Provider Policies Library | Helpful Resources

Please note that the current policy list is not exhaustive, but rather a collection of policies that providers have expressed an interest in viewing. Amendments, modifications, supplements to these posted policies and/or additional policies may be posted in the near future. If you have any questions regarding these policies, please contact your Provider Relations Representative.


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Clinical Policies


Clinical Documents (A-Z)
Clinical Policy: Allogeneic SCT (Adults)
  • Reference Number: CP.FC.31
  • PDF Publish Date: 4/1/2021

    Clinical Policy: Allogeneic SCT (Pediatric)
    • Reference Number: CP.FC.32
    • PDF Publish Date: 4/1/2021

    Clinical Policy: Autologous SCT (Adults)
    • Reference Number: CP.FC.30
    • PDF Publish Date: 4/1/2021

    Clinical Policy: Autologous SCT (Pediatric)
    • Reference Number: CP.FC.33
    • PDF Publish Date: 4/1/2021

    Clinical Policy: Balloon Sinus Ostial Dilation
    • Reference Number: CP.MP.119
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Caudal Epidural Steroid Injections
    • Reference Number: CP.MP.164
    • PDF Publish Date: 8/1/2021

    Clinical Policy: Carpal Tunnel Syndrome Injections
    • Reference Number: CP.FC.42
    • PDF Publish Date: 7/1/2021

    Clinical Policy: Clinical Policy Committee
    • Reference Number: CP.CPC.01
    • PDF Publish Date: 3/1/2021

    Clinical Policy: Clinical and Preventive Health Guidelines
    • Reference Number: CP.FC.43
    • PDF Publish Date: 7/1/2021

    Clinical Policy: Clinical Trials
    • Reference Number: CP.MP.94
    • PDF Publish Date: 7/1/2021

    Clinical Policy: Cosmetic and Reconstructive Procedures
    • Reference Number: CP.MP.31
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Dental Anesthesia and Facility Services
    • Reference Number: CP.FC.02
    • PDF Publish Date: 4/1/2021

    Clinical Policy: Diaphragmatic Phrenic Nerve Stimulation
    • Reference Number: CP.MP.203
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Discography
    • Reference Number: CP.MP.115
    • PDF Publish Date: 7/1/2021

    Clinical Policy: Donor Lymphocyte Infusion
    • Reference Number: CP.MP.101
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Durable Medical Equipment (DME) Guidelines
    • Reference Number: CP.FC.06
    • PDF Publish Date: 10/1/2021

    Clinical Policy: Electromyography and Nerve Conduction
    • Reference Number: CP.MP.211
    • PDF Publish Date: 5/1/2021

    Clinical Policy: Facet Joint Interventions
    • Reference Number: CP.FC.18
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Fetal Surgery in Utero
    • Reference Number: CP.MP.129
    • PDF Publish Date: 8/1/2021

    Clinical Policy: Gastric Electrical Stimulation
    • Reference Number: CP.MP.40
    • PDF Publish Date: 10/1/2021

    Clinical Policy: Genetic and Pharmacogenetic Testing
    • Reference Number: CP.MP.89
    • PDF Publish Date: 4/1/2021

    Clinical Policy: Heart-Lung Transplant
    • Reference Number: CP.MP.132
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Intradiscal Steroid Injections
    • Reference Number: CP.MP.167
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Intestinal and Multivisceral Transplant
    • Reference Number: CP.MP.58
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Laser Therapy for Skin Conditions
    • Reference Number: CP.MP.123
    • PDF Publish Date: 7/1/2021

    Clinical Policy: Lung Transplantation
    • Reference Number: CP.MP.57
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Mechanical Stretching Devices
    • Reference Number: CP.MP.144
    • PDF Publish Date: 5/1/2021

    Clinical Policy: Medical Necessity Criteria
    • Reference Number: CP.FC.05
    • PDF Publish Date: 7/1/2021

    Clinical Policy: Multiple Sleep Latency Testing
    • Reference Number: CP.MP.24
    • PDF Publish Date: 5/1/2021

    Clinical Policy: Nerve Blocks for Pain Management
    • Reference Number: CP.MP.170
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Nonmyeloablative Allogeneic SCT
    • Reference Number: CP.MP.141
    • PDF Publish Date: 3/1/2021

    Clinical Policy: Out-of-Network
    • Reference Number: CP.FC.20
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Outpatient Testing for DOA
    • Reference Number: CP.FC.17
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Pancreas Transplantation
    • Reference Number: CP.MP.102
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Panniculectomy
    • Reference Number: CP.MP.109
    • PDF Publish Date: 5/1/2021

    Clinical Policy: Pasteurized Donor Human Milk
    • Reference Number: CP.FC.36
    • PDF Publish Date: 4/1/2021

    Clinical Policy: Pediatric Heart Transplant
    • Reference Number: CP.MP.138
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Pediatric Liver Transplant
    • Reference Number: CP.MP.120
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Pediatric Oral Function Therapy
    • Reference Number: CP.MP.188
    • PDF Publish Date: 6/1/2021

    Clinical Policy: Pediatric Tonsillectomy Inpatient
    • Reference Number: CP.FC.25
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Penile Prosthesis Implantation
    • Reference Number: CP.FC.44
    • PDF Publish Date: 10/1/2021

