22-892 Summary Update: Medical Policies - 3rd Quarter 2022

Date: 10/27/22

Review new policies, latest changes to existing policies and an update to the clinical practice guidelines grid

The medical policies listed in the complete update were approved by Centene’s Corporate Clinical Policy Committee and/or Health Net’s Medical Advisory Council (MAC) in the third quarter of 2022.

The complete update with an overview of the medical policies is found in 22-892m, Medical Policies – 3rd Quarter 2022. 

For a complete description of the background, criteria, references, and coding implications for the medical policies, visit the medical policies page.

Purpose of medical policies

Medical policies offer guidelines to help determine medical necessity for certain procedures, equipment and services. They are not intended to give medical advice or tell providers how to practice. If required, providers must get prior authorization before services are given.

Medical policies vs. member contract

All services must be medically needed, unless the member’s benefit plan coverage document states otherwise. This document defines member benefits in addition to eligibility requirements, and coverage exclusions and limits.

• If legal or regulatory mandates apply, they may override medical policy.
• If there are any conflicts between medical policy guidelines and related member benefits contract language, the benefits contract will apply.

For Medicare Advantage plans, apply the Medicare national and local policies for primary coverage guidance. For Medi-Cal plans, appropriate coverage guidelines take precedence over these plan policies and must be applied first.

For Cal MediConnect plans, Medicare and Medicaid national and local policies must be applied first for primary coverage guidance.

Additional information

Providers are encouraged to access Health Net’s provider portal  for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email within 60 days, by phone or through the Health Net provider website.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.