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

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
25-Hydroxyvitamin D testing in Children and Adolescents (PDF)
Effective Date: 12/29/17
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
Effective Date: 4/30/18
Radial Head Implant (PDF)
Effective Date: 5/31/18
Acupuncture (PDF)
Effective Date: 11/30/17
Inhaled Nitric Oxide (PDF)
Effective Date: 9/30/17
Reduction Mammoplasty and Gynecomastia Surgery (PDF)
Effective Date: 7/31/18
ADHD Assessment and Treatment (PDF)
Effective Date: 5/31/18
Injections for Pain Management (PDF)
Effective Date: 7/30/18
Sacroiliac Joint Fusion (PDF)
Effective Date: 6/30/18
Allergy Testing and Therapy (PDF)
Effective Date: 1/31/18
Intensity-Modulated Radiotherapy (PDF)
Effective Date: 2/28/18
Sclerotherapy for Vericose Veins (PDF)
Effective Date: 4/30/18
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF)
Effective Date: 2/28/18
Intestinal and Multivisceral Transplant (PDF)
Effective Date: 6/30/18
Sickle Cell Disease Observation (PDF)
Effective Date: 7/31/18
Ambulatory EEG (PDF)
Effective Date: 9/30/17
Laser Therapy for Skin Conditions (PDF)
Effective Date: 6/30/18
Spinal Cord Stimulation (PDF)
Effective Date: 5/31/18
Ambulatory Surgery Center Optimization (PDF)
Effective Date: 2/16/18
Long Term Care Placement Criteria (PDF)
Effective Date: 4/30/18
Stereotactic Body Radiation Therapy (PDF)
Effective Date: 1/31/18
Applied Behavioral Analysis for Autism (PDF)
Effective Date: 1/31/18
Low-frequency Ultrasound Therapy for Wound Management (PDF)
Effective Date: 1/31/18
Tandem Transplant (PDF)
Effective Date: 7/31/18
Articular Cartilage Defect Repairs (PDF)
Effective Date: 4/30/18
Lung Transplantation (PDF)
Effective Date: 11/30/17
Testing for Rupture of Fetal Membranes (PDF)
Effective Date: 6/30/18
Assisted Reproductive Technology (PDF)
Effective Date: 3/31/18
Lysis of Epidural Lesions (PDF)
Effective Date: 5/31/18
Testing for Select Genitourinary Conditions (PDF)
Effective Date: 9/30/17
Balloon Sinus Ostial Dilation (PDF)
Effective Date: 11/31/17
Measurement of Serum 1,25-Dihydroxyvitamin D (PDF)
Effective Date: 12/29/2017
Therapy Services (PT/OT/ST) (PDF)
Effective Date: 6/22/18
Bariatric Surgery (PDF)
Effective Date: 6/30/18
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
Effective Date: 3/31/18
