.31311/17/2018
Prasterone (Intrarosa) (PDF)CP.PMN.9902/18/2019
Pretomanid (PDF)CP.PMN.22209/01/2021
Progesterone (Crinone, Endometrin, Milprosa) (PDF)CP.PMN.24305/06/2020
protein c concentrate, human (Ceprotin) (PDF)CP.PHAR.33002/15/2019
Pyrimethamine (Daraprim) (PDF)CP.PMN.4405/06/2020
QL of Diabetic Test Strips not receiving insulin (PDF)CP.PMN.15102/14/2019
Quantity Limit Overrides (PDF)CP.PMN.5902/01/2019
Quetiapine ER (Seroquel XR) (PDF)CP.PMN.6405/06/2020
Quinine Sulfate (Qualaquin) (PDF)CP.PMN.26206/01/2021
ramucirumab (Cyramza) (PDF)CP.PHAR.11909/13/2019
ranibizumab (Byooviz, Lucentis, Susvimo) (PDF)CP.PHAR.18606/26/2019
Ravulizumab-cwvz (Ultomiris) (PDF)CP.PHAR.41505/13/2019
Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF)CP.PHAR.16804/02/2019
Request for Medically Necessary Drug not on the PDL (PDF)CP.PMN.1611/14/2018
reslizumab (Cinqair) (PDF)CP.PHAR.22302/14/2019
Resmetirom (Rezdiffra) (PDF)CP.PHAR.64704/01/2024
retifanlimab-dlwr (Zynz) (PDF)CP.PHAR.62906/01/2023
Rifamycin (Aemcolo) (PDF)CP.PMN.19605/13/2019
rifapentine (Priftin) (PDF)CP.PMN.0502/15/2019
RimabotulinumtoxinB (Myobloc) (PDF)CP.PHAR.23305/16/2019
Risdiplam (Evrysdi) (PDF)CP.PHAR.47711/01/2020
Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF)CP.PHAR.2606/26/2019
romidepsin (Istodax) (PDF)CP.PHAR.31403/06/2019
romiplostim (Nplate) (PDF)CP.PHAR.17903/06/2019
Romosozumab-aqqg (Evenity) (PDF)CP.PHAR.42808/12/2019
Ropeginterferon alfa-2b-njft (Besremi) (PDF)CP.PHAR.57003/01/2022
Rozanolixizumab-noli (Rystiggo) (PDF)CP.PHAR.64810/01/2023
rufinamide (Banzel) (PDF)CP.PMN.15708/17/2019
Sacituzumab govitecan-hziy (Trodelvy) (PDF)CP.PHAR.47503/01/2021
sapropterin (Kuvan) (PDF)CP.PHAR.4305/16/2019
Sarecycline (Seysara) (PDF)CP.PMN.18905/30/2019
sargramostim (Leukine) (PDF)CP.PHAR.29508/15/2019
sebelipase alfa (Kanuma) (PDF)CP.PHAR.15905/17/2019
Setmelanotide (Imcivree) (PDF)CP.PHAR.49106/01/2021
siltuximab (Sylvant) (PDF)CP.PHAR.32902/15/2019
Sipuleucel-T (Provenge) (PDF)CP.PHAR.12005/16/2019
Sodium Oxybate (Xyrem, Lumryz) and Calcium Magnesium Potassium Sodium Oxybate (Xywav) (PDF)CP.PMN.4205/17/2019
sodium phenylbutyrate (Buphenyl) (PDF)CP.PHAR.20802/14/2019
Sodium Phenylbutyrate-Taurursodiol (Relyvrio) (PDF)CP.PHAR.58401/01/2023
Sodium thiosulfate (Pedmark) (PDF)CP.PHAR.61003/01/2023
Sodium zirconium cyclosilicate (Lokelma) (PDF)CP.PMN.16308/17/2019
sotatercept (Winrevair) (PDF)CP.PHAR.65705/01/2024
sparsentan (Filspari) (PDF)CP.PHAR.63106/01/2023
Stiripentol (Diacomit) (PDF)CP.PMN.18411/26/2018
Sutimlimab (Enjaymo) (PDF)CP.PHAR.50303/01/2022
Tadalafil BPH - ED (Cialis) (PDF)CP.PMN.13205/06/2020
