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Clinical & Payment 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 NH Healthy Families Clinical Policy Manual apply to NH Healthy Families members. Policies in the NH Healthy Families Clinical Policy Manual may have either a NH Healthy Families or a “Centene” heading.  NH Healthy Families utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a NH Healthy Families 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 NH Healthy Families. In addition, NH Healthy Families 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 NH Healthy Families.   

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

A-H I-Q R-Z
Applied Behavioral Analysis (PDF)        
Effective Date: 1/1/2018
Laser Skin Treatment (PDF)
Effective Date: 6/1/2009
Thyroid Testing in Pediatrics (PDF)     
Effective Date: 12/1/2017
ADHD Assessment and Treatment (PDF)         
Effective Date: 5/1/2018
Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/2018
Ultrasound in Pregnancy (PDF)
Effective Date: 8/1/2017
Allergy Testing (PDF)
Effective Date: 1/1/2018
Measure Serum 1, 25 Vitamin D (PDF)
Effective Date: 12/1/2017
Urodynamic Testing (PDF)
Effective Date: 10/1/2017
Ambulatory EEG (PDF)
Effective Date: 9/1/2017
Mechanical Stretch Devices (PDF)
Effective Date: 3/1/2018
Vitamin D Testing in Children (PDF)
Effective Date: 12/1/2017                                   
Bariatric Surgery Policy (PDF)
Effective Date: 6/1/2009
Medical Policy Adoption Policy (PDF)
Effective Date: 3/15/2018
Wheelchair Seating (PDF)
Effective Date: 10/1/2017
Biopharm ARQ Change (PDF)
Effective Date: 6/1/2009
PROM Testing (PDF)
Effective Date: 8/1/2017
Wireless Motility Capsule (PDF)
Effective Date: 3/1/2018
Bronchial Thermoplasty (PDF)
Effective Date: 3/1/2018
Proton and Neutron Beam Testing(PDF)
Effective Date: 2/1/2018
 
