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.
- Adopted Clinical Practice and Preventive Health Guidelines CPG Grid (PDF)
- Air Ambulance CP.MP.175 (PDF)
- Applied Behavior Analysis CP.BH.104 (PDF)
- Articular Cartilage Defect Repairs CP.MP.26 (PDF)
- Attention Deficit Hyperactivity Disorder Assessment and Treatment CP.BH.124 (PDF)
- Bariatric Surgery CP.MP.37 (PDF)
- Behavioral Health Treatment Documentation Requirements CP.BH.500 (PDF)
- Benign Skin Lesion Removal WI.MP.01 (PDF)
- Biofeedback CP.MP.168 (PDF)
- Biofeedback for Behavioral Health Disorders CP.BH.300 (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 CP.MP.164 (PDF)
- Clinical Trials CP.MP.94 (PDF)
- Cochlear Implant Replacements CP.MP.14 (PDF)
- Concert Genetic Testing: Aortopathies and Connective Tissue Disorders V2.2024 (PDF)
- Concert Genetic Testing: Cardiac Disorders V2.2024 (PDF)
- Concert Genetic Testing: Dermatologic Conditions V2.2024 (PDF)
- Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions V2.2024 (PDF)
- Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders V2.2024 (PDF)
- Concert Genetic Testing: Eye Disorders V2.2024 (PDF)
- Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) V2.2024 (PDF)
- Concert Genetic Testing: General Approach to Genetic and Molecular Testing V2.2024 (PDF)
- Concert Genetic Testing: Hearing Loss V2.2024 (PDF)
- Concert Genetic Testing: Hematologic Conditions (non-cancerous) V2.2024 (PDF)
- Concert Genetic Testing: Hereditary Cancer Susceptibility V2.2024 (PDF)
- Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders V2.2024 (PDF)
- Concert Genetic Testing: Kidney Disorders V2.2024 (PDF)
- Concert Genetic Testing: Lung Disorders V2.2024 (PDF)
- Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders V2.2024 (PDF)
- Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay V2.2024 (PDF)
- Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) V2.2024 (PDF)
- Concert Genetic Testing: Pharmacogenetics V2.2024 (PDF)
- Concert Genetic Testing: Preimplantation Genetic Testing V2.2024 (PDF)
- Concert Genetic Testing: Prenatal and Preconception Carrier Screening V2.2024 (PDF)
- Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss V2.2024 (PDF)
- Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders V2.2024 (PDF)
- Concert Genetics Oncology: Algorithmic Testing V2.2024 (PDF)
- Concert Genetics Oncology: Cancer Screening V2.2024 (PDF)
- Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) V2.2024 (PDF)
- Concert Genetics Oncology: Cytogenetic Testing V2.2024 (PDF)
- Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies V2.2024 (PDF)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder CP.BH.201 (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation CP.MP.203 (PDF)
- Disc Decompression Procedures CP.MP.114 (PDF)
- Discography CP.MP.115 (PDF)
- Durable Medical Equipment and Orthotics and Prosthetics Guidelines CP.MP.107 (PDF)
- Drugs of Abuse: Definitive Testing CP.MP.50 (PDF)
- Electric Tumor Treating Fields CP.MP.145 (PDF)
- Evoked Potential Testing CP.MP.134 (PDF)
- Experimental Technologies CP.MP.36 (PDF)
- Facet Joint Interventions CP.MP.171 (PDF)
- Facility-based Sleep Studies for Obstructive Sleep Apnea CP.MP.248 (PDF)
- Fecal Incontinence Treatments CP.MP.137 (PDF)
- Ferriscan R2-MRI CP.MP.53 (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations CP.MP.129 (PDF)
- Functional MRI CP.MP.43 (PDF)
- Gastric Electrical Stimulation CP.MP.40 (PDF)
- Gender-Affirming Procedures CP.MP.95 (PDF)
- Heart-Lung Transplant CP.MP.132 (PDF)
- Holter Monitors CP.MP.113 (PDF)
- Home Births CP.MP.136 (PDF)
- Home Ventilators CP.MP.184 (PDF)
- Hospice Services CP.MP.54 (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea CP.MP.180 (PDF)
- Implantable Loop Recorder CP.MP.243 (PDF)
- Implantable Intrathecal or Epidural Pain Pump CP.MP.173 (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring CP.MP.160 (PDF)
- Intensity-Modulated Radiotherapy CP.MP.69 (PDF)
- Intestinal and Multivisceral Transplant CP.MP.58 (PDF)
- Intradiscal Steroid Injections for Pain Management CP.MP.167 (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures CP.MP.61 (PDF)
- Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy CP.MP.250 (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)
- Multiple Sleep Latency Testing CP.MP.24 (PDF)
- Neonatal Abstinence Syndrome Guidelines CP.MP.86 (PDF)
- Neonatal Sepsis Management CP.MP.85 (PDF)
- Nerve Blocks and Neurolysis for Pain Management CP.MP.170 (PDF)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) CP.MP.48 (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)
- Obstetrical Home Care Programs CP.MP.91 (PDF)
- Orthognathic Surgery CP.MP.202 (PDF)
- Osteogenic Stimulation CP.MP.194 (PDF)
- Outpatient Cardiac Rehabilitation CP.MP.176 (PDF)
- Outpatient Oxygen Use CP.MP.190 (PDF)
- Pancreas Transplantation CP.MP.102 (PDF)
- Pediatric Heart Transplant CP.MP.138 (PDF)
- Pediatric Kidney Transplant CP.MP.246 (PDF)
- Pediatric Liver Transplant CP.MP.120 (PDF)
- Pediatric Oral Function Therapy CP..MP.188 (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention CP.MP.147 (PDF)
- Physical, Occupational, and Speech Therapy Services CP.MP.49 (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction CP.MP.133 (PDF)
- Proton and Neutron Beam Therapies CP.MP.70 (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery CP.MP.51 (PDF)
- Repair of Nasal Valve Compromise CP.MP.210 (PDF)
- Sacroiliac Joint Fusion CP.MP.126 (PDF)
- Sacroiliac Joint Interventions for Pain Management CP.MP.166 (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders CP.MP.146 (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections CP.MP.165 (PDF)
- Short Inpatient Hospital Stay CP.MP.182 (PDF)
- Skin and Soft Tissue Substitutes for Chronic Wounds CP.MP.185 (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation CP.MP.117 (PDF)
- Stereotactic Body Radiation Therapy CP.MP.22 (PDF)
- Substance Use Disorders Treatment and Services CP.BH.100 (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide CP.MP.87 (PDF)
- Total Artificial Heart CP.MP.127 (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition CP.MP.163 (PDF)
- Transcatheter Closure of Patent Foramen Ovale CP.MP.151 (PDF)
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression CP.BH.200 (PDF)
- Transplant Service Documentation Requirements CP.MP.247 (PDF)
- Trigger Point Injections for Pain Management CP.MP.169 (PDF)
- Urinary Incontinence Devices and Treatments CP.MP.142 (PDF)
- Vagus Nerve Stimulation CP.MP.12 (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 - Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing CP.MP.209 (PDF)
- 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 - Leveling of Emergency Room Services CC.PP.053 (PDF)
Effective Date: 6/1/24 - 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 - Optum Comprehensive Payment Integrity (CPI) CC.PP.074 (PDF)
Effective 5/1/2023 - 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: 4/1/24 - Severe Malnutrition CC.PP.145 (PDF)
Effective Date: 4/1/24 - 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