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Clinical & Pharmacy 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 Trillium Community Health Plan Clinical Policy Manual apply to Trillium Community Health Plan members. Policies in the Trillium Community Health Plan Clinical Policy Manual may have either a Trillium Community Health Plan or a “Centene” heading.  Trillium Community Health Plan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Trillium Community 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 Trillium Community Health Plan. In addition, Trillium Community 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 Trillium Community Health Plan.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-E F-O P-Z
Abraxane (PDF) Fabrazyme (PDF) Panhematin (PDF)
Abstral,Actiq,Fentora,Lazan (PDF) Factor IX (Human, Recombinant) (PDF) Parsabiv (PDF)
Actonel,Atelvia (PDF) Factor VIII (PDF) Peginterferon Beta-1-Plegridy (PDF)
Adcetris (PDF) Factor VIII-vonWillebrand (PDF) PegIntron, Sylatron (PDF)
Adcirca (PDF) Fareston (PDF) Perjeta (PDF)
Adempas (PDF) Farydak (PDF) Phosphate Binders (PDF)
AdvairDiskus, AdvairHFA (PDF) Fasenra (PDF) Pomalyst (PDF)
Afinitor (PDF) Feiba (PDF)  
Aformoterol,Formoterol (PDF) Feraheme (PDF) Praluent (PDF)
Agents for Gout (PDF) Ferriprox (PDF) Prasugrel Hydrochloride (PDF)
Aggrenox (PDF) Ferrlecit (PDF) Prevymis (PDF)
Akynzeo (PDF) Firazyr (PDF) Probuphine Sublocade (PDF)
Aldurazyme (PDF) Flolan, Veletri (PDF) Prolia Xgeva (PDF)
Alecensa (PDF) Fluconazole (PDF) Promacta (PDF)
Alimta (PDF) For Loprox-clopirox olamine, clioquinol-hydrocortisone (PDF) Provenge (PDF)
Aliqopa (PDF) For supplemental, herbal & vitamin products (PDF) Pulmozyme (PDF)
Almotriptan, eletriptan, frova (PDF) Forteo (PDF) QL_of Diabetic Test Strips Not Receiving Insulin (PDF)
Alora, Vivelle-Dot, Minivelle, Menostar, Climara (PDF) Fragmin (PDF) Radicava (PDF)
Alpha-1 Proteinase Inhibitors (PDF) Fuzeon (PDF) Ranexa (PDF)
Alunbrig (PDF) Fycompa (PDF) Ravicti (PDF)
Ampyra (PDF) Gattex (PDF) Rayaldee (PDF)
Analgescis, Non-Steroid (PDF) Gilenya (PDF) Reclast, Zometa (PDF)
Anoro Ellipta (PDF) Gilotrif (PDF) Regranex (PDF)
Antifungals (PDF) Gleevec (PDF) Repatha (PDF)
Anzemet (PDF) GLP-1 Receptor Agonists (PDF) Restasis (PDF)
Arcalyst (PDF) Glumetza (PDF) Revatio (PDF)
Arixtra (PDF) Gocovri (PDF) Revlimid (PDF)
Aubagio (PDF) GrifulvinV, Gris-Peg (PDF) Rhopressa (PDF)
Avastin (PDF) Growth Hormones Rifapentine (PDF)
Banzel (PDF) H.P. Acthar (PDF) Rosuvastatin (PDF)
Bavencio (PDF) Hemangeol (PDF) Rubraca (PDF)
Belsomra (PDF) Hep C Direct-Acting Antiviral (PDF) Rydapt (PDF)
Benlysta (PDF) Herceptin, Ogivir (PDF) Sabril (PDF)
Benznidazole (PDF) Hetlioz (PDF) Sandostatin (PDF)
Berinert, Cinryze, Haegarda, Ruconest (PDF) Hycamtin (PDF) Savella (PDF)
Besponsa (PDF) Ibrance (PDF) Selsun Shampoo (PDF)
