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 Meridian Clinical Policy Manual apply to Meridian members. Policies in the Meridian Clinical Policy Manual may have either a Meridian or a “Centene” heading. Meridian utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Meridian 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 Meridian. In addition, Meridian 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 Meridian.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- Air Ambulance (PDF)
- Bariatric Surgery (PDF)
- Bronchial Thermoplasty (PDF)
- Chiropractic Care (PDF)
- Continuous Glucose Monitoring (PDF)
- Cosmetic and Reconstructive Surgery (PDF)
- Elective Abortion (PDF)
- Evaluation of New Technology (PDF)
- Fecal Incontinence Treatments (PDF)
- Gender Affirming Procedures (PDF)
- Genetics Policy (PDF)
- Genetic Testing and Prenatal and Preconception Carrier Screening (PDF)
- Heart-Lung Transplant (PDF)
- Hematopoietic Cell Transplant for Aplastic Anemia and Bone Marrow Failure Syndromes (PDF)
- Hematopoietic Cell Transplantation in Beta Thalassemia Major (PDF)
- Hematopoietic Cell Transplantation in Hodgkin's Lymphoma - InterQual 2020
October 2020 Release, CP: Procedures Transplantation, Allogenic Stem Cell - Hematopoietic Cell Transplantation for Multiple Myeloma (PDF)
- Hematopoietic Cell Transplantation for Primary Immunodeficiency Disorders (PDF)
- Hematopoietic Cell Transplantation in Sickle Cell Disease (PDF)
- Home Births (PDF)
- Home INR Monitor (PDF)
- Hospice (PDF)
- Infertility (PDF)
- Inhaled Nitric Oxide (PDF)
- Intensity Modulated Radiation Therapy (IMRT) (PDF)
- Kidney Transplant - InterQual 2020
April 2020 Release, CP: Procedures Transplantation, Renal - Liver Transplant (PDF)
- Medical Necessity Criteria (PDF)
- Neuropsychological Testing - InterQual 2020
October 2020 Release, CP: procedures Neuropsychological and Developmental Testing - Orthognathic Surgery (PDF)
- Out of Network and Non-emergent Out of State Services (PDF)
- Palliative Care (PDF)
- Pancreas transplant (PDF)
- Panniculectomy (PDF)
- PCR Respiratory Viral Panel Testing (PDF)
- Pediatric Heart Transplant (PDF)
- Pediatric Liver Transplant (PDF)
- Phototherapy and Laser Therapy for Skin Conditions (PDF)
- Physical, Occupational, and Speech Therapy Services (PDF)
- Physician Advisory Committee (PDF)
- Readmission Review (Medicaid) (PDF)
- Replacement Cochlear Implant and Speech Processors (PDF)
- Reduction Mammoplasty, Mastopexy, Gynecomastia Surgery (PDF)
- Relizorb (PDF)
- Removal or Biopsy of Suspicious Skin Lesions (PDF)
- Review of Non-Emergent Out of State Services (PDF)
- Sclerotherapy and Endovascular Ablation (PDF)
- Sexual Dysfunction and Impotence (PDF)
- Short Inpatient Hospital Stay (PDF)
- Small Intestine, Small Intestine with Liver of Multivisceral Transplant (PDF)
- Stereotactic Body Radiation Therapy (SBRT) (PDF)
- Sterilization (PDF)
- Transplant Evaluation (PDF)
- Urgent and Emergent Care (PDF)
- Urinary Incontinence Devices and Treatments (PDF)
- Ventricular Assist Devices (PDF)
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 Meridian Payment Policy Manual apply with respect to Meridian members. Policies in the Meridian Payment Policy Manual may have either a Meridian or a “Centene” heading. In addition, Meridian 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 Meridian.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
CC.PI.04 Clean Claim Reviews (PDF)
CC.PI.06 Cost to Charge Adjustments on Clean Claim Reviews (PDF)
CC.PI.10 Unbundling Adjustments on Clean Claim Reviews (PDF)
CC.PP.007 Maximum Units of Service (PDF)
CC.PP.009 Unlisted Procedure Codes (PDF)
CC.PP.010 EM Bundling with Labs and Radiology (PDF)
CC.PP.011 Code Editing Overview (PDF)
CC.PP.012 Intravenous Hydration (PDF)
CC.PP.013 Clinical Validation of Modifier 25 (PDF)
CC.PP.014 Clinical Validation of Modifier 59 (PDF)
CC.PP.015 Moderate Conscious Sedation (PDF)
CC.PP.016 Reporting the Global Maternity Package (PDF)
CC.PP.017 Never Paid Events (PDF)
CC.PP.018 Inpatient Only Procedures (PDF)
CC.PP.019 Professional Services Billed With Labs (PDF)
CC.PP.020 Distinct Procedural Modifiers (PDF)
CC.PP.023 Hospital Visit Codes Billed with Labs (PDF)
CC.PP.024 Cosmetic Procedures (PDF)
CC.PP.025 Pulse Oximetry with Office Visits (PDF)
CC.PP.027 Professional Component Modifier (PDF)
CC.PP.028 Modifier to Procedure Code Validation (PDF)
CC.PP.029 Assistant Surgeon (PDF)
CC.PP.030 Add-on Code Billed without Primary Code (PDF)
CC.PP.031 NCCI Unbundling (PDF)
CC.PP.032 Supplies billed on Same day as Surgery (PDF)
CC.PP.033 Multiple CPT Code Replacement (PDF)
CC.PP.034 Modifier DOS Validation (PDF)
CC.PP.035 Sleep Studies Place of Service (PDF)
CC.PP.036 New Patient (PDF)
CC.PP.037 Bilateral Services (PDF)
CC.PP.038 Inpatient Consultation (PDF)
CC.PP.039 Outpatient Consultation (PDF)
CC.PP.040 Same Day Visits (PDF)
CC.PP.041 Preoperative Visits (PDF)CC.PP.050 Robotic Surgery (PDF)
CC.PP.052 Problem Oriented Visits with Surgical Procedures (PDF)
CC.PP.053 Non-Emergent ER Services (PDF)
CC.PP.054 Physician's Consultation Services (PDF)
CC.PP.056 Urine Specimen Validity Testing (PDF)
CC.PP.057 Problem Oriented Visits with Preventative Visits (PDF)
CC.PP.061 NonOB and OBTA and Transvaginal Ultrasounds (PDF)
CC.PP.063 Place of Service Mismatch (PDF)
CC.PP.065 Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)
CC.PP.066 Leveling of Care Evaluation and Management Overcoding (PDF)
CC.PP.067 Renal Hemodialysis (PDF)
CC.PP.068 Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
CC.PP.069 Multiple Procedure Reduction Ophthalmology (PDF)
CC.PP.071 Evaluation and Management Services Billed with Treatment Rooms (PDF)
CC.PP.073 Sepsis Diagnosis (PDF)
CC.PP.500 3 Day Payment Window (PDF)
CC.PP.502 Wheelchair Accessories (PDF)