The Fragmentation of U.S. Health Care: Causes and Solutions 0000176964 00000 n Management of High-Risk Pregnancy: An Evidence-Based Approach endobj QwRa.Jb|SD Ytgx\' 5_ 7x&jWm^bhe*,97-XSJi%_?-#}%b1@?1 Policies in the Coordinated Care Clinical Policy Manual may have either a Coordinated Care or a Centene heading. All member information is regarded as confidential and obtainable only to authorized persons. H\j@FzY& k?5xdi Clinical Policy: Continuous Glucose Monitors 0000013608 00000 n Intent of the procedure meets one of the following: 1. Title: GA.MP.13 Policy and Procedure Author: Peach State Health Plan Subject: Elective Circumcision Centene to comply with Centenes Business Ethics and Conduct policy, federal and state laws, CMS regulations and guidance, and all other regulatory requirements related to sales activities. Medical Management: __Approval on file_____ This policy outlines the indications for which anesthesia services are considered medically necessary. COVID-19 pandemic information. Centene Corporation retains the right to change or amend this policy at any time. 1098 59 endstream endobj 638 0 obj <>/Filter/FlateDecode/Index[95 480]/Length 38/Size 575/Type/XRef/W[1 1 1]>>stream It is the policy of Health Plans affiliated with Centene Corporation that revision procedures for affirming gender are medically necessary when the revision is required to address complications of a prior gender affirming procedure (wound dehiscence, fistula, chronic pain directly related to the surgery, etc.). 0000003411 00000 n 0 This book examines some fundamental issues, including: How children's specific diagnoses should affect educational assessment and planning How we can support the families of children with autism Features of effective instructional and <> POLICY: The medical record shall be maintained to serve the patient/member and healthcare provider in compliance with legal, accrediting and regulatory agency requirements. Centene Claims Department, Corporate and Sunshine State Health Plan (Sunshine Health) Provider Relations, and Medical Management Departments. at the end of this policy for important regulatory and legal information. <<9C6B5A3FEFB0D744A779355657E5D52F>]/Prev 481593/XRefStm 2030>> Developed IQAP for new Plan implementation. RARE CANCER AGENDA 2030 Ten Recommendations from the EU Joint Action on Rare Cancers 1. Rare cancers are the rare diseases of oncology 2. Rare cancers should be monitored 3. Health systems should exploit networking 4. Diagnostic evaluation of infertility is a covered benefit for members > age 18 and < age 45 if the procedure has been determined to be appropriate and medically hA 04XF{\GczC. POLICY: Sunshine Health shall establish and maintain a formal Provider relations It is the policy of health plans affiliated with Centene Corporation. on all procedures billed with modifier - 25. 0000104076 00000 n 0000002508 00000 n 0000002462 00000 n 0000120160 00000 n Social Isolation and Loneliness in Older Adults considers clinical tools and methodologies, better education and training for the health care workforce, and dissemination and implementation that will be important for translating research To reflect these rapid advances, this new edition of Optical Coherence Tomography of Ocular Diseases features a complete and thorough revision of the existing text as well as the addition of cutting-edge content to bring this classic PROCEDURE: Centene Corporation is a fully integrated government services managed care company with health plans in several states. Policy/Criteria I. t is the policy of I health plans affiliated with Centene Corporation that open discectomy and microdiscectomy are medically necessary when meeting all of the following: A. Centene Health Plans will adjust these policies and procedures to comply with state regulations, as needed, reporting these changes to the Corporate Pharmacy Department. 0000003878 00000 n Centene Corporate Pharmacy Department and Envolve Pharmacy Solutions receive drug alerts and review the FDA notices and available supportive documents to determine appropriate safety and communication measures needed. 02/08 : Add the Centene Health Plan Notification Letter as an attachment. COSMETIC PROCEDURES policy. procedures established by Centene, and in accordance with applicable State and federal requirements and NCQA standards. POLICY: Peach State Health Plan, in conjunction with Centene Corporate Pharmacy Department and Envolve Pharmacy Solutions, will identify all providers and members affected by a FDA drug recall, when there is a potential to result in serious adverse health consequences. CPT is medically necessary. 0000042724 00000 n At Cenpatico, we take privacy and confidentiality seriously. You can also view information designed to assist you in using the RadMD Website to obtain and check authorizations. Policy/Criteria . 0000006337 00000 n POLICY: The Centene Pharmacy and Therapeutics (P&T) Committee is responsible for approving all changes to the Centene PDL, in cooperation with and approval by the Health Plan P&T Committees. POLICY: Centene Corporation Health Plans authorize pharmacies to provide a 72-hour supply of medication while awaiting a PA or medical necessity (MN) determination for drug coverage. political contributions made by Centene and its Political Action Committee, CentenePAC, including the purpose and benefit of such contributions. 