Políticas clínicas y de pago

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 Provider 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 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 Provider Services and ask to be directed to the Medical Management department.

Policy TitleEffective Date
3-Day Payment Window (PDF)Effective Date: 3/1/18
30-Day Readmission (PDF)Effective Date: 2/20/18
Add on Code Billed Without Primary Code (PDF)Effective Date: 2/24/18
Assistant Surgeon (PDF)Effective Date: 3/1/18
Bilateral Procedures (PDF)Effective Date: 3/1/18
Cerumen Removal (PDF)Effective Date: 2/28/18
Clean Claims (PDF)Effective Date: 6/9/18
Clinic Facility Change (PDF)Effective Date: 5/8/18
Clinical Validation of Modifer 25 (PDF)Effective Date: 2/24/18
Clinical Validation of Modifier 59 (PDF)Effective Date: 2/24/18
Coding Overview (PDF)Effective Date: 6/9/18
Concert Laboratory Payment Policy (PDF)Effective Date: 6/1/24
Cosmetic Procedures (PDF)Effective Date: 6/20/18
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)Effective Date: 3/10/18
Duplicate Primary Code Billing (PDF)Effective Date: 3/10/18
E & M Bundling with Labs and Radiology (PDF)Effective Date: 2/24/18
E&M Medical Decision-Making (PDF)Effective Date: 8/7/17
Global Maternity Package (PDF)Effective Date: 3/1/18
Hospital Visit Codes Billed with Labs (PDF)Effective Date: 6/20/18
Infectious Disease: Dermatologic Lab Testing (PDF)Effective Date: 6/1/24
Infectious Disease: Gastroenterologic Lab Testing (PDF)Effective Date: 6/1/24
Infectious Disease: Genitourinary Lab Testing (PDF)Effective Date: 6/1/24
Infectious Disease: Multisystem Lab Testing (PDF)Effective Date: 6/1/24
Infectious Disease: Primary Care & Preventive Lab Screening (PDF)Effective Date: 6/1/24
Infectious Disease: Respiratory Lab Testing (PDF)Effective Date: 6/1/24
Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (PDF)Effective Date: 6/1/24
Inpatient Consultation (PDF)Effective Date: 3/10/18
Inpatient Only Procedures (PDF)Effective Date: 3/10/18
Intravenous Hydration (PDF)Effective Date: 2/25/18
Leveling of ER Services (PDF)Effective Date: 5/17/18
Maximum Units (PDF)Effective Date: 5/11/18
Moderate Conscious Sedation (PDF)Effective Date: 3/5/18
Modifier DOS Validation (PDF)Effective Date: 2/24/18
Modifier to Procedure Code Validation (PDF)Effective Date: 2/23/18
Multiple CPT Code Replacement (PDF)Effective Date: 2/28/18
NCCI Unbundling (PDF)Effective Date: 9/9/16
Never Paid Events (PDF)Effective Date: 3/5/18
New Patient (PDF)Effective Date: 3/10/18
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)Effective Date: 6/1/2018
Not Medically Necessary IP Serv (PDF)Effective Date: 6/1/18
Outpatient Consultations (PDF)Effective Date: 3/13/18
Physician's Consultation Services (PDF)Effective Date: 11/25/17
Physician's Office Lab Testing (PDF)Effective Date: 05/14/21
Place of Service Mismatch (PDF)Effective Date: 9/1/2018
Post-operative Visits (PDF)Effective Date: 3/1/18
Pre-operative Visits (PDF)Effective Date: 3/1/18
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
Sleep Studies Place of Service (PDF)Effective Date: 5/1/17
Status "B" Bundled Services (PDF)Effective Date: 3/10/18
Status "P" Bundled Services (PDF)Effective Date: 4/27/17
Supplies Billed on Same Day as Surgery (PDF)Effective Date: 2/28/18
Transgender Related Services (PDF)Effective Date: 2/15/18
Unbundled Professional Services (PDF)Effective Date: 3/1/18
Unlisted Procedure Codes (PDF)Effective Date: 2/24/18
Urine Specimen Validity Testing (PDF)Effective Date: 8/13/17
Visits On Same Day As Surgery (PDF)Effective Date: 3/1/18
Wheelchairs and Accessories (PDF)Effective Date: 1/13/17
Problem Oriented Visits Billed with Surgical Procedures (PDF) 
Problem Oriented Visits Bill with Preventative Services (PDF) 
Sepsis Diagnosis (PDF) Last review 3-22