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- Antidepressant Medication
- Baby Partners
- CAHPS Resources
- Care Guidelines
- Developmental Screenings and Surveillance
- Diabetes Prevention Programs
- Disease and Medication Management
- EPSDT / Bright Futures
- ICD-10 Coding and Risk Adjustment
- Lead Screening
- Medication Management and Adherence
- Oral Health Resources
- Quality and Population Health
- Patient Management
- Patient Safety Reporting
- Member Rewards
- Smoking Cessation
- TiPS: Telephonic Psychiatric Consultation Service Program
Providers
Policy Bulletin Library
Policy bulletins are complementary to our provider manual.
Our policy bulletins communicate our medical, claim payment reimbursement and drug positions for services administered to members.
We have created three sections of the library below: medical policies, claim payment policies and drug policies.
Medical Policy Bulletins
Our medical policy bulletins define medical necessity criteria and coverage positions on topics such as medical services, procedures, durable medical equipment and therapies.
| Policy Bulletin # | Title | Summary | Version Date |
|---|---|---|---|
MN.004.C |
New Technology | Documents our coverage position for new technologies | 6/3/2024 |
MN.005.D |
Experimental and Investigational (E&I) Services, Investigational Device Exemption (IDE), and Coverage with Evidence Development (CED) | Documents our coverage position for E&I Services, IDEs, and CEDs | 8/21/2024 |
| MN.006.I | Cosmetic & Reconstructive Services | Documents our coverage position for cosmetic and reconstructive services | 4/17/2024 |
| MN.008.C | Genetic Testing | Documents our coverage position on genetic testing | 7/1/2020 |
| MN.010.G | Gender Confirmation Surgery | Documents our position on gender confirmation surgery | 12/18/2024 |
MN.011.D |
Whole Genome Sequencing (WGS)/Whole Exome Sequencing (WES) (30-day notification) |
Documents our coverage position on WGS and WES | 12/1/2023 |
MN.013.E |
Documents our position on the shift care, personal care, and medical daycare | 11/1/2023 |
|
| MN.015.B | Standards of Medical Necessity | Documents our position related to medical necessity | 9/1/2021 |
| MN.016.A | Injectable/Specialty Drugs Prior Authorization Requirements | Documents our prior authorization requirements for injectable/specialty drugs | 12/1/2019 |
| MN.018.A | Medical Nutritional Support | Documents our policies on enteral nutrition. | 11/20/24 |
| MN.020.B | Peroral Endoscopic Myotomy (POEM) | Documents our position related to POEM | 3/1/2022 |
| MN.021.A | Panniculectomy and Abdominoplasty | Documents our position related to panniculectomy and abdominoplasty | 2/1/2023 |
| MN.022.A | Reduction Mammoplasty | Documents our position related to reduction mammoplasty | 8/1/2023 |
| MN.024.A | Relizorb (Immobilized Lipase Cartridge) | Documents our position related to Relizorb | 3/20/2024 |
Medical Policy Type Key: MN = Medical Necessity
Claim Payment Policy Bulletins
Our claim payment policy bulletins provide reimbursement rules and billing guidelines necessary to ensure timely and appropriate payment.
| Policy Bulletin # | Title | Summary | Version Date |
|---|---|---|---|
RB.001.D |
Ambulance Ground Mileage Claim | Documents our reimbursement rules for ambulance ground mileage and ambulance services | 8/15/2023 |
RB.004.A |
Modifier 50, Bilateral Procedure | Documents our position on modifier 50, bilateral procedure | 3/31/2016 |
| RB.005.A | Modifier 25 | Documents our position on Modifier 25 | 7/1/2016 |
| RB.006.C | STAT Labs | Provides reporting requirements and reimbursement rules for STAT laboratory tests (a.k.a. labs) | 1/1/2023 |
| RB.007.D | Durable Medical Equipment (DME) Continuous Rental | Documents our position on DME rentals | 5/25/2018 |
| RB.009.A | Sepsis and Severe Sepsis Diagnosis Related Groups (DRG) Clinical Validation Review | Documents our position on Sepsis and Severe Sepsis DRG Clinical Validation review | 4/1/2020 |
| RB.014.C | Observation Care | Documents our position on Observation Care services Provides answers to common questions |
2/1/2022 |
| RB.015.C | Cataract Removal and Related Ophthalmologic Testing | Documents our position on cataract removal and related ophthalmologic testing | 5/1/2022 |
| RB.017.C | Continuous Glucose Monitors | Documents our position on continuous glucose monitors | 12/9/2022 |
| RB.018.A | Medicare Readmissions | Documents our position on Medicare readmissions | 1/1/2021 |
| RB.019.A | Health Care Acquired Conditions (HCAC) and Preventable Serious Adverse Events (PSAE) | Documents our position on HCAC and PSAE | 1/1/2021 |
| RB.020.A | Obstetric Anesthesia Services | Documents our position on obstetric anesthesia services. | 12/1/2021 |
| RB.021.A | Professional Telehealth Services (Medicare) | Updates our policy on telehealth services, specifically for Medicare members. | 1/1/2022 |
| RB.022.C | Rapid Hemoglobin A1c (HbA1c) Testing | Documents our position on rapid HbA1c testing. | 3/13/2023 |
| RB.023.B | Diabetic Retinopathy Screening and Fundus Photography | Documents our position on diabetic retinopathy screening and fundus photography. | 12/9/2022 |
| RB.024.A | Professional Telehealth Services (Medicaid and CHIP) | Updates our policy on telehealth services for Medicaid and CHIP members. | 8/1/2022 |