0000042491 00000 n These procedures include, but are not limited to: A. Excision of excessive skin B. POLICY: POLICY: Centene Corporation and its subsidiary health plans have timelines in place for providers to notify the plan of a service request and for the health plan to make UM decisions and notifications to the member and provider. PURPOSE: POLICY AND PROCEDURE DEPARTMENT: Medical Management Superior HealthPlan utilizes InterQual criteria for those medical technologies, procedures or pharmaceutical treatments for which a Superior HealthPlan clinical policy does not exist. Policy Overview . The aim of this particular volume is to offer an up-to-date review of the most recent advances in antiepileptic drug development, considered from various viewpoints: (i) general, by taking into account the size of refractory epilepsy and Found inside Page 559Strong positive findings in the above areas are sufficient to indicate that a surgical procedure is SOC. Anthem, Humana, Aetna, Wellpoint, Cigna, Highmark, Kaiser, Centene, HealthNet, Wellcare, Molina, Magellan, etc.). medically necessary. 0000004965 00000 n Assign new participants to the Service Coordination team following Centene policies and procedures Maintain appropriate records, files, and documentation. It is the policy of health plans affiliated with Centene Corporation (Centene) that laser It is the policy of health plans affiliated with Centene Corporation that continuous glucose monitors are . Reveals how federal criminal laws have become dangerously disconnected from the English common law tradition and how prosecutors can pin arguable federal crimes on any citizen of any social class or profession, for even the most seemingly 0000008252 00000 n It is the policy of MeridianHealth affiliated with Centene Corporation that diagnostic evaluation of infertility is medically necessary for the following indications: A. 0000240410 00000 n POLICY AND PROCEDURE APPROVAL The electronic approval retained in Compliance 360, Centene Policy and Procedure Management software is considered equivalent to a physical signature. 02/08 : Addressed the Class II and Class III recalls in the POLICY section with a 0000240624 00000 n 0000005763 00000 n Policy Overview The health plan administers unbundling edits based on the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI). I. 0000006308 00000 n Policy/Criteria . Centene Corporate Medical Management department will review the authorization list regularly to determine if any services 0000065873 00000 n The purpose of this payment policy is to provide a guide to payment, which is a component of Intended as a physician education, training, and reference, this guide offers a complete manual, pocket-sized cue cards, plus supplements on developmental and psychosocial issues. 0000103860 00000 n Section 1557 is the nondiscrimination provision of the Affordable Care Act (ACA). This brief guide explains Section 1557 in more detail and what your practice needs to do to meet the requirements of this federal law. The misuse of modifiers that override correct coding edits represent challenges for payers. when meeting all of the following: A. 0000010178 00000 n It is Centenes comprehensive plan for delivering our integrated care management program for members with special needs It promotes quality measures, care management policy and procedures and operational systems <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 10 0 R 12 0 R 15 0 R 23 0 R 24 0 R 25 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Centene Corporate Health Insurance Marketplace (HIM), Ambetter Program PURPOSE: The following reimbursement policy applies to Centene Corporate Ambetter (HIM) commercial program. The date of posting policies may be developed and adopted as needed, at any time. We appreciate your partnership with Cenpatico in maintaining the highest quality and Director, Medical Management: Approval on File Manager, Medical Management: Approval on File More than one cystometrogram (CPT codes 51725 or 51726) or uroflowmetry study (CPT codes 51736 or 51741) per visit. POLICY: The Centene Pharmacy and Therapeutics (P&T) Committee is responsible for approving all changes to the Centene PDL, in cooperation with Peach State Health Plans P&T Committee. 0000005309 00000 n The purpose of this payment policy is to provide a guide to payment, which is a component of 0000004488 00000 n payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plans affiliates, as applicable. 0000002235 00000 n Policy/Criteria I. :u+XWYQ9"GR(REJH)r)E"Q9U\. 0000020363 00000 n 0000003555 00000 n This book will help health care leaders, regulators, and policy makers incorporate exemplary practices, and the underlying themes they embody, into the very heart and soul of health care organizations. POLICY AND PROCEDURE APPROVAL The electronic approval retained in Compliance 360, Centene Policy and Procedure Management software is considered equivalent to a physical signature. <>>> 0000007785 00000 n 0000240149 00000 n 1156 0 obj <>stream 0000176759 00000 n xref not medically necessary: A. 0000019057 00000 n This policy references Current Procedural Terminology (CPT). Revise PROCEDURE to reflect the updated procedure among the PBM, Corporate Pharmacy Department, and the Health Plan Pharmacy Departments. Policy/Criteria . 0000140039 00000 n 0000002364 00000 n prepayment clinical claims review. 0000003694 00000 n Policies in the Coordinated Care Clinical Policy Manual may have either a Coordinated Care or a Centene heading. 