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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 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.

 

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.

A-H I-Q R-Z
30-Day Readmission CC.PP.501 (PDF)
Effective Date: 3/1/17
Inpatient Consultation CC.PP.038 (PDF)
Effective Date: 1/1/14
Reporting the Global Maternity Package CC.PP.016 (PDF)
Effective Date: 1/1/13
3-Day Payment Window CC.PP.500 (PDF)
Effective Date: 7/1/14
Inpatient Only Procedures CC.PP.018 (PDF)
Effective Date: 1/1/13
Robotic Surgery CC.PP.050 (PDF)
Effective Date: 9/1/17
Add-on Code Billed Without Primary Code CC.PP.030 (PDF)
Effective Date: 1/1/13
Intravenous Hydration CC.PP.012 (PDF)
Effective Date: 1/1/13
Same Day Visits CC.PP.040 (PDF)
Effective Date: 3/1/18
Assistant Surgeon CC.PP.029 (PDF)
Effective Date: 1/1/14
Maximum Units of Services CC.PP.007 (PDF)
Effective Date: 1/1/13
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) OC.UM.CP.0014 (PDF)
Effective Date: 1/1/18
Bilateral Procedures CC.PP.037 (PDF)
Effective Date: 1/1/14
Moderate Conscious Sedation CC.PP.015 (PDF)
Effective Date: 1/1/13
Sleep Studies Place of Services CC.PP.035 (PDF)
Effective Date: 5/1/17
Cerumen Removal CC.PP.008 (PDF)
Effective Date: 1/1/14
Modifier DOS Validation CC.PP.034 (PDF)
Effective Date: 1/1/13
Status "B" Bundled Services CC.PP.046 (PDF)
Effective Date: 1/1/14
Clean Claims CC.PP.021 (PDF)
Effective Date: 1/1/13
Modifier to Procedure Code Validation CC.PP.028 (PDF)
Effective Date: 1/1/13
Status "P" Bundled Services CC.PP.049 (PDF)
Effective Date: 3/15/17
Clinical Laboratory Improvement Amendments (CLIA) CC.PP.022 (PDF)
Effective Date: 1/1/13
Multiple CPT Code Replacement CC.PP.033 (PDF)
Effective Date: 1/1/14
Supplies billed on Same Day as Surgery CC.PP.032 (PDF)
Effective Date: 1/1/13
Clinical Validation of Modifier 25 CC.PP.013 (PDF)
Effective Date: 1/1/13
NCCI Unbundling CC.PP.031 (PDF)
Effective Date: 1/1/13
Transgender Related Services CC.PP.047 (PDF)
Effective Date: 1/1/17
Clinical Validation of Modifier 59 CC.PP.014 (PDF)
Effective Date: 1/1/13
Never Paid Events CC.PP.017 (PDF)
Effective Date: 1/1/13
Unbundled Professional Services CC.PP.043 (PDF)
Effective Date: 1/1/14
Code Editing Overview CC.PP.011 (PDF)
Effective Date: 1/1/13
New Patient CC.PP.036 (PDF)
Effective Date: 1/1/14
Unbundled Surgical Procedures CC.PP.045 (PDF)
Effective Date: 1/1/14
Cosmetic Procedures CC.PP.024 (PDF)
Effective Date: 1/1/14
Non-obstetrical Pelvic and Transvaginal Ultrasounds CC.PP.061 (PDF)
Effective Date: 50/30/18
Unlisted Procedure Codes CC.PP.009 (PDF)
Effective Date: 1/1/13
Distinct Procedural Modifiers CC.PP.020 (PDF)
Effective Date: 1/1/13
Outpatient Consultation CC.PP.039 (PDF)
Effective Date: 1/1/14
Visual Field Testing OC.UM.CP.0063
Effective Date: 1/1/18
Duplicate Primary Code Billing CC.PP.044 (PDF)
Effective Date: 1/1/14
Physician Visit Codes Billed with Labs CC.PP.019 (PDF)
Effective Date: 1/1/13
Wheelchair and Accessories CC.PP.502 (PDF)
Effective Date: 8/12/16
E&M Bundling Edits CC.PP.051(PDF)
Effective Date: 6/1/17
Place of Service Mismatch CC.PP.063
Effective Date: 9/1/18
 
Extended Ophthalmoscopy OC.UM.CP.0026 (PDF)
Effective Date: 1/1/18
Post-Operative Visits CC.PP.042 (PDF)
Effective Date: 1/1/14
 
External Ocular Photography OC.UM.CP.0043 (PDF)
Effective Date: 10/1/16
Pre-Operative Visits CC.PP.041 (PDF)
Effective Date: 1/1/14
 
Fluorescein Angiography OC.UM.CP.0028 (PDF)
Effective Date:1/1/18
Problem Oriented Visits With Preventative Visits CC.PP.057 (PDF)
Effective Date: 12/01/17
 
Fundus Photography OC.UM.CP.0029 (PDF)
Effective Date: 1/1/18
Professional Component Modifier CC.PP.027 (PDF)
Effective Date: 1/1/13
 
Gonioscopy OC.UM.CP.0031 (PDF)
Effective Date: 1/1/16
Pulse Oximetry With Office Visits CC.PP.025 (PDF)
Effective Date: 1/1/14
 
Hospital Visit Codes Billed With Labs CC.PP.023 (PDF)
Effective Date: 1/1/13