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

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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Acupuncture (PDF)

Effective Date: 12/1/2023

  
ADHD Assessment and Treatment (PDF)
Effective Date: 9/1/2022

H Pylori Testing (PDF)
Effective Date: 9/1/2022

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

Allergy Testing (PDF)
Effective Date: 9/1/2022

Holter Monitors (PDF)
Effective Date: 9/1/2022

Testing for Rupture of Fetal Membranes
Effective Date: 9/1/2022

Ambulatory EEG (PDF)
Effective Date: 9/1/2022

Homocysteine Testing (PDF)
Effective Date: 9/1/2022

Testing for Select Genitourinary Conditions

Effective Date: 9/1/2022

  

Sterilization (PDF)

Effective Date: 10/1/2023

Bevacizumab (PDF)
Effective Date: 1/1/2019

Laser Skin Treatment (PDF)
Effective Date: 9/1/2022

Ultrasound in Pregnancy (PDF)
Effective Date: 9/1/2022

Bronchial Thermoplasty (PDF)
Effective Date: 9/1/2022

Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 9/1/2022

Urodynamic Testing (PDF)
Effective Date: 9/1/2022

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

Measure Serum 1,25 Vitamin D (PDF)
Effective Date: 9/1/2022

Vitamin D Testing in Children (PDF)
Effective Date: 9/1/2022

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

Mechanical Stretch Devices (PDF)
Effective Date: 9/1/2022

Wheelchair Seating (PDF)
Effective Date: 9/1/2022

Digital Analysis of EEGs (PDF)
Effective Date: 9/1/2022

Opioid Analgesics (PDF)
Effective Date: 7/1/2017

Wireless Motility Capsule (PDF)
Effective Date: 9/1/2022

 

Out of Network and Non-emergent Out of State (PDF)

Effective Date: 11/1/2023

 

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

 

Paclitaxel (PDF)
Effective Date: 2/14/2019

 
Preferred Drug List (PDF)
Effective Date: 8/4/2020
 

EEG in Evaluation of Headache (PDF)
Effective Date: 9/1/2022

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

Endometrial Ablation (EA) (PDF)
Effective Date: 9/1/2022

Proton and Neutron Beam Therapy (PDF)
Effective Date: 9/1/2022

 

Elective Abortion (PDF)

Effective Date: 11/1/2023

  

EpiFix Wound Treatment (PDF)
Effective Date: 9/1/2022

  

Evoked Potentials (PDF)
Effective Date: 9/1/2022

 

 

Fecal Calprotectin Assay (PDF)
Effective Date: 9/1/2022

  

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

 

 
Fractional Exhaled Nitric Oxide (PDF)
Effective Date: 9/1/2022
  

Gender Affirming Surgery for the Treatment of Gender Dysphoria in Adults (PDF)

Effective Date: 11/1/2023

  

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

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
Renal Hemodialysis (PDF)
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
Testing for Select Genitourinary Conditions (PDF)
Clinical Validation of Modifer 25 (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 Modifier 59 (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
Coding Overview (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
 Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)Urine Specimen Validity Testing (PDF)
Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (PDF)
Cosmetic Procedures (PDF)
Effective Date: 10/20/2016
Multiple Procedure Reduction: Ophthalmology (PDF)Urine Specimen Validity Testing (PDF)
Effective Date: 10/8/2017
NCCI Unbundling (PDF)
Effective Date: 9/1/2016
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)
Effective Date: 10/20/2016
Never Paid Events (PDF)
Effective Date: 10/20/2016

Wheelchairs and Accessories (PDF)
Effective Date: 3/1/2018

Duplicate Primary Code Billing (PDF)
Effective Date: 2/6/2017
New Patient (PDF)
Effective Date: 3/14/2017
 
E & M Bundling with Labs and Radiology (PDF)
Effective Date: 4/6/2016
Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF) 
Not Medically Necessary Inpatient Services (PDF)
Effective Date: 8/15/2019
 
E & M Medical Decision-Making (PDF)
Effective Date: 7/26/2017
Outpatient Consultations (PDF)
Effective Date: 2/6/2017
 
Global Maternity Package (PDF)
Effective Date: 10/20/2016
Pelvic and Transabdominal Ultrasound (PDF)
Effective Date: 10/1/2018
 
 Place of Service Mismatch (PDF)
Effective Date: 10/1/2018
 
 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
 

Pharmacy Policies

YouthCare is committed to supplying proper, high-quality, and cost-effective drug therapy to all members. YouthCare pharmacy policies are one set of guidelines used to aid in administering YouthCare benefits, either by prior authorization or payment rules, and may be posted with a “YouthCare” or a “Centene” heading.