Bethkis, KitabisPak, TOBI (PDF) Iclusg (PDF) Sensipar (PDF)
Biologics for Autoimmune Diseases (PDF) Iluvien, Ozurdex, Retisert (PDF) SGLT2 (PDF)
Blincyto (PDF) Imbruvica (PDF) Sivextro (PDF)
Boniva Injectio (PDF) Imfinzi (PDF) Skelid (PDF)
Boniva Oral (PDF) Immune Globulins (PDF) Soliris (PDF)
Bosulif (PDF) Increlex (PDF) Solodyn (PDF)
Botulinum Toxins (PDF) Injectafer (PDF) Solosec (PDF)
BPH (PDF) Inlyta (PDF) Soriatane (PDF)
Brineura (PDF) Interferon Gamma 1b (PDF) Spinraza (PDF)
Bunavail, Suboxone, Zubsolv (PDF) Interferon Beta-1a Avonex, Rebif (PDF) Sprycel (PDF)
Buphenyl (PDF) Interferon Beta-1b Betaseron, Extavia (PDF) Stiolto Respimat (PDF)
Buprenorphine Subutex (PDF) Intrarosa (PDF) Stivarga (PDF)
Cabometyx, Cometriq (PDF) IPF (PDF) Sutent (PDF)
Calquence (PDF) Iressa (PDF) Sylvant (PDF)
Caprelsa (PDF) Jakafi (PDF) Symdeko (PDF)
Carbaglu (PDF) Juxtapid (PDF) Symlin (PDF)
Carisoprodol, metaxalone, orphenadrine (PDF) Jynarque (PDF) Synagis (PDF)
Cayston (PDF) Kadycla (PDF) Synribo (PDF)
Ceprotin (PDF) Kalbitor (PDF) Tafinlar (PDF)
Cerdelga (PDF) Kalydeco (PDF) Tagrisso (PDF)
Cerezyme (PDF) Kanuma (PDF) Tarceva (PDF)
Cesamet (PDF) Keytruda (PDF) Targretin (PDF)
Cinqair (PDF) Kisqali, Kisqali Femara (PDF) Tasigna (PDF)
CNS_Stimulants (PDF) Korlym (PDF) Tavalisse (PDF)
Compounded Medications (PDF) Krystexxa (PDF) Tecentriq (PDF)
Copaxone, Glatopa (PDF) Kuvan (PDF) Tecfidera (PDF)
Corifact (PDF) Kymriah (PDF) Temodar (PDF)
Corlanor (PDF) Kynamro (PDF) Thalomid (PDF)
Cortrosyn (PDF) Kytril, Sancuso (PDF) Thyrogen (PDF)
Cotellic (PDF) Lemtrada (PDF) Topical Immunomodulators (PDF)
Crysvita (PDF) Letairis (PDF) Tracleer (PDF)
Cubicin, CubicinRF (PDF) Leukine (PDF) Tranexamic Acid (PDF)
Cyramza (PDF) Lidoderm (PDF) Trelegy Ellipta (PDF)
Cystagon, Procysbi (PDF) Lindane Shampoo (PDF) Tretten (PDF)
Cystaran (PDF) Lonsurf (PDF) Trogarzo (PDF)
Cytogam (PDF) Lovenox (PDF) Tymlos (PDF)
Daliresp (PDF) Lucentis (PDF) Tysabri (PDF)
Darapim (PDF) Lumizyme (PDF) Uptravi (PDF)
Darzalex (PDF) Lutetium Lu177-Lutathera (PDF) Utibron Neohaler (PDF)
DDAVP, Stimate (PDF) Lynparza (PDF) Valchlor (PDF)
Desferal (PDF) Lyrica (PDF) Varubi (PDF)
Didronel (PDF) Macitentan (PDF) Vecamyl (PDF)
DOACs (PDF) Macugen (PDF) Venofer (PDF)
Donepezil HCL (PDF) Makena (PDF) Ventavis (PDF)
Doryx, Oracea, Acticlate (PDF) Marinol, Syndro (PDF) Verzenio (PDF)
Doxil, Lipodox50, Lipodox (PDF) Mekinist (PDF) Vimizim (PDF)
DPP-4Inhibitors (PDF) Memantine (PDF) Vimovo (PDF)
Drugs for Constipation (PDF) Mepsevii (PDF) Vimpat (PDF)
Duexis (PDF) Mesalamine Oral Therapy (PDF) Visudyne (PDF)
Dupixent (PDF) Minocycline (PDF) Vivitrol (PDF)
Elaprase (PDF) Mirvaso, Rhofade (PDF) VMAT2 (PDF)
Elelyso (PDF) Mozobil (PDF) Votrient (PDF)
Eliglustat (Cerdelga) Mvasi (PDF) VPRIV (PDF)
Emend (PDF) Mylotarg (PDF) Vytorin (PDF)
Emflaza (PDF) Naglazyme (PDF) Vyvanse (PDF)
EMLA (PDF) Natpara (PDF) Vyzulta (PDF)
