Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or claim 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. MHS follows applicable state and federal regulations regarding provision of benefits.
All policies found in the MHS Clinical Policy Manual apply to MHS members. Policies in the MHS Clinical Policy Manual may have either an MHS or a Centene heading. MHS will utilize InterQual for those medical technologies, procedures or pharmaceutical treatments for which an MHS clinical policy does not exist. InterQual will also be used for the following utilization management reviews; acute inpatient, skilled nursing facility, acute inpatient rehab, long-term acute care facility and behavioral health. InterQual is a nationally recognized, evidence-based decision support tool. In addition, MHS 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 guidelines is payable by MHS.
MHS may also use Medicare National Coverage Determination (NCDs), Local Coverage Determinations (LCDs), or InterQual for clinical decisions. Medicare NCDs and LCDs are applied to the Medicare population and can be found at the following address: cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.
The Clinical Policy Manuals may be accessed through the link. This site allows you to:
Search all folders by keyword by entering a search term in the keyword prompt and then pressing enter. Or you may browse by catalog subject by selecting the manual dropdowns on the left-hand side.
If you have any questions regarding these policies, please contact Provider Services and ask to be directed to the Medical Management department.