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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.

 

For Medicare information, please visit our Medicare Prior Authorization website.

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.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.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.049 Status "P" Bundled Services (PDF)
CC.PP.050 Robotic Surgery (PDF)
CC.PP.055 Physician's Office Lab Testing (PDF)
CC.PP.056 Urine Specimen Validity Testing (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.073 Sepsis Diagnosis (PDF) 
CC.PP.206 Skilled Nursing Facility Leveling (PDF)
CC.PP.500 3 Day Payment Window (PDF)
CC.PP.502 Wheelchair Accessories (PDF)
CP.MP.100 Allergy Testing and Therapy (PDF)
CP.MP.105 Digital EEG Spike Analysis (PDF)
CP.MP.106 Endometrial Ablation (PDF)
CP.MP.110 Bronchial Thermoplasty (PDF)
CP.MP.123 Laser Therapy for Skin Conditions (PDF)
CP.MP.134 Evoked Potential Testing (PDF)
CP.MP.139 Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)
CP.MP.143 Wireless Motility Capsule (PDF)
CP.MP.152 Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
CP.MP.153 Helicobacter Pylori Serology Testing (PDF)
CP.MP.155 EEG in the Evaluation of Headache (PDF)
CP.MP.156 Cardiac Biomarker Testing (PDF)
CP.MP.242 Pulmonary Function Testing (PDF)
CP.MP.38 Ultrasound in Pregnancy (PDF)
CP.MP.50 Drugs of Abuse: Definitive Testing (PDF)
CP.MP.98 Urodynamic Testing (PDF)
CP.MP.99 Wheelchair Seating (PDF)
CG.CC.PP.01 Concert Laboratory Payment Policy (PDF)
CG.CP.MP.01 Infectious Disease: Respiratory Lab Testing (PDF)
CG.CP.MP.02 Infectious Disease: Multisystem Lab Testing (PDF)
CG.CP.MP.03 Infectious Disease: Dermatologic Lab Testing (PDF)
CG.CP.MP.04 Infectious Disease: Gastroenterologic Lab Testing (PDF)
CG.CP.MP.05 Infectious Disease: Primary Care & Preventive Lab Screening (PDF)
CG.CP.MP.06 Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (PDF)
CG.CP.MP.07 Infectious Disease: Genitourinary Lab Testing (PDF)
CG.PP.551 Genetic and Molecular Testing Services (PDF)

Last Updated: 05/07/2025