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: 12/29/17
Biofeedback (PDF)
Effective Date: 5/31/18
Medical Necessity Criteria (PDF)
Effective Date: 6/30/18
Total Artificial Heart (PDF)
Effective Date: 12/29/17
Bone-anchored Hearing Aid (PDF)
Effective Date: 12/31/17
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
Effective Date: 5/31/18
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Effective Date: 4/30/18
Bronchial Thermoplasty (PDF)
Effective Date: 3/31/18
Multiple Sleep Latency Testing (PDF)
Effective Date: 4/30/18
Transcatheter Closure of Patent Foramen Ovale (PDF)
Effective Date: 12/29/17
Cardiac Biomarker Testing (PDF)
Effective Date: 3/30/18
Neonatal Abstinence Syndrome Guidelines (PDF)
Effective Date: 10/30/17
Ultrasound in Pregnancy (PDF)
Effective Date: 6/30/18
Carrier Screening in Pregnancy (PDF)
Effective Date: 5/31/18
Neonatal Sepsis Management (PDF)
Effective Date: 7/31/18
Urinary Incontinence Devices and Treatments (PDF)
Effective Date: 3/31/18
Cell-free Fetal DNA Testing (PDF)
Effective Date: 4/30/18
NICU Apnea Bradycardia Guidelines (PDF)
Effective Date: 5/31/18
Urodynamic Testing (PDF)
Effective Date: 10/30/17
Clinical Trials (PDF)
Effective Date: 11/30/17
NICU Discharge Guidelines (PDF)
Effective Date: 9/30/17
Vagus Nerve Stimulation (PDF)
Effective Date: 10/31/17
Cochlear Implant Replacements (PDF)
Effective Date: 7/31/18
Non-myeloablative Allogeneic Stem Cell Transplants (PDF)
Effective Date: 2/28/18
Ventricular Assist Devices (PDF)
Effective Date: 2/28/18
Cosmetic and Reconstructive Surgery (PDF)
Effective Date: 3/31/18
Obstetrical Home Health Care Programs (PDF)
Effective Date: 1/31/18
Ventriculectomy and Cardiomyoplasty (PDF)
Effective Date: 2/28/18
Dental Anesthesia (PDF)
Effective Date: 4/30/18
Optic Nerve Decompression Surgery (PDF)
Effective Date: 9/30/17
Wheelchair Seating (PDF)
Effective Date: 10/31/17
Digital Breast Tomosynthesis (PDF)
Effective Date: 10/31/17
Outpatient Testing for Drugs of Abuse (PDF)
Effective Date: 7/31/18
Wireless Motility Capsule (PDF)
Effective Date: 3/31/18
Digital Electroencephalography Spike Analysis (PDF)
Effective Date: 1/31/18
Pancreas Transplant (PDF)
Effective Date: 1/31/18
Zika Virus Testing (PDF)
Effective Date: 5/31/18
Disc Decompression Procedures (PDF)
Effective Date: 5/31/18
Panniculectomy (PDF)
Effective Date: 3/31/18
 