Tafamidis meglumine, Tafamidis (Vyndaquel, Vyndamax) (PDF)CP.PHAR.43208/16/2019
Tafasitamab-cxix (Monjuvi) (PDF)CP.PHAR.50811/01/2020
taliglucerase alfa (Elelyso) (PDF)CP.PHAR.15705/17/2019
Talimogene laherparepvec (Imlygic) (PDF)CP.PHAR.54207/01/2021
Talquetamab-tgvs (Talvey) (PDF)CP.PHAR.64910/01/2023
Tebentafusp-tebn (Kimmtrak) (PDF)CP.PHAR.57506/01/2022
Teclistamab-cqyv (Tecvayli) (PDF)CP.PHAR.61103/01/2023
teduglutide (Gattex) (PDF)CP.PHAR.11409/13/2019
Tegaserod (Zelnorm) (PDF)CP.PMN.20608/12/2019
Telotristat ethyl (Xermelo) (PDF)CP.PHAR.33705/16/2019
temasmorelin (Egrifta) (PDF)CP.PHAR.1098/15/2019
temsirolimus (Torisel) (PDF)CP.PHAR.32411/20/2018
Teplizumab-mzwv (Tzield) (PDF)CP.PHAR.49203/01/2023
Teprotumumab (Tepezza) (PDF)CP.PHAR.46505/06/2020
testosterone pellet (Testopel) (PDF)CP.PHAR.35409/13/2019
Tezepelumab (Tezspire) (PDF)CP.PHAR.57606/01/2022
thyrotropin alfa (Thyrogen) (PDF)CP.PHAR.9508/15/2019
tisagenlecleucel (Kymriah) (PDF)CP.PHAR.36105/01/2022
Tisotumab vedotin - tftv (Tivdak) (PDF)CP.PHAR.56112/01/2021
tocilizumab (Actemra) (PDF)CP.PHAR.26306/01/2021
Tofersen (Qalsody) (PDF)CP.PHAR.59107/01/2023
Tolvaptan (Jynarque, Samsca) (PDF)CP.PHAR.2708/15/2019
Topiramate ER (Qudexy XR, Trokendi XR (PDF)CP.PMN.28108/01/2022
Toripalimab (Loqtorzi) (PDF)CP.PHAR.66802/01/2024
trabectedin (Yondelis) (PDF)CP.PHAR.20402/14/2019
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)CP.PHAR.22809/13/2019
travoprost (iDose TR) (PDF)CP.PHAR.672 03/01/2024
Tremelimumab-actl (Imjudo) (PDF)CP.PHAR.61203/01/2023
Triamcinolone ER Injection  (Zilretta) (PDF)CP.PHAR.37102/15/2019
Triclabendazole (Egaten) (PDF)CP.PMN.20708/12/2019
Trientine (Syprine) (PDF)CP.PHAR.43805/06/2020
Triheptanoin (Dojolvi) (PDF)CP.PHAR.50911/01/2020
triptorelin pamoate (Trelstar, Triptodur) (PDF)CP.PHAR.17508/16/2019
Trofinetide (Daybue) (PDF)CP.PHAR.60006/01/2023
Ublituximab-xiiy (Briumvi) (PDF)CP.PHAR.62106/01/2023
Ulcer Therapy Combinations (Omeclamox Pak, Pylera, Talicia) (PDF)CP.PMN.27706/01/2022
Umbralisib (Ukoniq) (PDF)CP.PHAR.53106/01/2021
Valoctocogene Roxaparvovec (Roctavian) (PDF)CP.PHAR.46609/01/2023
Valrubicin (Valstar) (PDF)CP.PHAR.43905/06/2020
Vamorolone (Agamree) (PDF)CP.PHAR.65902/01/2024
velaglucerase alfa (VPRIV) (PDF)CP.PHAR.16305/16/2019
Velmanase Alfa (Lamazym, Lamzede) (PDF)CP.PHAR.60106/01/2023
verteporfin (Visudyne) (PDF)CP.PHAR.18702/13/2019
vestronidase alfa-vjbk (Mepsevii) (PDF)CP.PHAR.37405/17/2019
vigabatrin (Sabril) (PDF)CP.PHAR.16908/10/2019
vilazodone (Viibryd) (PDF)CP.PMN.14508/17/2019
Viltolarsen (Viltepso) (PDF)CP.PHAR.48409/01/2020
vincristine sulfate liposome injection (Marqibo) (PDF)CP.PHAR.31511/17/2018
