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Policies & Criteria

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.

Pharmacy Criteria

Trillium Community Health Plan’s goal is to offer the right drug coverage to our members. Trillium Oregon Health Plan (OHP) covers prescription and some over the counter drugs when they are ordered by a licensed prescriber registered with the state of Oregon to provide services to OHP members. The pharmacy program does not cover all drugs. Some drugs need prior approval and some have a limit on the amount of drug that can be given.

Clinical policies are one set of guidelines used to assist in administering health plan benefits. 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. 

The Trillium Pharmacy and Therapeutics (P&T) Committee is comprised of community doctors and pharmacists. Together we work to offer drugs used to treat many conditions and illnesses. All clinical policies are reviewed annually by the Trillium P&T Committee, which meets quarterly. Approved criteria and revisions made by the P&T Committee go into effect the first day of the month the start of the following quarter. All medications newly approved by the FDA (Food and Drug Administration) require prior approval until reviewed by our P&T Committee.

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. Polices listed as being approved for the Medicaid and/or Oregon Health Plan lines of business apply to prior authorization requests for Trillium OHP members.

All prior authorization requests are subject to the Oregon Health Plan’s Prioritized List and Guideline Notes in addition to applicable clinical policy coverage guidelines. Requests for non-preferred medications not listed on Trillium OHP’s Preferred Drug List (PDL) require trial and failure of preferred options prior to approval unless submitted documentation can support the medical necessity of the non-preferred medication.

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

Anti-Inflammatory Agents

Musculoskeletal Therapy Agents

Opioid Agents

Amebicides

Amnoglycosides

Antifungals

Antihelmintics

Anti-Infective Agents – Misc.

Antimalarials

Antimycobacterial Agents

Antivirals

Fluoroqunolones

Passive Immunizing and Treatment Agents

Tetracyclines

Alkylating Agents

Antimetabolites

Antineoplastic – Angiogenesis Inhibitors

Antineoplastic – Antibodies

Antineoplastic – BCL-2 Inhibitors

Antineoplastic – Cellular Immunotherapy

Antineoplastic – Hedgehog Pathway Inhibitors

Antineoplastic – Hormonal and Related Agents

Antineoplastic – Immunomodulators

Antineoplastic Antibiotics

Antineoplastic Combinations

Antineoplastic Enzyme Inhibitors

Antineoplastic Enzymes

Antineoplastic Radiopharmaceuticals

Antineoplastics Misc.

Chemotherapy Rescue/Antidote Agents

Mitotic Inhibitors

Topoisomerase I Inhibitors

Antidiabetics

Bone Density Regulators

Corticosteroids

Corticotropin

GNRH/LHRH Antagonists

Growth Hormone Receptor Antagonists

Growth Hormones

Insulin-Like Growth Factors (Somatomedins)

LHRH/GNRH Agonist Analog Pituitary Suppressants

Metabolic Modifiers

Posterior Pituitary Hormones

Progesterone Receptor Antagonists

Progestins

Somatostatic Agents

Vasopressin Receptor Antagonists

Antiemetics

Gastrointestinal Agents – Misc.

Genitourinary Agents – Misc.

Gout Agents

Vaginal Products

Anticoagulants

Hematological Agents – Misc.

Hematopoietic Agents

ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants

Anticonvulsants

Antiparkinson and Related Therapy Agents

Hypnotics/Sedatives/Sleep Disorder Agents

Migraine Products

Psychotherapeutic and Neurological Agents – Misc.

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.

