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 MHS Health Wisconsin Clinical Policy Manual apply to MHS Health Wisconsin members. Policies in the MHS Health Wisconsin Clinical Policy Manual may have either a MHS Health Wisconsin or a “Centene” heading. MHS Health Wisconsin utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a MHS Health Wisconsin 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 MHS Health Wisconsin. In addition, MHS Health Wisconsin 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 MHS Health Wisconsin.
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)
- ADHD Assessment and Treatment CP.MP.124 (PDF)
- Adolescents CP.MP.157 (PDF)
- Allogenic Hematopoietic Cell Transplants for Sickle Cell CP.MP.108 (PDF)
- Ambulatory Electroencephalography CP.MP.96 (PDF)
- Applied Behavioral Analysis for Autism CP.MP.104 (PDF)
- Articular Cartilage Defect Repairs CP.MP.26 (PDF)
- Assisted Reproductive Technology CP.MP.55 (PDF)
- Balloon Sinus Ostial Dilation CP.MP.119 (PDF)
- Bariatric Surgery CP.MP.37 (PDF)
- Bone-Anchored Hearing Aid CP.MP.93 (PDF)
- Bronchial Thermoplasty CP.MP.110 (PDF)
- Cardiac Biomarker Testing CP.MP.156 (PDF)
- Caudal or Interlaminar Epidural Steriod Injections for Pain Management CP.MP.164 (PDF)
- Cell-Free Fetal DNA Testing CP.MP.84 (PDF)
- Clinical Trials CP.MP.94 (PDF)
- Cochlear Implant Surgery Prior Authorization Criteria and Coverage (PDF)
- Cosmetic Reconstructive Surgery CP.MP.31 (PDF)
- Cystic Fibrosis Carrier Screening CP.MP.83 (PDF)
- Dental Anesthesia CP.MP.61 (PDF)
- Diagnosis of Vaginitis CP.MP.97 (PDF)
- Diagnostic Testing Guidelines for 2019-Novel Coronavirus CP.MP.183 (PDF)
- Digital EEG Spike Analysis CP.MP.105 (PDF)
- Disc Decompression Procedures CP.MP.114 (PDF)
- DME Coverage Guidelines CP.MP.107 (PDF)
- DNA Analysis of Stool CP.MP.125 (PDF)
- Donor Lymphocyte Infusion CP.MP.101 (PDF)
- Durable Medical Equipment CP.MP.107 (PDF)
- EEG in the Evaluation of Headache CP.MP.155 (PDF)
- Electric Tumor Treating Fields (Optune) CP.MP.145 (PDF)
- Endometrial Ablation CP.MP.106
- Evoked Potentials CP.MP.134 (PDF)
- Experimental Policy CP.MP.36 (PDF)
- Facet Joint Interventions for Pain Management CP.MP.171 (PDF)
- Fecal Calprotectin Assay CP.MP.135 (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 CP.MP.129 (PDF)
- Fixed Wing Air Transportation CP.MP.175 (PDF)
- Fractionated Exhaled Nitric Oxide (FeNO) Measurement CP.MP.103 (PDF)
- Functional MRI CP.MP.43 (PDF)
- Gastric Electric Stimulation CP.MP.40 (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing CP.MP.209 (PDF)
- Gender-Affirming Procedures CP.MP.95 (PDF)
- Genetic and Pharmacogenetic Testing CP.MP.89 (PDF)
- Heart-Lung Transplant CP.MP.132 (PDF)
- Holter Monitoring CP.MP.113 (PDF)
- Home Birth CP.MP.136 (PDF)
- Homocysteine Testing CP.MP.121 (PDF)
- Hyperbaric Oxygen Therapy CP.MP.27 (PDF)
- Hospice Clinical Coverage CP.MP.54 (PDF)
- Hyperemesis Gravidarum Treatment CP.MP.34 (PDF)
- Hyperhidrosis Treatments CP.MP.62 (PDF)
- Implantable Intrathecal Pain Pump CP.MP.173 (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring CP.MP.160
- Inhaled Nitric Oxide CP.MP.87 (PDF)
- Intensity-Modulated Radiotherapy CP.MP.69 (PDF)
- Intestinal and Multivisceral Transplant CP.MP.58 (PDF)
- Intradiscal Steriod Injections for Pain Management CP.MP.167 (PDF)
- Laser Therapy for Skin Conditions CP.MP.123 (PDF)
- Long Term Care Placement CP.MP.71 (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)
- Monitored Anesthesia Care for Gastrointestinal Endoscopy CP.MP.161
- Multiple Sleep Latency Testing CP.MP.24 (PDF)