    Clinical Policy: Percutaneous LAAD Stroke Prevention
    • Reference Number: CP.MP.147
    • PDF Publish Date: 6/1/2021

    Clinical Policy: Polysomnography (PSG)
    • Reference Number: CP.FC.22
    • PDF Publish Date: 7/1/2021

    Clinical Policy: Reduction Mammoplasty and Gynecomastia Surgery
    • Reference Number: CP.MP.51
    • PDF Publish Date: 10/1/2021

    Clinical Policy: Repair of Nasal Valve Compromise
    • Reference Number: CP.MP.210
    • PDF Publish Date: 6/1/2021

    Clinical Policy: Repeat Bariatric Surgery
    • Reference Number: CP.FC.24
    • PDF Publish Date: 7/1/2021

    Clinical Policy: Sacroiliac Joint Interventions
    • Reference Number: CP.MP.166
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Sclerotherapy for Varicose Veins
    • Reference Number: CP.MP.146
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Selective Dorsal Rhizotomy for Spasticity
    • Reference Number: CP.MP.174
    • PDF Publish Date: 3/1/2021

    Clinical Policy: Services not on Fee Schedule
    • Reference Number: CP.FC.41
    • PDF Publish Date: 4/1/2021

    Clinical Policy: Short Inpatient Hospital Stay
    • Reference Number: CP.FC.28
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Sickle Cell Anemia and β-Thalassemia Cell Transplant
    • Reference Number: CP.MP.108
    • PDF Publish Date: 1/1/2021

    Clinical Policy: Skin Substitutes Policy
    • Reference Number: CP.FC.34
    • PDF Publish Date: 4/1/2021

    Clinical Policy: State CP Process
    • Reference Number: CP.FC.40
    • PDF Publish Date: 6/1/2021

    Clinical Policy: Tandem Transplant
    • Reference Number: CP.MP.162
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Tendon Injection
    • Reference Number: CP.FC.27
    • PDF Publish Date: 5/1/2021

    Clinical Policy: Thymus Transplant
    • Reference Number: CP.MP.189
    • PDF Publish Date: 6/1/2021

    Clinical Policy: Thyroid Nodule Genetic Testing
    • Reference Number: CP.FC.35
    • PDF Publish Date: 7/1/2021

    Clinical Policy: Transfer Policy
    • Reference Number: CP.FC.03
    • PDF Publish Date: 6/1/2021

    Clinical Policy: Transforaminal Epidural Injections
    • Reference Number: CP.MP.165
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Trigger Point Injections
    • Reference Number: CP.MP.169
    • PDF Publish Date: 9/1/2021

    Clinical Policy: Urinary Incontinence Devices and Treatments
    • Reference Number: CP.MP.142
    • PDF Publish Date: 4/1/2021

    Clinical Policy: Vagus Nerve Stimulation
    • Reference Number: CP.FC.39
    • PDF Publish Date: 6/1/2021

    Clinical Policy: Video EEG Monitoring
    • Reference Number: CP.MP.177
    • PDF Publish Date: 1/1/2021


    Payment Policies


    Payment Documents (A-Z)
    Payment Policy: 14 Day Readmission (Medicaid)
    • Reference Number: FC.PP.003
    • PDF Publish Date: 8/1/2021

    Payment Policy: 30 Day Readmission (Medicare)
    • Reference Number: FC.PP.004
    • PDF Publish Date: 10/15/2021

    Payment Policy: Ambulatory Electroencephalography
    • Reference Number: FC.PP.015
    • PDF Publish Date: 9/1/2021

    Payment Policy: Claim Validation of Modifier 25
    • Reference Number: FC.PP.001
    • PDF Publish Date: 8/1/2021

    Payment Policy: Claim Validation of Modifier 59
    • Reference Number: FC.PP.002
    • PDF Publish Date: 8/1/2021

    Payment Policy: CMS Correct Coding Initiative
    • Reference Number: FC.PP.020
    • PDF Publish Date: 10/15/2021

    Payment Policy: Digital EEG Spike Analysis
    • Reference Number: FC.PP.011
    • PDF Publish Date: 2/1/2021

    Payment Policy: EEG in the Evaluation of Headache
    • Reference Number: FC.PP.014
    • PDF Publish Date: 9/1/2021

    Payment Policy: Emergency Department Evaluation and Management Claim Adjustment
    • Reference Number: FC.PP.005
    • PDF Publish Date: 2/1/2021

    Payment Policy: Endometrial Ablation
    • Reference Number: FC.PP.010
    • PDF Publish Date: 2/1/2021

    Payment Policy: Evaluation and Management Claim Adjustment
    • Reference Number: FC.PP.006
    • PDF Publish Date: 2/1/2021

    Payment Policy: Fractional Inhaled Nitric Oxide
    • Reference Number: FC.PP.016
    • PDF Publish Date: 5/1/2021

    Payment Policy: Measure of Serum 1.25 (Vitamin D)
    • Reference Number: FC.PP.012
    • PDF Publish Date: 2/1/2021

    Payment Policy: Thyroid Insulin Tests in Pediatrics
    • Reference Number: FC.PP.013
    • PDF Publish Date: 2/1/2021