Entresto (PDF) Nebivolol (PDF) Xadago (PDF)
Epipen, Epipen Jr (PDF) Neulasta (PDF) Xalkori (PDF)
Erivedge (PDF) Neupogen, Zarxio, Granix (PDF) Xeloda (PDF)
Erleada (PDF) Nexavar (PDF) Xepi (PDF)
Erwinaze (PDF) Nicotine gum, lozenge, patch (PDF) Xermelo (PDF)
ESAs (PDF) Ninlaro (PDF) Xiaflex (PDF)
Esomeprazole, AcipHexRabe (PDF) Nivolumab (Opdivo) (PDF) Xifaxan (PDF)
Eucrisa (PDF) No Coverage Criteria/Off Label Use (PDF) Xolair (PDF)
Evzio (PDF) Novantrone (PDF) Xopenex (PDF)
Exelon (PDF) Novo Seven RT (PDF) Xtandi (PDF)
Exjade, Jadenu (PDF) Nplate (PDF) Xyrem (PDF)
Exondys 51 (PDF) Nucala (PDF) Yervoy (PDF)
Eylea (PDF) Ocaliva (PDF) Yescarta (PDF)
  Ocrevus (PDF) Yondelis (PDF)
  Odomzo (PDF) Zavesca (PDF)
  Omega-3-Lovaza (PDF) Zelboraf (PDF)
  Onfi (PDF) Zemplar (PDF)
  Opioid Analgesics (PDF) Zetia (PDF)
  Orenitram, Remodulin, Tyvaso (PDF) Zinbryta (PDF)
  Orkambi (PDF) Zinplava (PDF)
    Zolinza (PDF)
    Zuplenz (PDF)
    Zurampic (PDF)
    Zykadia (PDF)
    Zytig (PDF)
    Zyvox (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 Trillium Community Health Plan Payment Policy Manual apply with respect to Trillium Community Health Plan members. Policies in the Trillium Community Health Plan Payment Policy Manual may have either a Trillium Community Health Plan or a “Centene” heading.  In addition, Trillium Community 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 Trillium Community Health Plan.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-I M-Q R-Z
30-Day Readmission (PDF)
Effective Date: 4/15/18
Maximum Units (PDF)
Effective Date: 1/1/18
Same Day Visits (PDF)
Effective Date: 1/1/18
3-Day Payment Window (PDF)
Effective Date: 4/15/18
Moderate Conscious Sedation (PDF)
Effective Date: 1/1/18
Status "B" Bundled Services (PDF)
Effective Date: 1/1/18
Add on Code Billed Without Primary Code (PDF)
effective Date: 1/1/18
Modifier -25 clinical validation (PDF)
Effective Date: 1/1/18
Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/18
Assistant Surgeon (PDF)
Effective Date: 1/1/18
Modifier -59 clinical validation (PDF)Effective Date: 1/1/18 Transgender Related Services (PDF)
Effective Date: 1/1/18
Bilateral Procedures (PDF)
Effective Date: 1/1/18
Modifier DOS Validation (PDF)
Effective Date: 1/1/18
Unbundled Professional Services (PDF)
Effective Date: 1/1/18
Cerumen Removal (PDF)
Effective Date: 1/1/18
Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/18
Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/18
Clean Claims (PDF)
Effective Date: 1/1/18
Monitored Anesthesia Care (PDF)
Effective Date: 10/1/18
Unlisted Procedure Codes
Effective Date: 1/1/18
CLIA Number (PDF)
Effective Date: 1/1/18
Multiple CPT Code Replacement (PDF) Effective Date: 1/1/18 Urine Specimen Validity Testing (PDF)
Effective Date: 4/15/18
Coding Overview (PDF)
Effective Date: 1/1/18
NCCI Unbundling (PDF) 
Effective Date: 1/1/18
 