- Neonatal Abstinence Syndrome Guidelines CP.MP.86 (PDF)
- Neonatal Sepsis Management Guidelines CP.MP.85 (PDF)
- Nerve Blocks for Pain Management CP.MP.170 (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)
- Novel Coronavirus Testing CP.MP.183 (PDF)
- Optic Nerve Decompression Surgery CP.MP.128 (PDF)
- Outpatient Testing for Drugs of Abuse CP.MP.50 (PDF)
- Pancreas Transplantation CP.MP.102 (PDF)
- Panniculectomy CP.MP.109 (PDF)
- Pediatric Heart Transplant CP.MP.138 (PDF)
- Pediatric Liver Transplant CP.MP.120 (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction CP.MP.133 (PDF)
- Proton Beam and Neutron Beam Therapy CP.MP.70 (PDF)
- Radiofrequency Ablation of Uterine Fibroids CP.MP.187 (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery CP.MP.51 (PDF)
- Sacroiliac Joint Fusion CP.MP.126 (PDF)
- Sacroiliac Joint Interventions for Pain Management CP.MP.166 (PDF)
- Sclerotherapy for Varicose Veins CP.MP.146 (PDF)
- Selective Dorsal Rhizotomy CP.MP.174 (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management CP.MP.165 (PDF)
- Sepsis Diagnosis CP.PP.073 (PDF)
- Short Inpatient Hospital Stay CP.MP.182 (PDF)
- Sickle Cell Disease Observation CP.MP.88 (PDF)
- Skin Substitutes for Chronic Wounds CP.MP.185 (PDF)
- Spinal Cord Stimulation CP.MP.117 (PDF)
- Stereotactic Body Radiation Therapy CP.MP.22 (PDF)
- Tandem Transplant CP.MP.162 (PDF)
- Testing Select GU Conditions CP.MP.97 (PDF)
- Therapy Services (PT/OT/ST) CP.MP.49 (PDF)
- Total Artificial Heart CP.MP.127 (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (TPN IDPN) CP.MP.163 (PDF)
- Transcranial Magnetic Stimulation CP.BH.200 (PDF)
- Trigger Point Injections for Pain Management CP.MP.169 (PDF)
- 25-hydroxyvitamin D Testing in Children and Adolescents CP.MP.157 (PDF)
- Ultrasound in Pregnancy CP.MP.38 (PDF)
- Urinary Incontinence Devices and Treatments CP.MP.142 (PDF)
- Urodynamic Testing CP.MP.98 (PDF)
- Vagus Nerve Stimulation CP.MP.12 (PDF)
- Ventricular Assist Devices CP.MP.46 (PDF)
- Ventriculectomy and Cardiomyoplasty CP.MP.56 (PDF)
- Video Electroencephalographic (VEEG) Monitoring CP.MP.177 (PDF)
- Wheelchair Seating CP.MP.99 (PDF)
- Wireless Motility Capsule CP.MP.143 (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 MHS Health Wisconsin Payment Policy Manual apply with respect to MHS Health Wisconsin members. Policies in the MHS Health Wisconsin Payment Policy Manual may have either a MHS Health Wisconsin or a “Centene” heading. In addition, MHS Health Wisconsin 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 MHS Health Wisconsin.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- 340B Drug Payment Reduction CC.PP.070 (PDF)
- Effective Date: 5/1/21
- 30-Day Readmission CC.PP.501 (PDF)
Effective Date: 3/1/17 - 3-Day Payment Window CC.PP.500 (PDF)
Effective Date: 7/1/14 - Add-on Code Billed Without Primary Code CC.PP.030 (PDF)
Effective Date: 1/1/13 - Assistant Surgeon CC.PP.029 (PDF)
Effective Date: 1/1/14 - Bilateral Procedures CC.PP.037 (PDF)
Effective Date: 1/1/14 - Cerumen Removal CC.PP.008 (PDF)
Effective Date: 1/1/14 - Clean Claims CC.PP.021 (PDF)
Effective Date: 1/1/13 - Clean Claims Review CC.PI.04 (PDF)
Effective Date: 11/1/12 - Clinical Validation of Modifier 25 CC.PP.013 (PDF)
Effective Date: 1/1/13 - Clinical Validation of Modifier 59 CC.PP.014 (PDF)
Effective Date: 1/1/13 - Code Editing Overview CC.PP.011 (PDF)
Effective Date: 1/1/13 - Cosmetic Procedures CC.PP.024 (PDF)
Effective Date: 1/1/14 - Cost to Charge Adjustments on Clean Claim Reviews CC.PI.06 (PDF)
Effective Date: 9/1/22 - Distinct Procedural Modifiers CC.PP.020 (PDF)