RB.025.C
RB.025.D |
Pediatric Shift Care When Multiple Members in a Household Are Receiving Care Pediatric Shift Care When Multiple Members in a Household Are Receiving Care |
Documents our position on pediatric shift care when multiple members in a household are receiving care. | 3/15/2023
11/1/2023 |
| RB.026.A | Remote Patient Monitoring | Provides information on remote patient monitoring. | 10/14/2022 |
| RB.027.A | Tobacco Cessation Program | Provides information on tobacco cessation certification. | 7/1/2022 |
| RB.028.B | CMS and DHS Payment Systems Update and Maintenance Payment Policy | Provides information on CMS and DHS policies. | 12/17/2024 |
| RB.029.B | Diabetes Prevention Program | Provides information on the Diabetes Prevention Program | 5/8/2023 |
| RB.030.B | Newborn Authorizations | Provides information on authorizations for newborns | 1/1/2023 |
| RB.031.A | Maternity Billing and Reimbursement Guidelines | Provides information on authorizations for maternity billing and reimbursement | 5/15/2023 |
| RB.032.A | Adjudication of Claims from Non-Participating Providers - Medicaid & CHIP | Documents our coverage position for adjudication of claims for non-participating providers | 9/25/2023 |
| RB.033.B | Vaccine Coding and Reimbursement | Provides information on vaccine coding and administration | 9/1/2023 |
| RB.034.A | Adjudication of Claims from Non-Participating Providers - Medicare | Documents our coverage position for adjudication of claims for non-participating providers | |
| RB.035.A | Preventive Care Services - Individual & Family Plan | ||
| RB.037.A | Readmissions - Individual & Family Plan | Documents our position on Individual & Family Plan readmissions | |
| RB.038.A | Professional Telehealth Services - Individual & Family Plan | Updates our policy on telehealth services for Individual & Family Plan members. | |
| RB.039.A | Reporting Requirements for Anesthesia Services |
Claim Payment Policy Type Key: RB = Reimbursement
Drug Policy Bulletins
Our drug policy bulletins document our position on pharmaceutical topics and drugs.
| Policy Bulletin # | Title | Summary | Version Date |
|---|---|---|---|
DR.002.F |
Intravenous Immune Globulin (IVIG) | Documents our position regarding IVIG Therapy. | 9/18/2024 |
DR.003.D |
Ocrevus (Ocrelizumab) | Documents our position on Ocrevus (Ocrelizumab). | 4/24/2023 |
| DR.004.E | Spinraza (Nusinersen) | Documents our position on Spinraza (Nusinersen). | 4/24/2023 |
| DR.005.D | Zolgensma (onasemnogene abeparvovec-xioi) | Documents our position on Zolgensma (onasemnogene abeparvovec-xioi). | 4/17/2024 |
| DR.006.E | Complement Inhibitors: Eculizumab (Soliris) & Ravulizumab(Ultomiris) | Documents our position on Eculizumab (Soliris) and Ravulizumab (Ultomiris). | 11/20/2024 |
DR.007.C
DR.007.C |
Adakveo (Crizanlizumab-tcma) (30 Day Notification) |
Documents our position on Adakveo (Crizanlizumab-tcma). | 11/1/2023
11/1/2023 |
| DR.008.B | Sandostatin LAR Depot (octreotide acetate) | Documents our position on Sandostatin LAR Depot (octreotide acetate). | 9/1/2023 |
| DR.009.C | TEPEZZA® (teprotumumab-trbw) | Documents our position on TEPEZZA (teprotumumab-trbw). | 9/1/2023 |
| DR.010.C | Xiaflex (Collagenase clostridium histolyticum) | Documents our position on Xiaflex (Collagenase clostridium histolyticum). | 9/1/2023 |
| DR.011.D | IgG1 Monoclonal Antibodies for Alzheimer’s | Documents our position on IgG1 Monoclonal Antibodies for Alzheimer’s | 5/14/2024 |
| DR.013.A | Relizorb (immobilized lipase) Cartridge | Documents our position on Relizorb (immobilized lipase). | 3/22/2023 |
| DR.014.B | Gene Therapy | Documents our position on Etranacogene dezaparvovec-drlb (Hemgenix®), Viltolarsen (Viltepso®), and Nadofaragene firadenovec-vncg (Adstiladrin®). | 7/1/2023 |
| DR.015.A | ROCTAVIAN® (valoctocogene roxaparvovec-rvox) | Documents our position on ROCTAVIAN® (valoctocogene roxaparvovec-rvox). | 5/15/2024 |
| DR.016.B | Documents our position on ELEVIDYS® (Delandistrogene moxeparvovec-rokl) | TBD | |
| DR.017.A | Adstiladrin® (Nadofaragene firadenovec-vncg) | Documents our position on Adstiladrin® (Nadofaragene firadenovec-vncg). | 7/1/2024 |
| DR.018.A | Viltepso® (Viltolarsen) | Documents our position on Viltepso® (Viltolarsen) | 7/1/2024 |
| DR.019.A | Hemgenix® (Etranacogene dezaparvovec-drlb) | Documents our position on Hemgenix® (Etranacogene dezaparvovec-drlb) | 7/1/2024 |
| DR.020.A | Casgevy | Documents our position on Casgevy® | 00/00/0000 |
| DR.021.A | Lyfgenia | Documents our position on Lyfgenia® | 8/21/2024 |
| DR.022.A | Zyntegla | Documents our position on Zyntegla® | TBD |
Drug Policy Type Key: DR = Drug
Frequently Asked Questions
Why does the effective date pre-date the date of availability?
The effective date of select policy bulletins found above may considerably pre-date the actual date of their availability on this page. The current policy bulletin library includes PDFs of policies that have been in effect for many years but were not published on our website.
How often is the library updated?
New and updated policy bulletins will typically be published in the policy bulletin library 30 to 60 days prior to their implementation date, ensuring that your office is given appropriate notification of changes and updates that may affect your office.