Discography (PDF)
Effective Date: 6/30/18
Pediatric Heart Transplant (PDF)
Effective Date: 1/31/18
 
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF)
Effective Date: 7/31/18
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
Effective Date: 5/31/18
 
Donor Lymphocyte Infusion (PDF)
Effective Date: 11/30/17
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
Effective Date: 10/30/17
 
Durable Medical Equipment (DME) (PDF)
Effective Date: 7/31/18
Proton and Neutron Beam Therapy (PDF)
Effective Date: 2/28/18
 
Electric Tumor Treating Fields (PDF)
Effective Date: 3/31/18
   
Electroencephalography in the Evaluation of Headache (PDF)
Effective Date: 12/29/18
   
Endometrial Ablation (PDF)
Effective Date: 7/31/18
   
EpiFix Wound Treatment (PDF)
Effective Date: 3/31/18
   
Essure Removal (PDF)
Effective Date: 11/30/17
   
Evoked Potential Testing (PDF)
Effective Date: 11/30/17
   
Experimental Technologies (PDF)
Effective Date: 6/30/18
   
Fecal Calprotectin Assay (PDF)
Effective Date: 11/30/17
   
Fecal Incontinence Treatments (PDF)
Effective Date: 12/29/17
   
Ferriscan R2-MRI (PDF)
Effective Date: 11/30/17
   
Fertility Preservation (PDF)
Effective Date: 10/30/17
   
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)
Effective Date: 10/30/17
   
Fractional Exhaled Nitric Oxide (PDF)
Effective Date: 12/29/17
   
Functional MRI (PDF)
Effective Date: 10/31/17
   
Gastric Electrical Stimulation (PDF)
Effective Date: 10/31/17
   
Gender Reassignment Surgery (PDF)
Effective Date: 11/30/17
   
Genetic Testing (PDF)
Effective Date: 4/30/18
   
H. Pylori Serology Testing (PDF)
Effective Date: 12/29/17
   
Heart-Lung Transplant (PDF)
Effective Date: 4/30/18
   
Holter Monitors (PDF)
Effective Date: 6/30/18
   
Home Birth (PDF)
Effective Date: 12/29/17
   
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)
Effective Date: 12/21/17
   
Homocysteine Testing (PDF)
Effective Date: 5/31/18
   
Hospice Services (PDF)
Effective Date: 1/1/18
   
Hyperbaric Oxygen Therapy (PDF)
Effective Date: 2/28/18
   
Hyperemesis Gravidarum Treatment (PDF)
Effective Date: 3/30/18
   
Hyperhidrosis Treatments (PDF)
Effective Date: 2/28/18
   
A-H I-Q R-Z
72-Hour Emergency Supply of Medication (PDF)
Reviewed Date: 10/2017
Ledipasvir/Sofosbuvir (Harvoni) (PDF)
Reviewed Date: 09/2017
Simeprevir (Olysio) (PDF)
Reviewed Date: 09/2017
Approval of Brand Name Override (PDF)
Reviewed Date: 04/2018

Lost, Stolen, Spilled or Broken Medication (PDF)

Reviewed Date: 04/2018

Sofosbuvir (Sovaldi) (PDF)

Reviewed Date: 09/2017
Aripiprazole (Abilify) for Oral Use (PDF)
Reviewed Date: 01/2018

Medicaid Pharmacy Appeals (PDF)
Reviewed Date: 11/2017

Sofosbuvir/Velpatasvir (Epclusa) (PDF)

Reviewed Date: 09/2017
Coordinated Services Program [CSP] (PDF)
Reviewed Date: 12/2017

Ombitasvir/Paritaprevir/Ritonavir (Technivie) (PDF)
Reviewed Date: 09/2017

Sofosbuvir Velpatasvir Voxilaprevir (Vosevi) (PDF)

Reviewed Date: 09/2017
Daclatasvir (Daklinza) (PDF)
Reviewed Date: 09/2017

Opioid Analgesics (PDF)

Reviewed Date: 01/2018

Specialty Pharmacy Program (PDF)

Reviewed Date: 10/2017

Dasabuvir, Ombitasvir, Paritaprevir, Ritonavir

(Viekira XR, Viekira Pak) (PDF)

Reviewed Date: 09/2017

Opioid Rx Limits (PDF)

Reviewed Date: 10/2017

Stribild (PDF)

Reviewed Date: 12/2017
Drug Recall Notification (PDF)
Reviewed Date: 10/2017

PBM Inquiry for Additional Information During PA/MN Review Process (PDF)

Reviewed Date: 10/2017

Vacation Overrides (PDF)

Reviewed Date: 11/2017
Drug Utilization Review (PDF)
Reviewed Date: 01/2018
Pharmacy Compounds (PDF)
Reviewed Date: 04/2018
 
Elbasvir/Grazoprevir (Zepatier) (PDF)
Reviewed Date: 09/2017
Pharmacy and Therapeutics Committee (PDF)

Reviewed Date: 01/2018
 
Glecaprevir/Pibrentasvir (Mavyret) (PDF)
Reviewed Date: 09/2017
Pharmaceutical Management (PDF)

Reviewed Date: 10/2017
 
  Pharmaceutical Transition for New Members (PDF)

Reviewed Date: 04/2018
 
 

Pharmacy and Therapeutics Committee Members Confidentiality Statement (PDF)

Reviewed Date: 11/2017

 
  Pharmacy and Therapeutics Committee Member Documentation and Tracking (PDF)

Reviewed Date: 11/2017
 
 

Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)

Reviewed Date: 10/2017

 
 

Pharmacy Program (PDF)

Reviewed Date: 10/2017

 
 

Preferred Drug List (PDF)

Reviewed Date: 10/2017

 
 

Provider Requests for Pharmacy Profiles (PDF)

Reviewed Date: 10/2017

 