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 3/1/2018
   
Dental Anesthesia & Facility Policy (PDF)
Effective Date: 9/1/2018


 
Diagnosis of Vaginitis (PDF)
Effective Date: 9/1/2017
   
Digital Analysis of EEGs (PDF)
Effective Date: 1/1/2018
   
Digital Breast Tomosynthesis (DBT) (PDF)
Effective Date: 10/1/2017
   
DNA Analysis of Stool (PDF)
Effective Date: 9/1/2017
   
EEG in Evaluation of Headache (PDF)
Effective Date: 12/1/2017
   
Endometrial Ablation (PDF)
Effective Date: 9/1/2017
   
Enteral Nutrition Policy (PDF)
Effective Date: 6/1/2017


 
EpiFix Wound Treatment (PDF)
Effective Date: 3/1/2018
   
Evoked Potentials (PDF)
Effective Date: 11/1/2017
   
Fecal Calprotectin Assay (PDF)
Effective Date: 11/1/2017
   
FeNo Testing (PDF)
Effective Date: 1/1/2018
   
H Pylori Testing (PDF)
Effective Date: 12/1/2017
   
Holter Monitors (PDF)
Effective Date: 6/1/2018
   
Home Health Policy (PDF)
Effective Date: 9/15/2018
   
Homocysteine Testing (PDF)
Effective Date: 8/1/2017
   
A-H I-Q R-Z
Abaloparatide (Tymlos) (PDF) 
Effective Date: 5/1/2017
Ibalizumab-uiyk (Trogarzo) (PDF)  Effective Date: 4/17/2018 Ramucirumab (Cyramza) (PDF)             
Effective Date: 5/1/2015
Abatacept (Orencia) (PDF) 
Effective Date: 8/1/2016
Ibandronate Oral (Boniva) (PDF)
Effective Date: 3/1/2018
Ranibizumab (Lucentis) (PDF) 
Effective Date: 3/1/2016
Abemaciclib (Verzenio) (PDF) 
Effective Date: 10/24/2017
Ibandronate Sodium (Boniva) (PDF) 
Effective Date: 11/15/2017
Ranolazine (Ranexa) (PDF) 
Effective Date: 8/1/2009
Abiraterone (Zytiga) (PDF) 
Effective Date: 10/1/2011
Ibrutinib (Imbruvica) (PDF) 
Effective Date: 10/1/2015
Regorafenib (Stivarga) (PDF) 
Effective Date: 12/1/2012
AbobotulinumtoxinA (Dysport) (PDF) 
Effective Date: 7/1/2016
Ibuprofen and Famotidine (Duexis) (PDF) 
Effective Date: 6/1/2018
Request for Medically Necessary Drug not on the PDL (PDF) 
Effective Date: 9/1/2006
Acalabrutinib (Calquence) (PDF) 
Effective Date: 12/5/2017
Icatibant (Firazyr) (PDF) 
Effective Date: 3/1/2016
Reslizumab (Cinqair) (PDF) 
Effective Date: 5/1/2016
ACEI and ARB Duplicate Therapy (PDF) 
Effective Date: 8/1/2014
Idursulfase (Elaprase) (PDF) 
Effective Date: 2/1/2016
Ribociclib (Kisqali, Kisqali Femara) (PDF) 
Effective Date: 5/1/2017
Acitretin (Soriatane) (PDF) 
Effective Date: 8/1/2010
Iloprost (Ventavis) (PDF) 
Effective Date: 3/1/2016
Rifapentine (Priftin) (PDF) 
Effective Date: 2/1/2016
Adalimumab (Humira) (PDF) 
Effective Date: 8/1/2016
Imatinib (Gleevec) (PDF) 
Effective Date: 6/1/2011
Rifaximin (Xifaxan) (PDF) 
Effective Date: 11/1/2011
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) 
Effective Date: 8/1/2016
Imiglucerase (Cerezyme) (PDF) 
Effective Date: 2/1/2016
RimabotulinumtoxinB (Myobbloc) (PDF) 
Effective Date: 7/1/2016
Afatinib (Gilotrif) (PDF) 
Effective Date: 1/1/2017
Immune Globulins (PDF) 
Effective Date: 8/1/2012
Riociguat (Adempas) (PDF) 
Effective Date: 3/1/2016
Aflibercept (Eylea) (PDF) 
Effective Date: 3/1/2016
Immunization Coverage (PDF) 
Effective Date: 10/1/2008
Risedronate (Actonel, Atelvia) (PDF) 
Effective Date: 3/1/2018
Agalsidase Beta (Fabrazyme) (PDF) 
Effective Date: 2/1/2016
IncobotulinumtoxinA (Xeomin) (PDF) 
Effective Date: 7/1/2016
Rituximab (Rituxan), Rituximab and Hyaluronidase (Rituxan Hycela) (PDF) 
Effective Date: 7/1/2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) 
Effective Date: 3/13/2018
Infliximab (Remicade, Inflectra, Renflexis) (PDF) 
Effective Date: 7/1/2016
Rivastigmine (Exelon) (PDF) 
Effective Date: 12/1/2013
Alectinib (Alecensa) (PDF) 
Effective Date: 11/16/2016
Inhaled Combination (PDF) 
Effective Date: 11/1/2015
Roflumilast (Daliresp) (PDF) 
Effective Date: 11/1/2011
Alemtuzumab (Lemtrada) (PDF) 
Effective Date: 6/1/2018
Inotuzumab Ozogamicin (Besponsa) (PDF) 
Effective Date: 9/26/2017
Rolapitant (Varubi) (PDF) 
Effective Date: 2/1/2017
Alendronate (Binosto, Fosamax plus D) (PDF) 
Effective Date: 3/1/2018
Interferon beta-1a (Avonex, Rebif) (PDF) 
Effective Date: 8/1/2016
Romidepsin (Istodax) (PDF) 
Effective Date: 1/1/2017
Alglucosidase Alfa (Lumizyme) (PDF) 
Effective Date: 2/1/2016
Interferon beta-1b (Betaseron, Extavia) (PDF) 
Effective Date: 8/1/2016
Romiplostim (Nplate) (PDF) 
Effective Date: 3/1/2016
Alirocumab (Praluent) (PDF) 
Effective Date: 11/16/2016
Interferon Gamma-1b (Actimmune) (PDF) 
Effective Date: 6/1/2010
Rosuvastatin (Crestor) (PDF) 
Effective Date: 11/28/2017
