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

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

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

Maximum Units (PDF)

Cerumen Removal (PDF)

Unlisted Procedure Codes (PDF)

EM Bundling Edits (PDF)

Coding Overview (PDF)

IV Hydration (PDF)

Modifier -25 clinical validation (PDF)

Modifier -59 clinical validation (PDF)

Moderate Conscious Sedation (PDF)

Global Maternity Billing (PDF)

Never Paid Events (PDF)

Inpatient Only Procedures (PDF)

Physician Visit Codes Billed with Labs (PDF)

Distinct Procedural Modifiers (PDF)

Clean Claims (PDF)

Hospital Visit Codes Billed with Labs (PDF)

Cosmetic Procedures (PDF)

Pulse Oximetry (PDF)

Professional Component (PDF)

Modifier to Procedure Code Validation (PDF)

Assistant Surgeon (PDF)

Add on Code Billed Without Primary Code (PDF)

NCCI Unbundling (PDF)

Supplies Billed on Same Day As Surgery (PDF)

Multiple CPT Code Replacement (PDF)

Modifier DOS Validation (PDF)

New Patient (PDF)

Bilateral Procedures (PDF)

Inpatient Consultation (PDF)

Outpatient Consultation (PDF)

Same Day Visits (PDF)

Pre-Operative Visits (PDF)

Post-Operative Visits (PDF)

Unbundled Professional Services (PDF)

Duplicate Primary Code Billing (PDF)

Problem Oriented Visits with Preventative Visits (PDF)

Place of Service Mismatch (PDF)

3-Day Payment Window (PDF)

Unbundled Surgical Procedures (PDF)

Status "B" Bundled Services (PDF)

Transgender Related Services (PDF)

Status P Bundled Services (PDF)

E&M Medical Decision-Making (PDF)

Problem Oriented Visits with Surgical Procedures (PDF)

Leveling of ER Services (PDF)

Urine Specimen Validity Testing (PDF)

Wheelchair Accessories (PDF)