Voclosporin (Lupkynis) (PDF)CP.PHAR.50406/01/2021
Voretigene neparvovec-rzyl (Luxturna) (PDF)CP.PHAR.37202/15/2019
vortioxetine HBr (Trintellix) (PDF)CP.PMN.6508/16/2019
Vosoritide (Voxzogo) (PDF)CP.PHAR.52501/01/2022
vutrisiran (Amvuttra) (PDF)CP.PHAR.55012/01/2022
ziv-aflibercept (Zaltrap) (PDF)CP.PHAR.32511/20/2018
zoledronic acid (Reclast, Zometa) (PDF)CP.PHAR.5902/14/2019
Zuranolone (Zurzuvae) (PDF)CP.PHAR.65010/01/2023

 

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 Nebraska Total Care Payment Policy Manual apply with respect to Nebraska Total Care members. Policies in the Nebraska Total Care Payment Policy Manual may have either a Nebraska Total Care or a “Centene” heading.  In addition, Nebraska Total Care 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 Nebraska Total Care.     

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

 

Payment Policies
Policy TitlePolicy NumberEffective Date
3-Day Payment Window (PDF)CC.PP.50007/01/2014
30-Day Readmission (PDF)CC.PP.50101/01/2015
Add on Code Billed Without Primary Code (PDF)CC.PP.03001/01/2013
Assistant Surgeon (PDF)CC.PP.02901/01/2014
Bilateral Procedures (PDF)CC.PP.03701/01/2014
Cerumen Removal (PDF)CC.PP.00801/01/2014
Clean Claim Reviews (PDF)CC.PI.0411/01/2012
Clean Claims (PDF)CC.PP.02101/01/2013
Clinic Facility Charge (PDF)CC.PP.05901/29/2018
Coding Editing Overview (PDF)CC.PP.01101/01/2013
Comprehensive Payment Integrity (CPI) (PDF)CC.PP.07408/01/2023
Concert Laboratory Payment Policy (PDF)CG.CC.PP.0107/01/2024
Cosmetic Procedures (PDF)CC.PP.02401/01/2014
Cost to Charge Adjustments on Clean Claim Reviews (PDF)CC.PI.0609/01/2022
Distinct Procedural Modifiers (PDF)CC.PP.02001/01/2013
Duplicate Primary Code Billing (PDF)CC.PP.04401/01/2014
E&M Medical Decision-Making (PDF)CC.PP.05106/2017
External Ocular Photography (PDF)OC.UM.CP.004310/01/2016
Fluorescein Angiography (PDF)OC.UM.CP.002801/01/2018
Fundus Photography (PDF)OC.UM.CP.002901/01/2018
Genetic and Molecular Testing Services (PDF)CG.PP.55107/01/2024
Global Maternity Billing (PDF)CC.PP.01601/01/2013
Gonioscopy (PDF)OC.UM.CP.003110/01/2016
Hospital Visit Codes Billed with Labs (PDF)CC.PP.02301/01/2013
Inpatient Consultation (PDF)CC.PP.03801/01/2014
Incidental Diagnostic and Laboratory Tests Billed with Evaluation and Management Services (PDF)CC.PP.01001/01/2013
Infectious Disease: Dermatologic Lab Testing (PDF)CG.CP.MP.0307/01/2024
Infectious Disease: Gastroenterologic Lab Testing (PDF)CG.CP.MP.0407/01/2024
Infectious Disease: Genitourinary Lab Testing (PDF)CG.CP.MP.0707/01/2024
Infectious Disease: Multisystem Lab Testing (PDF)CG.CP.MP.0207/01/2024