Alpha-1 Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C Zemaira) (PDF) 
Effective Date: 3/1/2012
Intra Baclofen (Gablofen) (PDF) 
Effective Date: 12/1/2015
Rucaparib (Rubraca) (PDF) 
Effective Date: 9/1/2017
Amantadine ER (Gocovri) (PDF) 
Effective Date: 10/10/2017
Ipilimumab (Yervoy) (PDF) 
Effective Date: 3/1/2017
Sacubitril/Valsartan (Entresto) (PDF) 
Effective Date: 11/1/2015
Ambrisentan (Letairis) (PDF) 
Effective Date: 3/1/2016
Irinotecan Liposome (Onivyde) (PDF) 
Effective Date: 2/1/2017
Safinamide (Xadago) (PDF) 
Effective Date: 7/1/2017
Anakinra (Kineret) (PDF) 
Effective Date: 8/1/2016
Iron Sucrose (Venofer) (PDF) 
Effective Date: 3/1/2016
Sapropterin Dihydrochloride (Kuvan) (PDF) 
Effective Date: 2/1/2010
Anti-Allergy Opthalmics (PDF) 
Effective Date: 2/1/2013
Isotretinoin (Claravis, Sotret, Amnesteem, Myorisan) (PDF) 
Effective Date: 9/5/2017
Sargramostim (Leukine) (PDF) 
Effective Date: 12/1/2016
Anit-Inhibitor Coagulant Complex (Feiba) (PDF) 
Effective Date: 5/1/2016
Itraconazole (Sporanox, Onmel) (PDF) 
Effective Date: 11/1/2006
Sarilumab (Kevzara) (PDF) 
Effective Date: 7/18/2017
Apalutamide (Erleada) (PDF) 
Effective Date: 3/13/2018
Ivabradine (Corlanor) (PDF) 
Effective Date: 11/1/2015
Sebelipase Alfa (Kanuma) (PDF) 
Effective Date: 2/1/2016
Aprenilast (Otezla) (PDF) 
Effective Date: 8/1/2016
Ivacaftor (Kalydeco) (PDF) 
Effective Date: 11/16/2016
Secnidazole (Solosec) (PDF) 
Effective Date: 10/24/2017
Aprepitant (Emend) (PDF) 
Effective Date: 8/1/2017
Ixazomib (Ninlaro) (PDF) 
Effective Date: 2/1/2017
Secukinumab (Cosentyx) (PDF) 
Effective Date: 8/1/2016
Armodafinil (Nuvigil) (PDF) 
Effective Date: 5/1/2018
Ixekizumab (Taltz) (PDF) 
Effective Date: 8/1/2016
Selexipag (Uptravi) (PDF) 
Effective Date: 3/1/2016
Asfotase Alfa (Strensiq) (PDF) 
Effective Date: 3/1/2017
Lapatinib (Tykerb) (PDF) 
Effective Date: 10/1/2011
Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF) 
Effective Date: 8/1/2017
Aspirin-dipyridamole (Aggrenox) (PDF) 
Effective Date: 2/1/2018
Laronidase (Aldurazyme) (PDF) 
Effective Date: 2/1/2016
Sildenafil (Revatio) (PDF) 
Effective Date: 3/1/2016
Atezolizumab (Tecentriq) (PDF) 
Effective Date: 2/1/2018
Latanoprostene Bunod (Vyzulta) (PDF) 
Effective Date: 12/12/2017
Sildenafil (Viagra) (PDF) 
Effective Date: 6/1/2018
Atomoxetine (Strattera) (PDF) 
Effective Date: 8/1/2017
Lenalidomide (Revlimid) (PDF) 
Effective Date: 7/1/2011
Siltuximab (Sylvant) (PDF) 
Effective Date: 3/1/2017
Atypical Antipsychotics (PDF)
Effective Date: 12/1/2013
Letermovir (Prevymis) (PDF)
Effective Date: 11/28/2017
Sipuleucel-T (Provenge) (PDF) 
Effective Date: 6/1/2015
Avelumab (Bavencio) (PDF) 
Effective Date: 5/1/2017
Leuprolide Acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF) 
Effective Date: 10/1/2016
Sodium Oxybate (Xyrem) (PDF) 
Effective Date: 5/1/2011
Axicabtagene Ciloleucel (Yescarta) (PDF) 
Effective Date: 10/31/2017
Levelbuterol (Xopenex) (PDF)
Effective Date: 9/1/2006
Sodium Phenylbutyrate (Buphenyl) (PDF) 
Effective Date: 5/1/2016
Axitinib (Inlyta) (PDF) 
Effective Date: 5/1/2012
Levoleucovorin (Fusilev) (PDF)
Effective Date: 2/1/2016
Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) 
Effective Date: 3/1/2018
Becaplermin (Regranex) (PDF) 
Effective Date: 2/1/2018
L-Glutamine (Endari) (PDF)
Effective Date: 8/22/2017
Somatropin (Growth Hormone) (PDF)
Effective Date: 3/1/2011
Belatacept (Nulojix) (PDF) 
Effective Date: 3/1/2016
Lidocaine Transdermal (Lidoderm) (PDF) 
Effective Date: 9/1/2006
Sonidegib (Odomzo) (PDF)
Effective Date: 5/1/2012
Belimumab (Benlysta) (PDF) 
Effective Date: 10/1/2011
Lifitegrast (Xiidra) (PDF)
Effective Date: 11/1/2016
Sorafenib (Nexavar) (PDF)
Effective Date: 7/1/2011
Belinostat (Beleodaq) (PDF) 
Effective Date: 2/1/2017
Linaclotide (Linzess) (PDF)
Effective Date: 11/1/2015
Step Therapy (PDF)
Effective Date: 12/28/2017
Bendamustine (Bendeka, Treanda) (PDF) 
Effective Date: 2/1/2017
Lindane Lotion Shampoo (PDF)
Effective Date: 11/1/2006
Sunitinib (Sutent) (PDF)
Effective Date: 9/1/2011
Benralizumab (Fasenra) (PDF) 
Effective Date: 1/16/2018
Linezolid (Zyvox) (PDF) 
Effective Date: 9/1/2006
Suvorexant (Belsomra) (PDF) 
Effective Date: 2/1/2017
Benznidazole (PDF) 
Effective Date: 10/17/2017
Lisdexamfetamine (Vyvanse) (PDF)
Effective Date: 12/1/2013
Tadalafil (Adcirca) (PDF)
Effective Date: 3/1/2016
Betrixaban (Bevyxxa) (PDF) 
Effective Date: 8/8/2017
