23-424sum Medical Policies - 1st Quarter 2023

Date: 05/11/23

Review new policies and the latest changes to existing medical policies for procedures and services

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 first quarter of 2023.

The complete update, 23-424, Medical Policies –1st Quarter 2023 (PDF), is a comprehensive description of the above topic.

For a complete description of the background, criteria, references, and coding implications for the medical policies, go to Health Net Medical Policies.

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.

 

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.