Cosmetic Procedures (PDF)
Effective Date: 1/1/18
Never Paid Events (PDF)
Effective Date: 1/1/18
 
Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18
New Patient (PDF)
Effective Date: 1/1/18
 
Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 10/1/18
 
E&M Medical Decision-Making (PDF)
Effective Date: 1/1/18
Outpatient Consultation (PDF)
Effective Date: 1/1/18
 
EM Bundling Edits (PDF)
Effective Date: 1/1/18
Physician Visit Codes Billed with Labs (PDF) 
Effective Date: 1/1/18
 
Global Maternity Billing (PDF)
Effective Date: 1/1/18
Physician's Consultation Services (PDF)
Effective Date: 4/15/18
 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18
Physician's Office Lab Testing (PDF)
Effective Date: 4/15/18
 
Inpatient Consultation (PDF)
Effective Date: 1/1/18
Place of Service Mismatch (PDF)
Effective Date: 10/1/18
 
Inpatient Only Procedures (PDF)
Effective Date: 1/1/18
Post-Operative Visits (PDF)
Effective Date: 1/1/18
 
IV Hydration (PDF)
Effective Date: 1/1/18
Pre-Operative Visits (PDF)
Effective Date: 1/1/18
 
  Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: 1/1/18
 
  Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 1/1/18
 
  Professional Component (PDF)
Effective Date: 1/1/18
 
  PROM Testing (PDF)
Effective Date: 1/1/18
 
  Pulse Oximetry (PDF)
Effective Date: 1/1/18
 
A-I M-Q R-Z
30-Day Readmission (PDF)
Effective Date: 4/15/18
Maximum Units (PDF)
Effective Date: 1/1/18
Same Day Visits (PDF)
Effective Date: 1/1/18
3-Day Payment Window (PDF)
Effective Date: 4/15/18
Moderate Conscious Sedation (PDF)
Effective Date: 1/1/18
Status "B" Bundled Services (PDF)
Effective Date: 1/1/18
Add on Code Billed Without Primary Code (PDF)
effective Date: 1/1/18
Modifier -25 clinical validation (PDF)
Effective Date: 1/1/18
Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/18
Assistant Surgeon (PDF)
Effective Date: 1/1/18
Modifier -59 clinical validation (PDF) Effective Date: 1/1/18 Transgender Related Services (PDF)
Effective Date: 1/1/18
Bilateral Procedures (PDF)
Effective Date: 1/1/18
Modifier DOS Validation (PDF)
Effective Date: 1/1/18
Unbundled Professional Services (PDF)
Effective Date: 1/1/18
Cerumen Removal (PDF)
Effective Date: 1/1/18
Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/18
Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/18
Clean Claims (PDF)
Effective Date: 1/1/18
Monitored Anesthesia Care (PDF)
Effective 10/1/18
Unlisted Procedure Codes
Effective Date: 1/1/18
CLIA Number (PDF)
Effective Date: 1/1/18
Multiple CPT Code Replacement (PDF) Effective Date: 1/1/18 Urine Specimen Validity Testing (PDF)
Effective Date: 4/15/18
Coding Overview (PDF)
Effective Date: 1/1/18
NCCI Unbundling (PDF) 
Effective Date: 1/1/18
 
Cosmetic Procedures (PDF)
Effective Date: 1/1/18
Never Paid Events (PDF)
Effective Date: 1/1/18
 
Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18
New Patient (PDF)
Effective Date: 1/1/18
 
Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 10/1/18
 
E&M Medical Decision-Making (PDF)
Effective Date: 1/1/18
Outpatient Consultation (PDF)
Effective Date: 1/1/18
 
EM Bundling Edits (PDF)
Effective Date: 1/1/18
Physician Visit Codes Billed with Labs (PDF) 
Effective Date: 1/1/18
 
Global Maternity Billing (PDF)
Effective Date: 1/1/18
Physician's Office Lab Testing (PDF)
Effective Date: 4/15/18
 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18
Physician's Office Lab Testing (PDF)
Effective Date: 4/15/18
 
Inpatient Consultation (PDF)
Effective Date: 1/1/18
Place of Service Mismatch (PDF)
Effective Date: 10/1/18
 
Inpatient Only Procedures (PDF)
Effective Date: 1/1/18
Post-Operative Visits (PDF)
Effective Date: 1/1/18
 
IV Hydration (PDF)
Effective Date: 1/1/18
Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: 1/1/18
 
  Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 1/1/18
 
  Professional Component (PDF)
Effective Date: 1/1/18
 
  PROM Testing (PDF)
Effective Date: 1/1/18
 
  Pulse Oximetry (PDF)
Effective Date: 1/1/18