30-Day Readmission (PDF)
Effective Date: 4/15/18

3-Day Payment Window (PDF)
Effective Date: 4/15/18

Add on Code Billed Without Primary Code (PDF)
effective Date: 1/1/18

Assistant Surgeon (PDF)
Effective Date: 1/1/18

Bilateral Procedures (PDF)
Effective Date: 1/1/18

Cerumen Removal (PDF)
Effective Date: 1/1/18

Clean Claims (PDF)
Effective Date: 1/1/18

CLIA Number (PDF)
Effective Date: 1/1/18

Coding Overview (PDF)
Effective Date: 1/1/18

Cosmetic Procedures (PDF)
Effective Date: 1/1/18

Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18

Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18

E&M Medical Decision-Making (PDF)
Effective Date: 1/1/18

EM Bundling Edits (PDF)
Effective Date: 1/1/18

EpiFix Wound Treatment (PDF)
Effective Date: 1/1/19

Global Maternity Billing (PDF)
Effective Date: 1/1/18

Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18

Inpatient Consultation (PDF)
Effective Date: 1/1/18

Inpatient Only Procedures (PDF)
Effective Date: 1/1/18

IV Hydration (PDF)
Effective Date: 1/1/18

Maximum Units (PDF)
Effective Date: 1/1/18

Moderate Conscious Sedation (PDF)
Effective Date: 1/1/18

Modifier -25 clinical validation (PDF)
Effective Date: 1/1/18

Modifier -59 clinical validation (PDF)
Effective Date: 1/1/18

Modifier DOS Validation (PDF)
Effective Date: 1/1/18

Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/18

Monitored Anesthesia Care (PDF)
Effective Date: 10/1/18

Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/18

NCCI Unbundling (PDF) 
Effective Date: 1/1/18

Never Paid Events (PDF)
Effective Date: 1/1/18

New Patient (PDF)
Effective Date: 1/1/18

Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 10/1/18

Outpatient Consultation (PDF)
Effective Date: 1/1/18

Paclitaxel (PDF)
Effective Date: 1/1/19

Physician Visit Codes Billed with Labs (PDF) 
Effective Date: 1/1/18

Physician's Consultation Services (PDF)
Effective Date: 4/15/18

Physician's Office Lab Testing (PDF)
Effective Date: 4/15/18

Place of Service Mismatch (PDF)
Effective Date: 10/1/18

Post-Operative Visits (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

Rituximab (PDF)
Effective Date: 1/1/19

Same Day Visits (PDF)
Effective Date: 1/1/18

Status "B" Bundled Services (PDF)
Effective Date: 1/1/18

Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/18

Transgender Related Services (PDF)
Effective Date: 1/1/18

Unbundled Professional Services (PDF)
Effective Date: 1/1/18

Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/18

Unlisted Procedure Codes
Effective Date: 1/1/18

Urine Specimen Validity Testing (PDF)
Effective Date: 4/15/18

30-Day Readmission (PDF)
Effective Date: 4/15/18

3-Day Payment Window (PDF)
Effective Date: 4/15/18

Add on Code Billed Without Primary Code (PDF)
effective Date: 1/1/18

Assistant Surgeon (PDF)
Effective Date: 1/1/18

Bilateral Procedures (PDF)
Effective Date: 1/1/18

Cerumen Removal (PDF)
Effective Date: 1/1/18

Clean Claims (PDF)
Effective Date: 1/1/18

CLIA Number (PDF)
Effective Date: 1/1/18

Coding Overview (PDF)
Effective Date: 1/1/18

Cosmetic Procedures (PDF)
Effective Date: 1/1/18

Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18

Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18

E&M Medical Decision-Making (PDF)
Effective Date: 1/1/18

EM Bundling Edits (PDF)
Effective Date: 1/1/18

EpiFix Wound Treatment (PDF)
Effective Date: 1/1/19

Global Maternity Billing (PDF)
Effective Date: 1/1/18

Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18

Inpatient Consultation (PDF)
Effective Date: 1/1/18

Inpatient Only Procedures (PDF)
Effective Date: 1/1/18

IV Hydration (PDF)
Effective Date: 1/1/18

Maximum Units (PDF)
Effective Date: 1/1/18

Moderate Conscious Sedation (PDF)
Effective Date: 1/1/18

Modifier -25 clinical validation (PDF)
Effective Date: 1/1/18

Modifier -59 clinical validation (PDF)
Effective Date: 1/1/18

Modifier DOS Validation (PDF)
Effective Date: 1/1/18

Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/18

Monitored Anesthesia Care (PDF)
Effective Date: 10/1/18

Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/18

NCCI Unbundling (PDF) 
Effective Date: 1/1/18

Never Paid Events (PDF)
Effective Date: 1/1/18

New Patient (PDF)
Effective Date: 1/1/18

Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 10/1/18

Outpatient Consultation (PDF)
Effective Date: 1/1/18

Paclitaxel (PDF)
Effective Date: 1/1/19

Physician Visit Codes Billed with Labs (PDF) 
Effective Date: 1/1/18

Physician's Consultation Services (PDF)
Effective Date: 4/15/18

Physician's Office Lab Testing (PDF)
Effective Date: 4/15/18

Place of Service Mismatch (PDF)
Effective Date: 10/1/18

Post-Operative Visits (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

Rituximab (PDF)
Effective Date: 1/1/19

Same Day Visits (PDF)
Effective Date: 1/1/18

Status "B" Bundled Services (PDF)
Effective Date: 1/1/18

Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/18

Transgender Related Services (PDF)
Effective Date: 1/1/18

Unbundled Professional Services (PDF)
Effective Date: 1/1/18

Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/18

Unlisted Procedure Codes
Effective Date: 1/1/18

Urine Specimen Validity Testing (PDF)
Effective Date: 4/15/18