Effective Date: 1/1/13 - Duplicate Primary Code Billing CC.PP.044 (PDF)
Effective Date: 1/1/14 - E&M Bundling Edits CC.PP.051(PDF)
- Effective Date: 6/1/17
- E&M Services Billed with Treatment Room Revenue Codes (PDF)
- Effective Date: 01/19/22
- Extended Ophthalmoscopy OC.UM.CP.0026 (PDF)
Effective Date: 1/1/18 - External Ocular Photography OC.UM.CP.0043 (PDF)
Effective Date: 10/1/16 - Fluorescein Angiography OC.UM.CP.0028 (PDF)
Effective Date:1/1/18 - Fundus Photography OC.UM.CP.0029 (PDF)
Effective Date: 1/1/18 - Gonioscopy OC.UM.CP.0031 (PDF)
Effective Date: 1/1/16 - Hospital Visit Codes Billed With Labs CC.PP.023 (PDF)
Effective Date: 1/1/13' - Inpatient Consultation CC.PP.038 (PDF)
Effective Date: 1/1/14 - Inpatient Only Procedures CC.PP.018 (PDF)
Effective Date: 1/1/13 - Intravenous Hydration CC.PP.012 (PDF)
Effective Date: 1/1/13 - Maximum Units of Services CC.PP.007 (PDF)
Effective Date: 1/1/13 - Moderate Conscious Sedation CC.PP.015 (PDF)
Effective Date: 1/1/13 - Modifier DOS Validation CC.PP.034 (PDF)
Effective Date: 1/1/13 - Modifier to Procedure Code Validation CC.PP.028 (PDF)
Effective Date: 1/1/13 - Multiple CPT Code Replacement CC.PP.033 (PDF)
Effective Date: 1/1/14 - Multiple Diagnostic Cardiovascular Procedure Payment Reduction CC.PP.065 (PDF)
Effective Date: 5/1/21 - Multiple Procedure Payment Reduction for Therapeutic Services CC.PP.068 (PDF)
Effective Date: 5/1/21 - Multiple Procedure Reduction: Ophthalmology CC.PP.069 (PDF)
Effective Date: 5/1/21 - NCCI Unbundling CC.PP.031 (PDF)
Effective Date: 1/1/13 - Never Paid Events CC.PP.017 (PDF)
Effective Date: 1/1/13 - New Patient CC.PP.036 (PDF)
Effective Date: 1/1/14 - Non-obstetrical Pelvic and Transvaginal Ultrasounds CC.PP.061 (PDF)
Effective Date: 05/01/21 - Not Medically Necessary Inpatient Professional Services CC.PP.60 (PDF)
Effective Date: 6/1/18 - Outpatient Consultation CC.PP.039 (PDF)
Effective Date: 1/1/14 - Physician Visit Codes Billed with Labs CC.PP.019 (PDF)
Effective Date: 1/1/13 - Place of Service Mismatch CC.PP.063 (PDF)
Effective Date: 9/1/18 - Post-Operative Visits CC.PP.042 (PDF)
Effective Date: 1/1/14 - Pre-Operative Visits CC.PP.041 (PDF)
Effective Date: 1/1/14 - Problem Oriented Visits With Preventative Visits CC.PP.057 (PDF)
Effective Date: 12/01/17 - Professional Component Modifier CC.PP.027 (PDF)
Effective Date: 1/1/13 - Pulse Oximetry With Office Visits CC.PP.025 (PDF)
Effective Date: 1/1/14 - Reporting the Global Maternity Package CC.PP.016 (PDF)
Effective Date: 1/1/13 - Robotic Surgery CC.PP.050 (PDF)
Effective Date: 9/1/17 - Same Day Visits CC.PP.040 (PDF)
Effective Date: 3/1/18 - Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) OC.UM.CP.0014 (PDF)
Effective Date: 1/1/18 - Sepsis Diagnosis CC.PP.073 (PDF)
Effective Date: 3/1/22 - Sleep Studies Place of Services CC.PP.035 (PDF)
Effective Date: 5/1/17 - Status "B" Bundled Services CC.PP.046 (PDF)
Effective Date: 1/1/14 - Status "P" Bundled Services CC.PP.049 (PDF)
Effective Date: 3/15/17 - Supplies billed on Same Day as Surgery CC.PP.032 (PDF)
Effective Date: 1/1/13 - Transgender Related Services CC.PP.047 (PDF)
Effective Date: 1/1/17 - Unbundled Professional Services CC.PP.043 (PDF)
Effective Date: 1/1/14 - Unbundled Surgical Procedures CC.PP.045 (PDF)
Effective Date: 1/1/14 - Unbundling Adjustments on Clean Claim Reviews CC.PI.10 (PDF)
Effective Date: 9/1/22 - Unlisted Procedure Codes CC.PP.009 (PDF)
Effective Date: 1/1/13 - Visual Field Testing OC.UM.CP.0063
Effective Date: 1/1/18 - Wheelchair and Accessories CC.PP.502 (PDF)
Effective Date: 8/12/16