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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