Lomitapide (Juxtapid) (PDF) 
Effective Date: 10/1/2016
Tadalafil BHP-ED (Cialis) (PDF) 
Effective Date: 6/1/2018
Bevacizumab (Avastin) (PDF) 
Effective Date: 12/1/2011
Long-Acting Injectible Atypical Antipsychotics (PDF)
Effective Date: 3/1/2018
Taliglucerase Alfa (Elelyso) (PDF) 
Effective Date: 2/1/2016
Bevacizumab-awwb (Mvasi) (PDF) 
Effective Date: 10/17/2017
Lumacaftor-Ivacaftor (Orkambi) (PDF) 
Effective Date: 5/1/2016
Tasimelteon (Hetlioz) (PDF) 
Effective Date: 2/1/2017
Bexarotene (Targretin) (PDF) 
Effective Date: 9/1/2011
Macitentan (Opsumit) (PDF) 
Effective Date: 3/1/2016
Tavaborole (Tazorac) (PDF) 
Effective Date: 11/1/2016
Bezlotoxumab (Zinplava) (PDF) 
Effective Date: 11/16/2016
Mecamylamine (Vecamyl) (PDF) 
Effective Date: 5/1/2017
Tedizolid (Sivextro) (PDF) 
Effective Date: 3/1/2015
Blinatumomab (Blincyto) (PDF) 
Effective Date: 2/1/2017
Mecasermin (Increlex) (PDF) 
Effective Date: 3/1/2011
Teduglutide (Gattex) (PDF) 
Effective Date: 5/1/2013
Bosentan (Tracleer) (PDF) 
Effective Date: 3/1/2016
Mepolizumab (Nucala) (PDF) 
Effective Date: 4/1/2016
Telotristat Ethyl (Xermelo) (PDF) 
Effective Date: 6/1/2017
Bosutinib (Bosulif) (PDF) 
Effective Date: 10/1/2012
Mesalamine Oral Therapy (PDF) 
Effective Date: 11/1/2011
Temasmorelin (Egrifta) (PDF) 
Effective Date: 3/1/2014
Brentuximab Vedotin (Adcetris) (PDF) 
Effective Date: 2/1/2017
Metformin ER (Glumetza) (PDF) 
Effective Date: 11/1/2015
Temozolomide (Temodar) (PDF) 
Effective Date: 9/1/2011
Brigatinib (Alunbrig) (PDF) 
Effective Date: 7/17/2017
Methadone (Dolophine) (PDF) 
Effective Date: 11/1/2016
Temsirolimus (Torisel) (PDF) 
Effective Date: 3/1/2017
Brimonidine Tartrate (Mirvaso), Oxymetazoline (Rhofade) (PDF) 
Effective Date: 11/16/2016
Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (PDF) 
Effective Date: 6/1/2016
Teriflunomide (Aubagio) (PDF) 
Effective Date: 8/1/2016
Brodalummab (Siliq) (PDF) 
Effective Date: 6/1/2018
Methylphenidate Transdermal Patch (Daytrana) (PDF) 
Effective Date: 1/1/2007
Teriparatide (Forteo) (PDF) 
Effective Date: 11/15/2017
Buprenorphine (Subutex) (PDF)
Effective Date: 9/30/2017
Midostaurin (Rydapt) (PDF) 
Effective Date: 6/1/2017
Testosterone Pellet (Testopel) (PDF) 
Effective Date: 8/1/2017
Buprenorphine Implant, Injectible (Probuphine, Sublocade) (PDF)
Effective Date: 11/30/2016
Mifepristone (Korlym) (PDF) 
Effective Date: 5/1/2012
Tetrabenazine (Xenazine) (PDF) 
Effective Date: 12/1/2017
Buprenorphine-Naloxone (Suboxone, Bunavail, Zubsolv) (PDF)
Effective Date: 9/30/2017
Miglustat (Zavesca) (PDF) 
Effective Date: 2/1/2016
Tezacaftor/Ivacafter; Ivacaftor (Symdeko) (PDF) 
Effective Date: 4/3/2018
Bupropion/Naltrexone (Contrave) (PDF) 
Effective Date: 5/1/2017
Milnacipran (Savella) (PDF) 
Effective Date: 8/1/2012
Thalidomide (Thalomid) (PDF) 
Effective Date: 9/1/2011
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda) (PDF) 
Effective Date: 3/1/2016
Minocycline ER and Microspheres (Solodyn) (PDF) 
Effective Date: 5/1/2017
Thyrotropin Alfa (Thyrogen) (PDF) 
Effective Date: 3/1/2012
Cabazitaxel (Jevtana) (PDF) 
Effective Date: 12/1/2013
Mipomersen (Kynamro) (PDF) 
Effective Date: 10/1/2016
Tiludronate (Skelid) (PDF) 
Effective Date: 3/1/2018
Cabozantinib (Cometriq, Cabometyx) (PDF) 
Effective Date: 11/16/2016
Mitoxantrone (Novantrone) (PDF) 
Effective Date: 8/1/2016
Timothy Grass Pollen Allergen Extract (Grastek) (PDF) 
Effective Date: 8/1/2017
Calcifediol (Rayaldee) (PDF) 
Effective Date: 11/1/2016
Mixed Pollens Allergen Extract (Oralair) (PDF) 
Effective Date: 8/1/2017
Tisagenlecleucel (Kymriah) (PDF) 
Effective Date: 9/26/2017
Canakinumab (Ilaris) (PDF) 
Effective Date: 8/1/2016
Modafinil (Provigil) (PDF) 
Effective Date: 5/1/2008
Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF) 
Effective Date: 5/1/2016
Capecitabine (Xeloda) (PDF) 
Effective Date: 5/1/2011
Nafarelin Acetate (Synarel) (PDF) 
Effective Date: 10/1/2016
Tocilizumab (Actemra) (PDF) 
Effective Date: 7/1/2016
Carbamazepine ER (Equetro) (PDF) 
Effective Date: 3/13/2018
Naldemedine (Symproic) (PDF) 
Effective Date: 5/1/2017
Tofacitinib (Xeljanz, Xeljanz XR) (PDF) 
Effective Date: 1/30/2017
Carfilzomib (Kyprolis) (PDF) 
Effective Date: 2/1/2017
Naltrexone (Vivitrol) (PDF) 
Effective Date: 3/1/2012
Topical Immunomodulators (PDF)    
Effective Date: 9/1/2006
Cariprazine (Vraylar) (PDF) 
Effective Date: 11/16/2016
Naproxen and Esomeprazole Magnesium (Vimovo) (PDF) 