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

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
3-Day Payment Window (PDF)
Effective Date: 3/1/18
Inpatient Consultation (PDF)
Effective Date: 3/10/18
Sleep Studies Place of Service (PDF)
Effective Date: 5/1/17
30-Day Readmission (PDF)
Effective Date: 2/20/18
Inpatient Only Procedures (PDF)
Effective Date: 3/10/18
Status "B" Bundled Services (PDF)
Effective Date: 3/10/18
Add on Code Billed Without Primary Code (PDF)
Effective Date: 2/24/18
Intravenous Hydration (PDF)
Effective Date: 2/25/18
Status "P" Bundled Services (PDF)
Effective Date: 4/27/17
Assistant Surgeon (PDF)
Effective Date: 3/1/18
Leveling of ER Services (PDF)
Effective Date: 5/17/18
Supplies Billed on Same Day as Surgery (PDF)
Effective Date: 2/28/18
Bilateral Procedures (PDF)
Effective Date: 3/1/18
Maximum Units (PDF)
Effective Date: 5/11/18
Transgender Related Services (PDF)
Effective Date: 2/15/18
Cerumen Removal (PDF)
Effective Date: 2/28/18
Moderate Conscious Sedation (PDF)
Effective Date: 3/5/18
Unbundled Professional Services (PDF)
Effective Date: 3/1/18
Clean Claims (PDF)
Effective Date: 6/9/18
Modifier DOS Validation (PDF)
Effective Date: 2/24/18
Unbundled Surgical Procedures (PDF)
Effective Date: 3/1/18
Clinic Facility Change (PDF)
Effective Date: 5/8/18
Modifier to Procedure Code Validation (PDF)
Effective Date: 2/23/18
Unlisted Procedure Codes (PDF)
Effective Date: 2/24/18
Clinical Labatory Improvement Amendments (CLIA) (PDF) Effective Date: 2/27/18
Multiple CPT Code Replacement (PDF)
Effective Date: 2/28/18
Urine Specimen Validity Testing (PDF)
Effective Date: 8/13/17

Clinical Validation of Modifer 25 (PDF)

Effective Date: 2/24/18

NCCI Unbundling (PDF)
Effective Date: 9/9/16
Visits On Same Day As Surgery (PDF)
Effective Date: 3/1/18
Clinical Validation of Modifier 59 (PDF)
Effective Date: 2/24/18
Never Paid Events (PDF)
Effective Date: 3/5/18
Wheelchairs and Accessories (PDF)
Effective Date: 1/13/17
Coding Overview (PDF)
Effective Date: 6/9/18
New Patient (PDF)
Effective Date: 3/10/18
 
Cosmetic Procedures (PDF)
Effective Date: 6/20/18

Non-obstetrical Pelvic and
Transvaginal Ultrasounds (PDF)

Effective Date: 6/1/2018

 
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)
Effective Date: 3/10/18
Not Medically Necessary IP Serv (PDF)
Effective Date: 6/1/18
 
Duplicate Primary Code Billing (PDF)
Effective Date: 3/10/18
Outpatient Consultations (PDF)
Effective Date: 3/13/18
 
E & M Bundling with Labs and Radiology (PDF)
Effective Date: 2/24/18
Physician's Consultation Services (PDF)
Effective Date: 11/25/17
 
E&M Medical Decision-Making (PDF)
Effective Date: 8/7/17
Physician's Office Lab Testing (PDF)
Effective Date: 10/4/17
 
Global Maternity Package (PDF)
Effective Date: 3/1/18

Place of Service Mismatch (PDF)

Effective Date: 9/1/2018

 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 6/20/18
Post-operative Visits (PDF)
Effective Date: 3/1/18
 
  Pre-operative Visits (PDF)
Effective Date: 3/1/18
 
  Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: 10/30/17
 
  Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 12/11/17
 
  Professional Component (PDF)
Effective Date: 6/28/18
 
  Professional Services (Visit Codes) Billed With Labs (PDF)
Effective Date: 3/10/18
 
  Pulse Oximetry (PDF)
Effective Date: 2/13/18
 
  Robotic Surgery (PDF)
Effective Date: 4/21/17