0000071108 00000 n List Policy and Procedure, CC.PHAR.10, attachment PDL Change Request Form); criteria, protocols and procedures approved by the Centene Corporate and Health Plan P&T Committees, and in accordance with applicable state and federal requirements, NCQA standards The Centene Employee Formulary is a list of covered drugs used to treat common diseases or health problems. The formulary is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. This clinical policy is effective as of the date determined by the Health Plan. 0000013329 00000 n 0000162078 00000 n 0000000016 00000 n The Risk Adjustment Coding and HCC Guide brings together hard-to-find information about risk adjustment (RA) coding and hierarchical condition categories (HCCs) in a new comprehensive resource that explains this complex reimbursement 0000240549 00000 n 0000008699 00000 n trailer If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. This policy is the property of Centene Corporation. Centene or its subsidiaries does not discriminate on the basis of race, color, national origin, sex, 0000012611 00000 n POLICY: The Centene Pharmacy and Therapeutics (P&T) Committee is responsible for approving all changes to the Centene PDL, in cooperation with and approval by the Health Plan P&T Committees. 0000139678 00000 n policy and procedure approval The electronic approval retained in Compliance 360, Centene's P&P management software, is considered equivalent to a physical signature. 0000051304 00000 n 0000007633 00000 n Policies in the Buckeye Health Plan Clinical Policy Manual may have either a Buckeye Health Plan or a Centene heading. 0000012156 00000 n payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plans affiliates, as applicable. 0000144144 00000 n Centene / Coordinated Care. Policy Overview . POLICY: Absolute Total Care will require prior authorization for those procedures which have either a significant financial or quality of care impact that can be favorably influenced by the authorization. Times are changing and the labor markets are under immense burden from the collective effects of various megatrends. medically necessary . Intent of the procedure meets one of the following: 1. For updates related to agency-wide DHS programs, visit the DHS homepage.It has information for providers, counties, tribal nations and members of the public as we respond to the COVID-19 pandemic. on all procedures billed with modifier - 25. The procedure is performed to improve the function of an abnormal body part caused endstream endobj 1155 0 obj <>/Filter/FlateDecode/Index[50 1048]/Length 51/Size 1098/Type/XRef/W[1 1 1]>>stream PROCEDURE: A. This policy is based on CMS reimbursement methodologies for MPPR and applies a multiple procedure payment reduction to therapeutic procedures assigned a multiple procedure indicator (MPI) of 5 on the CMS National Physician Fee Schedule (NPFS). 0000199049 00000 n 0000240387 00000 n 0000213647 00000 n 0000002991 00000 n The policy is to define the process for reimbursing the member and donor for travel expenses related to transplant services. 3 0 obj California Health & Wellness utilizes InterQual criteria for those medical technologies, procedures or pharmaceutical treatments for which a California Health & Wellness clinical policy does not exist. 575 65 hb```b``?[ B@1v@i{45IOv~)v2VX4&.k@/(*:8.nwh2tRqx?!?OLbM7>YZ&K ?O//8'g1QfB0 3v[ZZ:\q\^ @," KcPPP((P,PtYYYR|N={@fFFon|A"a:Gz22\bofh{9 PP9ZiRV Distribute emails and faxes to providers Policies in the Buckeye Health Plan Clinical Policy Manual may have either a Buckeye Health Plan or a Centene heading. for the patient. A widely adopted practitioner resource and course text, this book shows how to apply knowledge about behavior change in general -- and the stages-of-change model in particular -- to make substance abuse treatment more effective. In addition, the Centene P&T Committee will determine which drugs included Welcome to the Centene / Coordinated Care page. The procedure is performed to improve the function of an abnormal body part caused 0000010151 00000 n Working knowledge of the field's concepts, practices, and procedures. The 1999 edition includes more than 500 code changes. To make coding easy, color-coded keys are used for identifying section and sub-headings, and pre-installed thumb-notch tabs speed searching through codes. This policy is current at the time of publication. POLICY AND PROCEDURE DEPARTMENT: Medical Management DOCUMENT NAME: Mental Health Rehab Medical Necessity Criteria (MNC) Policy for Crisis Centene's P&P management software, is considered equivalent to a physical signature. Policies in the California Health & Wellness Clinical Policy Manual may have either a California Health & Wellness or a Centene heading. 0000010703 00000 n Receiving a call for an early refill request (documentation). This is the most comprehensive CPT coding resource published by the American Medical Association. The misuse of modifiers that override correct coding edits represent challenges for payers. 0000013006 00000 n 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. Coordinated Care utilizes InterQual criteria for those medical technologies, procedures or pharmaceutical treatments for which a Coordinated Care clinical policy does not exist. payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plans affiliates, as applicable. [ >1)L[HY73o*'Td?|u]#\Ge/|] m)*hH(]NX=4#XRr%m- tx`~(}:7v(2S +I&gvO[Gn')au:~H&,Z#h@tD:@"y(ET`@UYex-v8mhp;!BvdgS"Z%OT?A l\zxt=Dqu7Yzgt7Rg>>R~@y]\Y{-1V"->#Y1l!i@81MgFp,Jfs?G8n>0?G>/s4[.?K6ELleTjXv7s#!
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