Infectious Disease: Primary Care & Preventive Lab Screening (PDF)CG.CP.MP.0507/01/2024
Infectious Disease: Respiratory Lab Testing (PDF)CG.CP.MP.0107/01/2024
Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (PDF)CG.CP.MP.0607/01/2024
Inpatient Only Procedures (PDF)CC.PP.01801/01/2013
IV Hydration (PDF)CC.PP.01201/01/2013
Leveling of Care: Evaluation and Management Overcoding (PDF)CC.PP.06611/01/2020
Leveling of ER Services (PDF)CC.PP.05310/01/2017
Maximum Units of Service (PDF)CC.PP.00701/01/2013
Moderate Conscious Sedation (PDF)CC.PP.01501/01/2013
Modifier -25 clinical validation (PDF)CC.PP.01301/01/2013
Modifier -59 clinical validation (PDF)CC.PP.01401/01/2013
Modifier DOS Validation (PDF)CC.PP.03401/01/2013
Modifier to Procedure Code Validation (PDF)CC.PP.02801/01/2013
Multiple CPT Code Replacements (PDF)CC.PP.03301/01/2014
NCCI Unbundling (PDF)CC.PP.03101/01/2013
Never Paid Events (PDF)CC.PP.01701/01/2013
New Patient (PDF)CC.PP.03601/01/2014
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)CC.PP.06105/30/18
Not Medically Necessary IP Services (PDF)CC.PP.06006/01/2018
Outpatient Consultation (PDF)CC.PP.03901/01/2014
Physician Visit Codes Billed with Labs (PDF)CC.PP.01901/01/2013
Physician's Consultation Services (PDF)CC.PP.05411/01/2017
Place of Service Mismatch (PDF)CC.PP.06309/01/2018
Post-Operative Visits (PDF)CC.PP.04201/01/2014
Pre-Operative Visits (PDF)CC.PP.04101/01/2014
Problem Oriented Visits with Preventive Visits (PDF)CC.PP.05711/1/2017
Problem Oriented Visits with Surgical Procedures (PDF)CC.PP.05211/1/2017
Professional Component Modifier -26 (PDF)CC.PP.02701/01/2013
Pulse Oximetry (PDF)CC.PP.02501/01/2014
Robotic Surgery (PDF)CC.PP.05008/2017
Same Day Visits (PDF)CC.PP.04011/01/2019
Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)OC.UM.CP.001401/01/2018
Sepsis Diagnosis (PDF)CC.PP.0734/24/2024
Severe Malnutrition (PDF)CC.PP.1454/24/2024
Skilled Nursing Facility Leveling (PDF)CC.PP.2061/24/2024
Sleep Studies Place of Services (PDF)CC.PP.03505/01/2017 
Status "B" Bundled Services (PDF)CC.PP.04601/01/2014
Status "P" Bundled Services (PDF)CC.PP.04903/15/2017
Supplies Billed on Same Day As Surgery (PDF)CC.PP.03201/01/2013
Testing for Select Genitourinary Conditions (PDF)NE.CP.MP.9711/1/2022
Transgender Related Services (PDF)CC.PP.04701/01/2017
Unbundled Professional Services (PDF)CC.PP.04301/01/2014
Unbundled Surgical Procedures (PDF)CC.PP.04501/01/2014
Unbundling Adjustments on Clean Claim Reviews (PDF)CC.PI.1009/01/2022
Unlisted Procedure Codes (PDF)CC.PP.00901/01/2013
Urine Specimen Validity Testing (PDF)CC.PP.05611/01/2017 
Visual Field Test (PDF)OC.UM.CP.006301/01/2018
Wheelchair Accessories (PDF)CC.PP.50207/01/2016