Effective Date: 6/1/2018
Topotecan (Hycamtin) (PDF) 
Effective Date: 6/1/2011
Celecoxib (Celebrex) (PDF) 
Effective Date: 1/1/2007
Natalizumab (Tysabri) (PDF) 
Effective Date: 7/1/2016
Toremifene (Fareston) (PDF) 
Effective Date: 4/1/2010
Ceritinib (Zykadia) (PDF) 
Effective Date: 7/1/2017
Necitumumab (Portrazza) (PDF) 
Effective Date: 3/1/2017
Trabectedin (Yondelis) (PDF) 
Effective Date: 5/1/2016
Cerliponase Alfa (Brineura) (PDF) 
Effective Date: 7/1/2017
Neratinib (Nerlynx) (PDF) 
Effective Date: 9/5/2017
Trametinib (Mekinist) (PDF) 
Effective Date: 7/1/2016
Certolizumab (Cimzia) (PDF) 
Effective Date: 8/1/2016
Netarsudil (Rhopressa) (PDF) 
Effective Date: 2/13/2018
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) 
Effective Date: 6/1/2016
Cetuximab (Erbitux) (PDF) 
Effective Date: 2/1/2017
Nilotinib (Tasigna) (PDF) 
Effective Date: 9/1/2011
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) 
Effective Date: 3/1/2016
Ciclopirox (Penlac) (PDF) 
Effective Date: 9/1/2007
Nintedanib (Ofev) (PDF) 
Effective Date: 10/1/2016
Triamcinolone ER Injection (Zilretta) (PDF) 
Effective Date: 1/9/2018
Cinacalcet (Sensipar) (PDF) 
Effective Date: 5/1/2011
Nivolumab (Opdivo) (PDF) 
Effective Date: 7/1/2015
Triptorelin Pamoate (Trelstar, Triptodur) (PDF) 
Effective Date: 10/1/2016
Clobazam (Onfi) (PDF) 
Effective Date: 11/1/2012
No Coverage Criteria/Off-Label Use Policy (PDF) 
Effective Date: 9/12/2017
Ustekinumab (Stelara) (PDF) 
Effective Date: 8/1/2016
CNS Stimulants (PDF) 
Effective Date: 3/1/2018
Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renagel, Renvela, Velphoro) (PDF) 
Effective Date: 11/15/2017
Valbenazine (Ingrezza) (PDF) 
Effective Date: 7/1/2017
Colchicine (Colcrys) (PDF) 
Effective Date: 5/1/2011
Nusinersen (Spinraza) (PDF) 
Effective Date: 11/28/2018
Vandetanib (Caprelsa) (PDF) 
Effective Date: 10/1/2011
Collagenase (Xiaflex) (PDF) 
Effective Date: 10/1/2011
Obeticholic (Ocaliva) (PDF) 
Effective Date: 11/1/2016
Vedolizumab (Entyvio) (PDF) 
Effective Date: 7/1/2016
Copanlisib (Aliqopa) (PDF) 
Effective Date: 10/17/2017
Obinutuzumab (Gazyva) (PDF) 
Effective Date: 2/1/2017
Velaglucerase Alfa (VPRIV) (PDF) 
Effective Date: 2/1/2016
Corticotropin (H.P. Acthar Gel) (PDF) 
Effective Date: 3/1/2016
Ocrelizumab (Ocrevus) (PDF) 
Effective Date: 4/1/2017
Vemurafenib (Zelboraf) (PDF) 
Effective Date: 11/1/2011
Cosyntropin (Cortrosyn) (PDF) 
Effective Date: 4/1/2016
Octreotide (Sandostatin, Sandostatin LAR) (PDF) 
Effective Date: 3/1/2010
Verteporfin (Visudyne) (PDF) 
Effective Date: 3/1/2016
Crisaborole (Eucrisa) (PDF) 
Effective Date: 2/21/2017
Ofatumumab (Arzerra) (PDF) 
Effective Date: 2/1/2017
Vestronidase Alfa-vjbk (Mepsevii) (PDF) 
Effective Date: 1/9/2018
Crizotinib (Xalkori) (PDF) 
Effective Date: 11/1/2011
Olaparib (Lynparza) (PDF) 
Effective Date: 10/3/2017
Vigabatrin (Sabril) (PDF) 
Effective Date: 2/1/2016
Cyclosporine (Restasis) (PDF) 
Effective Date: 5/1/2012
Olaratumab (Lartruvo) (PDF) 
Effective Date: 4/1/2013
Vilazodone (Viibryd) (PDF)
Effective Date: 12/31/2013
Cysteamine Opthalmic (Cystaran) (PDF) 
Effective Date: 8/1/2017
Omacetaxine (Synribo) (PDF) 
Effective Date: 12/1/2013
Vincristine Sulfate Liposome Injection (Marqibo) (PDF)
Effective Date: 2/1/2017
Cysteamine Oral (Cystagon, Procysbi) (PDF) 
Effective Date: 2/1/2016
Omalizumab (Xolair) (PDF) 
Effective Date: 10/1/2008
Vismodegib (Erivedge) (PDF)
Effective Date: 8/1/2017
Dabigatran (Pradaxa) (PDF) 
Effective Date: 5/1/2012
Omega-3-Acid Ethyl Esters (Lovaza) (PDF) 
Effective Date: 8/1/2012
Voretigene Neparvovec-rzyl (Luxturna) (PDF)
Effective Date: 1/9/2018
Dabrafenib (Tafinlar) (PDF) 
Effective Date: 11/16/2016
OnobotulinumtoxinA (PDF) 
Effective Date: 7/1/2016
Vorinostat (Zolinza) (PDF)
Effective Date: 12/1/2012
Daclizumab (Zinbryta) (PDF) 
Effective Date: 8/1/2016
Opioid Analgesics (PDF)
Effective Date: 6/30/2016
Vortioxetine (Trintellix) (PDF)
Effective Date: 2/28/2014
Dalfampridine (Ampyra) (PDF) 
Effective Date: 8/1/2016
Oral Antiemetics (5-HT3 Antagonists) (PDF)
Effective Date: 9/1/2006
Ziv-Aflibercept (Zaltrap) (PDF)
Effective Date: 3/1/2017
Dalteparin (Fragmin) (PDF) 
Effective Date: 5/1/2016
Oral Biphosphonates (PDF)
Effective Date: 9/1/2006
Zoledronic Acid (Reclast, Zometa) (PDF)
Effective Date: 3/1/2011
Daptomycin (Cubicin, Cubicin RF) (PDF) 
Effective Date: 11/1/2017
Osimertinib (Tagrisso) (PDF)
Effective Date: 12/1/2016
 
