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Clinical & Payment Policies

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

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

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ADHD Assessment and Treatment (PDF)
Effective Date: 1/15/2017

H Pylori Testing (PDF)
Effective Date: 5/1/2018

Rituximab (PDF)
Effective Date: 8/18/2016

Adverse Determination (Denial) Notices (PDF)
Effective Date: 5/1/2011

Holter Monitors (PDF)
Effective Date: 1/15/2017

Thyroid Testing in Pediatrics (PDF)
Effective Date: 5/1/2018

Allergy Testing (PDF)
Effective Date: 8/18/2016

Homocysteine Testing (PDF)
Effective Date: 1/15/2017

Timeliness of UM Decisions and Notifications (PDF)
Effective Date: 3/21/2018

Ambulatory EEG (PDF)
Effective Date: 8/18/2016

Laser Skin Treatment (PDF)
Effective Date: 1/15/2017

Ultrasound in Pregnancy (PDF)
Effective Date: 8/15/2016

Appropriate UM Professionals (PDF)
Effective Date: 3/1/2016

Lost, Stolen, Spilled or Broken Medication & Vacation Overrides (PDF)
Effective Date: 4/1/2007

Urodynamic Testing (PDF)
Effective Date: 8/15/2016

ASC Steerage (PDF)
Effective Date: 8/1/2018

Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 9/1/2017

Vitamin D Testing in Children (PDF)
Effective Date: 5/1/2018

Bevacizumab (PDF)
Effective Date: 8/18/2016

Measure Serum 1,25 Vitamin D (PDF)
Effective Date: 5/1/2018

Wheelchair Seating (PDF)
Effective Date: 8/15/2016

Bronchial Thermoplasty (PDF)
Effective Date: 1/15/2017

Mechanical Stretch Devices (PDF)
Effective Date: 9/1/2017

Wireless Motility Capsule (PDF)
Effective Date: 9/1/2017

Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 5/1/2018

Monitored Anesthia (PDF)
Effective Date: 10/1/2018

 

Clinical Decision Criteria and Application (PDF)
Effective Date: 3/16/2016

Paclitaxel (PDF)
Effective Date: 10/12/2015

 

Clinical Information and Documentation (PDF)
Effective Date: 5/1/2011

Pharmacy Lock-In Program (PDF)
Effective Date: 7/1/2011

 

Diagnosis of Vaginitis (PDF)
Effective Date: 1/15/2017

Preferred Drug List (PDF)
Effective Date: 1/1/2018

 

Digital Analysis of EEGs (PDF)
Effective Date: 12/1/2016

PROM Testing (PDF)
Effective Date: 10/8/2017

 

DNA Analysis of Stool (PDF)
Effective Date: 5/1/2017

Proton and Neutron Beam Therapy (PDF)
Effective Date: 12/1/2016

 

EEG in Evaluation of Headache (PDF)
Effective Date: 5/1/2018

   

Emergency Services (PDF)
Effective Date: 5/1/2011

   

Endometrial Ablation (EA) (PDF)
Effective Date: 12/1/2016

   

EpiFix Wound Treatment (PDF)
Effective Date: 9/1/2017

 

 

Evoked Potentials (PDF)
Effective Date: 5/1/2017

 

 

Fecal Calprotectin Assay (PDF)
Effective Date: 5/1/2017

 

 

FeNo Testing (PDF)
Effective Date: 1/15/2017

 

 

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

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

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3 Day Payment Window (PDF)
Effective Date: 7/1/2014
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 10/20/2016
Robotic Surgery (PDF)
Effective Date: 9/1/2017
30-Day Readmission (PDF)
Effective Date: 2/1/2017
Inpatient Consultation (PDF)
Effective Date: 2/6/2017
Same Day Visits (PDF)
Effective Date: 2/6/2017
Add on Code Billed Without Primary Code (PDF)
Effective Date: 9/1/2016
Inpatient Only Procedures (PDF)
Effective Date: 10/20/2016
Sleep Studies Place of Service (PDF)
Effective Date: 5/1/2017
Assistant Surgeon (PDF)
Effective Date: 2/6/2017
Intravenous Hydration (PDF)
Effective Date: 10/20/2016
Status "B" Bundled Services (PDF)
Effective Date: 2/6/2017
Bilateral Procedures (PDF)
Effective Date: 2/6/2017
Leveling of ER Services (PDF)
Effective Date: 10/8/2017
Status "P" Bundled Services (PDF)
Effective Date: 4/1/2017
Cerumen Removal (PDF)
Effective Date: 4/6/2016
Maximum Units (PDF)
Effective Date: 4/6/2016
Supplies Billed on Same Day as Surgery (PDF)
Effective Date: 9/1/2016
Clean Claims (PDF)
Effective Date: 10/20/2016
Moderate Conscious Sedation (PDF)
Effective Date: 10/20/2016
Transgender Related Services (PDF)
Effective Date: 2/22/2017
Clinical Labatory Improvement Amendments (CLIA) (PDF)
Effective Date: 10/20/2016
Modifier DOS Validation (PDF)
Effective Date: 9/1/2016
Unbundled Professional Services (PDF)
Effective Date: 3/28/2017
Clinical Validation of Modifer 25 (PDF)
Effective Date: 10/20/2016
Modifier to Procedure Code Validation (PDF)
Effective Date: 11/9/2016
Unbundled Surgical Procedures (PDF)
Effective Date: 3/28/2017
Clinical Validation of Modifier 59 (PDF)
Effective Date: 10/20/2016
Multiple CPT Code Replacement (PDF)
Effective Date: 9/1/2016
Unlisted Procedure Codes (PDF)
Effective Date: 4/6/2016
Coding Overview (PDF)
Effective Date: 10/20/2016
NCCI Unbundling (PDF)
Effective Date: 9/1/2016
Urine Specimen Validity Testing (PDF)
Effective Date: 10/8/2017
Cosmetic Procedures (PDF)
Effective Date: 10/20/2016
Never Paid Events (PDF)
Effective Date: 10/20/2016
Wheelchairs and Accessories (PDF)
Effective Date: 3/1/2018
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)
Effective Date: 10/20/2016
New Patient (PDF)
Effective Date: 3/14/2017
 
Duplicate Primary Code Billing (PDF)
Effective Date: 2/6/2017
Outpatient Consultations (PDF)
Effective Date: 2/6/2017
 
E & M Bundling with Labs and Radiology (PDF)
Effective Date: 4/6/2016
Pelvic and Transabdominal Ultrasound (PDF)
Effective Date: 10/1/2018
 
E & M Medical Decision-Making (PDF)
Effective Date: 7/26/2017
Place of Service Mismatch (PDF)
Effective Date: 10/1/2018
 
Global Maternity Package (PDF)
Effective Date: 10/20/2016
Physician Services (Visit Codes) Billed With Labs (PDF)
Effective Date: 10/20/2016
 
  Physician's Consultation Services (PDF)
Effective Date: 10/8/2017
 
  Physician's Office Lab Testing (PDF)
Effective Date: 10/8/2017
 
  Post-operative Visits (PDF)
Effective Date: 2/6/2017
 
  Pre-operative Visits (PDF)
Effective Date: 2/6/2017
 
  Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: 10/8/2017
 
  Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 10/8/2017
 
  Professional Component (PDF)
Effective Date: 11/9/2016
 
  Pulse Oximetry (PDF)
Effective Date: 9/1/2016