Daratumumab (Darzalex) (PDF) 
Effective Date: 7/1/2017
Oxycodone SR (Oxycontin) (PDF)
Effective Date: 9/1/2006
 
Darbepoetin Alfa (Aranesp) (PDF) 
Effective Date: 6/1/2016
Ozenoxacin (Xepi) (PDF)
Effective Date: 1/30/2018
 
Dasatinib (Sprycel) (PDF) 
Effective Date: 6/1/2012
Paclitaxel, Protein-Bound (Abraxane) (PDF)
Effective Date: 7/1/2015
 
Daunorubicin/Cytarabine (Vyxeos) (PDF) 
Effective Date: 12/1/2017
Palbociclib (Ibrance) (PDF)
Effective Date: 10/1/2015
 
Defarasirox (Exjade Jadenu) (PDF) 
Effective Date: 11/1/2015
Palivizumab (Synagis) (PDF)
Effective Date: 8/1/2009
 
Deferiprone (Ferriprox) (PDF) 
Effective Date: 11/1/2015
Panitumumab (Vectibix) (PDF)
Effective Date: 3/1/2017
 
Deferoxamine (Desferal) (PDF
Effective Date: 11/1/2015
Paricalcitol Injection (Zemplar) (PDF)
Effective Date: 8/1/2016
 
Deflazacort (Emflaza) (PDF) 
Effective Date: 3/1/2017
Pasireotide (Signifor LAR) (PDF)
Effective Date: 3/1/2017
 
Degarelix Acetate (Firmagon) (PDF) 
Effective Date: 10/1/2016
Pazopanib (Votrient) (PDF)
Effective Date: 10/1/2011
 
Delafloxacin (Baxdela) (PDF) 
Effective Date: 8/1/2017
Pegaptanib (Macugen) (PDF)
Effective Date: 3/1/2016
 
Denosumab (Prolia, Xgeva) (PDF) 
Effective Date: 3/1/2011
Pegaspargase (Oncaspar) (PDF)
Effective Date: 9/5/2017
 
Desmopressin (DDAVP, Stimate) (PDF) 
Effective Date: 3/1/2016
Pegfilgrastim (Neulasta) (PDF)
Effective Date: 12/1/2016
 
Deutetrabenazine (Austedo) (PDF) 
Effective Date: 6/13/2017
Peginterferon Alfa-2B (Sylatron) (PDF)
Effective Date: 10/1/2011
 
Dexmethylphenidate ER (Focalin) (PDF) 
Effective Date: 5/1/2015
Peginterferon Beta-1A (Plegridy) (PDF)
Effective Date: 8/1/2016
 
Dextromethorphan-Quinidine (Nuedexta) (PDF) 
Effective Date: 12/5/2017
Pegloticase (Jakafi) (PDF)
Effective Date: 3/1/2012
 
Dimethyl Fumarate (Tecfidera) (PDF) 
Effective Date: 8/1/2016
Pegloticase (Krystexxa) (PDF)
Effective Date: 6/1/2013
 
Dipeptidyl Peptidase-4 Inhibitors (PDF) 
Effective Date: 3/1/2018
Pembrolizumab (Keytruda) (PDF)
Effective Date: 3/1/2017
 
Dornase Alfa (Pulmozyme) (PDF) 
Effective Date: 12/1/2013
Pemetrexed (Alimta) (PDF)
Effective Date: 10/31/2017
 
Dose Optimization (PDF) 
Effective Date: 5/1/2016
Pertuzumab (Perjeta) (PDF)
Effective Date: 6/1/2016
 
Doxycycline (Acticlate, Doryx, Oracea) (PDF) 
Effective Date: 5/1/2017
Phentermine (Adipex-P, Lomaira) (PDF)
Effective Date: 5/1/2017
 
Droxidopa (Northera) (PDF) 
Effective Date: 8/1/2016
Pimavanserin (Nuplazid) (PDF)
Effective Date: 8/1/2016
 
Dupilumab (Dupixent) (PDF) 
Effective Date: 5/1/2017
Pimecrolimus (Elidel) (PDF)
Effective Date: 12/1/2014
 
Duplicate SSRI SNRI Therapy (PDF) 
Effective Date: 5/1/2014
Pirfenidone (Esbriet) (PDF)
Effective Date: 10/1/2016
 
Durvalumab (Imfinzi) (PDF) 
Effective Date: 7/1/2017
Plecanatide (Trulance) (PDF)
Effective Date: 2/1/2017
 
Dutasteride (Avodart) and Dutasteride/Tamsulosin (Jalyn) (PDF) 
Effective Date: 5/1/2016
Plerixafor (Mozobil) (PDF)
Effective Date: 3/1/2017
 
Ecallantide (Kalbitor) (PDF) 
Effective Date: 3/1/2016
Pomalisomide (Pomalyst) (PDF)
Effective Date: 7/1/2013
 
Eculizumab (Soliris) (PDF) 
Effective Date: 3/1/2012
Ponatinib (Iclusig) (PDF)
Effective Date: 6/1/2013
 
Edaravone (Radicava) (PDF) 
Effective Date: 7/1/2017
Pralatrexate (Folotyn) (PDF)
Effective Date: 2/1/2017
 
Efinaconazole (Jublia) (PDF) 
Effective Date: 2/1/2017
Pramlintide (Symlin) (PDF)
Effective Date: 6/1/2018
 
Eliglustat (Cerdelga) (PDF) 
Effective Date: 2/1/2016
Prasterone (Intrarosa) (PDF)
Effective Date: 12/20/2016
 
Elosulfase Alfa (Vimizim) (PDF) 
Effective Date: 2/1/2016
Pregabalin (Lyrica) (PDF)
Effective Date: 1/1/2007
 
Elotuzumab (Empliciti) (PDF) 
Effective Date: 2/1/2017
Propranolol HCL Solution (Hemangeol) (PDF)
Effective Date: 5/1/2014
 
Eltrombopag (Promacta) (PDF) 
Effective Date: 3/1/2016
Protein C Concentrate, Human (Ceprotin) (PDF)
Effective Date: 3/1/2017
 
Enasidenib (Idhifa) (PDF) 
Effective Date: 9/5/2017
Pyrimethamine (Daraprim) (PDF)
Effective Date: 11/5/2015
 
Enfuvirtide (Fuzeon) (PDF) 
Effective Date: 6/1/2010
QL of Diabetes Test Strips for Members not Receiving Insulin (PDF)
Effective Date: 9/1/2017
 
Enoxaparin (Lovenox) (PDF) 
Effective Date: 5/1/2016
   
Enzalutamide (Xtandi) (PDF) 
Effective Date: 10/1/2012
   
Epinephrine (Epipen, Epipen JR) (PDF) 
Effective Date: 8/1/2016
   
Epoetin Alfa (Epogen and Procrit) (PDF) 
Effective Date: 6/1/2016
   
Epoprostenol (Flolan, Veletri) (PDF) 
Effective Date: 3/1/2016
   
Eribulin Mesylate (Halaven) (PDF) 
Effective Date: 3/1/2017
   
Erlotinib (Tarceva) (PDF) 
Effective Date: 9/1/2017
   
Erwina Aspariganase (Erwinaze) (PDF) 
Effective Date: 2/1/2017
   
Etanercept (Enbrel) (PDF) 
Effective Date: 8/1/2016
   
Eteplirsen (Exondys) (PDF)
Effective Date: 12/1/2016
   
Etidronate (Didronel) (PDF) 
Effective Date: 3/1/2018
   
Everolimus (Afinitor) (PDF) 
Effective Date: 6/1/2011
   
Evolocumab (Repatha) (PDF) 
Effective Date: 10/1/2015
   
Exemestane Step Therapy (PDF) 
Effective Date: 10/1/2010
   
Ezetimibe (Zetia) (PDF) 
Effective Date: 2/1/2017
   
Ezetimibe-Simvastatin (Vytorin) (PDF) 
Effective Date: 2/1/2017
   
Famciclovir (Famvir) (PDF) 
Effective Date: 9/1/2006
   
Febuxostat (Uloric) (PDF) 
Effective Date: 8/1/2013
   
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) 
Effective Date: 6/1/2015
   
Ferric Carboxymaltose (Injectafer) (PDF) 
Effective Date: 6/1/2016
   
Ferric Gluconate (Ferrlecit) (PDF) 
Effective Date: 3/1/2016
   
Ferumoxytol (Feraheme) (PDF) 
Effective Date: 3/1/2016
   
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-Filgrastim (Granix) (PDF) 
Effective Date: 12/1/2016
   
Fingolimod (Gilenya) (PDF) 
Effective Date: 8/1/2016
   
Fluticasone Proprionate (Xhance) (PDF) 
Effective Date: 10/24/2017
   
Fluticasone Salmeterol (Advair Diskus, Advair HFA) (PDF) 
Effective Date: 8/1/2016
   
Fondaparinux (Arixtra) (PDF) 
Effective Date: 5/1/2016
   
Galsulfase (Naglazyme) (PDF) 
Effective Date: 2/1/2016
   
Gefitinib (Iressa) (PDF) 
Effective Date: 1/1/2017
   
Gemtuzumab Ozogamicin (Mylotarg) (PDF) 
Effective Date: 10/3/2017
   
Glatiramer (Copaxone, Glatopa) (PDF) 
Effective Date: 8/1/2016
   
Global Biopharm (PDF) 
Effective Date: 3/1/2011
   
Glucagon-Like Peptide-1 Receptor Agonists (PDF) 
Effective Date: 3/1/2018
   
Golimumab (Simponi, Simponi Aria) (PDF) 
Effective Date: 7/1/2016
   
Goserelin Acetate (Zoladex) (PDF) 
Effective Date: 10/1/2016
   
Granisetron (Sancuso) (PDF) 
Effective Date: 11/1/2016
   
Guanfacine ER (Intuniv) (PDF) 
Effective Date: 4/1/2010
   
Guselkumab (Tremfya) (PDF) 
Effective Date: 8/29/2017
   
Hemin (Panhematin) (PDF) 
Effective Date: 2/1/2016
   
Histrelin Acetate (Vantas, Supprelin LA) (PDF) 
Effective Date: 10/1/2016
   
House dust mite allergen extract (Odactra) (PDF) 
Effective Date: 8/1/2017
   
Hyaluronate Derivatives (PDF) 
Effective Date: 10/1/2008
   
Hydroxyprogesterone Caproate (Makena) (PDF) 
Effective Date: 11/20/2017
   

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 NH Healthy Families Payment Policy Manual apply with respect to NH Healthy Families members. Policies in the NH Healthy Families Payment Policy Manual may have either a NH Healthy Families or a “Centene” heading.  In addition, NH Healthy Families 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 NH Healthy Families.     

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

A-H I-Q R-Z
30-Day Readmission (PDF)
Effective Date: 1/1/2015
Inpatient Consultation (PDF)    Effective Date: 1/1/2014 Robotic Surgery (PDF)  
Effective Date: 8/1/2017
3-Day Payment Window (PDF)
Effective Date: 3/1/2018
Inpatient Only Procedures (PDF)         
Effective Date: 1/1/2013
Same Day Visits (PDF)
Effective Date: 3/1/2018
Add on Code Billed Without Primary Code (PDF)
Effective Date: 1/1/2013
IV Hydration (PDF)
Effective Date: 1/1/2013
Sleep Studies Place of Services (PDF)
Effective Date: 5/1/2017
Assistant Surgeon (PDF)
Effective Date: 1/1/2014
Maximum Units (PDF)
Effective Date: 1/1/2013
Status "B" Bundled Services (PDF)                 
Effective Date: 1/1/2014
Bilateral Procedures (PDF)
Effective Date: 1/1/2014
Moderate Conscious Sedation (PDF)
Effective Date: 1/1/2013
Status "P" Bundled Services (PDF)
Effective Date: 3/15/2017
Cerumen Removal (PDF)
Effective Date: 1/1/2014
Modifier-25 Clinical Validation (PDF)
Effective Date: 1/1/2013
Supplies Billed on Same Day as Surgery (PDF)
Effective Date: 1/1/2013
Clean Claims (PDF)
Effective Date: 1/1/2013
Modifier-59 Clinical Validation (PDF)
Effective Date: 1/1/2013
Transgender Related Services (PDF)
Effective Date: 1/1/2017
CLIA Number (PDF)
Effective Date: 1/1/2013
Modifier DOS Validation (PDF)
Effective Date: 1/1/2013
Unbundled Professional Services (PDF)
Effective Date: 1/1/2014
Coding Overview (PDF)
Effective Date: 1/1/2013
Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/2013
Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/2014
Cosmetic Procedures (PDF)
Effective Date: 1/1/2014
Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/2014
Unlisted Procedure Codes (PDF)
Effective Date: 1/1/2013
Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/2013
NCCI Unbundling (PDF)
Effective Date: 1/1/2013
Wheelchair Accessories (PDF)
Effective Date: 10/1/2015
Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/2014
Never Paid Events (PDF)
Effective Date: 1/1/2013
 
E&M Medical Decision-Making (PDF)
Effective Date: 1/1/2017
New Patient (PDF)
Effective Date: 1/1/2014
 
EM Bundling Kits (PDF)
Effective Date: 1/1/2013
Outpatient Consultation (PDF)
Effective Date: 1/1/2014
 
Global Maternity Billing (PDF)
Effective Date: 1/1/2013
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013
 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013
Post-Operative Visits (PDF)
Effective Date: 1/1/2014
 
  Pre-Operative Visits (PDF)
Effective Date: 1/1/2014
 
  Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: 11/1/2017
 
  Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 11/1/2017
 
  Professional Compenent (PDF)
Effective Date: 1/1/2013
 
  Pulse Oximetry (PDF)
Effective Date: 1/1/2014
 
A-H I-Q R-Z
30-Day Readmission (PDF)
Effective Date: 1/1/2015
Inpatient Consultation (PDF)    Effective Date: 1/1/2014 Robotic Surgery (PDF)  
Effective Date: 8/1/2017
3-Day Payment Window (PDF)
Effective Date: 3/1/2018
Inpatient Only Procedures (PDF)         
Effective Date: 1/1/2013
Same Day Visits (PDF)
Effective Date: 3/1/2018
Add on Code Billed Without Primary Code (PDF)
Effective Date: 1/1/2013
IV Hydration (PDF)
Effective Date: 1/1/2013
Sleep Studies Place of Services (PDF)
Effective Date: 5/1/2017
Anesthesia Payment Policy (PDF)
Effective Date: 8/1/2017
Maximum Units (PDF)
Effective Date: 1/1/2013
Status "B" Bundled Services (PDF)                 
Effective Date: 1/1/2014
Assistant Surgeon (PDF)
Effective Date: 1/1/2014
Moderate Conscious Sedation (PDF)
Effective Date: 1/1/2013
Status "P" Bundled Services (PDF)
Effective Date: 3/15/2017
Bilateral Procedures (PDF)
Effective Date: 1/1/2014
Modifier-25 Clinical Validation (PDF)
Effective Date: 1/1/2013
Supplies Billed on Same Day as Surgery (PDF)
Effective Date: 1/1/2013
Cerumen Removal (PDF)
Effective Date: 1/1/2014
Modifier-59 Clinical Validation (PDF)
Effective Date: 1/1/2013
Transgender Related Services (PDF)
Effective Date: 1/1/2017
Clean Claims (PDF)
Effective Date: 1/1/2013
Modifier DOS Validation (PDF)
Effective Date: 1/1/2013
Unbundled Professional Services (PDF)
Effective Date: 1/1/2014
CLIA Number (PDF)
Effective Date: 1/1/2013
Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/2013
Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/2014
Coding Overview (PDF)
Effective Date: 1/1/2013
Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/2014
Unlisted Procedure Codes (PDF)
Effective Date: 1/1/2013
Cosmetic Procedures (PDF)
Effective Date: 1/1/2014
NCCI Unbundling (PDF)
Effective Date: 1/1/2013
Wheelchair Accessories (PDF)
Effective Date: 10/1/2015
CPAP Supplies Policy (PDF)
Effective Date: 4/1/2018
Never Paid Events (PDF)
Effective Date: 1/1/2013
 
Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/2013
New Patient (PDF)
Effective Date: 1/1/2014
 
Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/2014
Out of Network Payment Policy (PDF)
Effective Date: 1/1/2018
 
E&M Medical Decision-Making (PDF)
Effective Date: 1/1/2017
Outpatient Injectible Drugs Policy (PDF)
Effective Date: 1/1/2018
 
EM Bundling Kits (PDF)
Effective Date: 1/1/2013
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013
 
Global Maternity Billing (PDF)
Effective Date: 1/1/2013
Post-Operative Visits (PDF)
Effective Date: 1/1/2014
 
Home Health Policy (Payment) (PDF)
Effective Date: 9/15/2018
Pre-Operative Visits (PDF)
Effective Date: 1/1/2014
 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013
Professional Compenent (PDF)
Effective Date: 1/1/2013
 
  Pulse Oximetry (PDF)
Effective Date: 1/1/2014