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Tools and Resources

Policy Bulletin Library

HPP's policy bulletins communicate our medical, claim payment reimbursement, and drug positions for services administered in relation to the applicable member’s benefits.

We have created three sections of the library below: medical policies, claim payment polices, and drug policies.

All policy documents are considered complementary to our Provider Manual.

Medical Policy Bulletins

Our Medical policy bulletins define medical necessity criteria and coverage positions on topics such as medical services, procedures, DME, therapies, etc.

Policy Bulletin #



Version Date

MN.004.B New Technology Documents our coverage position for new technologies 3/6/2020
MN.005.C Experimental and Investigational Services, Investigational Device Exemption (IDE), and Coverage with Evidence Development (CED) Documents our coverage position for E&I Services, IDEs, and CEDs 11/1/2023
MN.006.H Cosmetic & Reconstructive Services Documents our coverage position for cosmetic and reconstructive services 9/1/2023
MN.008.C Genetic Testing Documents our coverage position on genetic testing 7/1/2020
MN.010.E Gender Confirmation Surgery Documents our position on gender confirmation surgery 5/1/2022


Whole Genome Sequencing/Whole Exome Sequencing

Documents our coverage position on WGS and WES



Shift Nursing, Personal Care, and Medical Daycare

Documents our position on the shift care, personal care, and medical daycare


MN.015.B Standards of Medical Necessity Documents our position related to medical necessity 9/1/2021
MN.016.A Injectable/Specialty Drugs Prior Authorization Requirements Documents our prior authorization requirements for injectable/specialty drugs 12/1/2019
MN.020.B Peroral Endoscopic Myotomy (POEM) Documents our position related to Peroral Endoscopic Myotomy (POEM) 3/1/2022
MN.021.A Panniculectomy and Abdominoplasty Documents our position related to panniculectomy and abdominoplasty 2/1/2023
MN.022.A Reduction Mammoplasty Documents our position related to reduction mammoplasty 8/1/2023

Medical Policy Type Key: MN = Medical Necessity

Claim Payment Policy Bulletins

Our Claim Payment policy bulletins provide reimbursement rules and billing guidelines necessary to ensure timely and appropriate payment.

Policy Bulletin #



Version Date

RB.001.C Ambulance Ground Mileage Claim Documents our reimbursement rules for ambulance ground mileage and ambulance services 8/15/2023
RB.004.A Modifier 50, Bilateral Procedure Documents our position on modifier 50, bilateral procedure 3/31/2016
RB.005.A Modifier 25 Documents our position on Modifier 25 7/1/2016
RB.006.C STAT Labs Provides reporting requirements and reimbursement rules for STAT laboratory tests (a.k.a. labs) 1/1/2023
RB.007.B DME Continuous Rental Documents our position on durable medical equipment (DME) rentals 5/25/2018
RB.009.A Sepsis and Severe Sepsis DRG Clinical Validation Review Documents our position on Sepsis and Severe Sepsis DRG Clinical Validation review 4/1/2020
RB.014.C Observation Care


Documents our position on Observation Care services

Provides answers to common questions

RB.015.C Cataract Removal and Related Ophthalmologic Testing Documents our position on cataract removal and related ophthalmologic testing 5/1/2022
RB.017.C Continuous Glucose Monitors Documents our position on continuous glucose monitors 12/9/2022
RB.018.A Medicare Readmissions Documents our position on Medicare readmissions 1/1/2021
RB.019.A Health Care Acquired Conditions (HCAC) and Preventable Serious Adverse Events (PSAE) Documents our position on Health Care Acquired Conditions and Preventable Serious Adverse Events 1/1/2021
RB.020.A Obstetric Anesthesia Services

Documents our position on obstetric anesthesia services.

RB.021.A Professional Telehealth Services (Medicare)

Updates our policy on telehealth services, specifically for Medicare members.

RB.022.C Rapid Hemoglobin A1c (HbA1c) Testing

Documents our position on rapid hemoglobin A1c (HbA1c) testing.

RB.023.B Diabetic Retinopathy Screening and Fundus Photography

Documents our position on diabetic retinopathy screening and fundus photography.

RB.024.A Professional Telehealth Services (Medicaid and CHIP)

Updates our policy on telehealth services for Medicaid and CHIP members.



Pediatric Shift Care When Multiple Members in a Household Are Receiving Care

Documents our position on pediatric shift care when multiple members in a household are receiving care.


RB.026.A Remote Patient Monitoring

Provides information on remote patient monitoring.

RB.027.A Tobacco Cessation Program

Provides information on tobacco cessation certification.

RB.028.A CMS and DHS Payment Systems Update and Maintenance Payment Policy

Provides information on CMS and DHS policies.

RB.029.B Diabetes Prevention Program

Provides information on the Diabetes Prevention Program

RB.030.A Newborn Authorizations

Provides information on authorizations for newborns

RB.031.A Maternity Billing and Reimbursement Guidelines

Provides information on authorizations for maternity billing and reimbursement

RB.032.A Adjudication of Claims from Non-Participating Providers

Documents our coverage position for Adjudication of claims for non participating providers





Vaccine Coding and Reimbursement

Vaccine Coding and Reimbursement (30-Day Notification)

Provides information on vaccine coding and administration




Claim Payment Policy Type Key: RB = Reimbursement

Drug Policy Bulletins

Our Drug policy bulletins documents our position on pharmaceutical topics and drugs.

Policy Bulletin #



Version Date

DR.002.E Intravenous Immune Globulin (IVIG) Documents our position regarding IVIG Therapy.


DR.003.D Ocrevus (Ocrelizumab) Documents our position on Ocrevus (Ocrelizumab). 4/24/2023
DR.004.E Spinraza (Nusinersen) Documents our position on Spinraza (Nusinersen). 4/24/2023


Zolgensma (onasemnogene abeparvovec-xioi)

Documents our position on Zolgensma (onasemnogene abeparvovec-xioi).



Complement Inhibitors: Eculizumab (Soliris) & Ravulizumab (Ultomiris)

Documents our position on Eculizumab (Soliris) and Ravulizumab (Ultomiris).



Adakveo (Crizanlizumab-tcma)

Documents our position on Adakveo (Crizanlizumab-tcma).


DR.008.B Sandostatin LAR Depot (octreotide acetate) Documents our position on Sandostatin LAR Depot (octreotide acetate). 9/1/2023
DR.009.B TEPEZZA® (teprotumumab-trbw) Documents our position on TEPEZZA (teprotumumab-trbw). 9/1/2023
DR.010.C Xiaflex (Collagenase clostridium histolyticum) Documents our position on Xiaflex (Collagenase clostridium histolyticum). 9/1/2023


IgG1 Monoclonal Antibodies for Alzheimer’s

Documents our position on IgG1 Monoclonal Antibodies for Alzheimer’s


DR.013.A Relizorb (immobilized lipase) Cartridge Documents our position on Relizorb (immobilized lipase). 3/22/2023
DR.014.A Gene Therapy Documents our position on Etranacogene dezaparvovec-drlb (Hemgenix®), Viltolarsen (Viltepso®), and Nadofaragene firadenovec-vncg (Adstiladrin®). 7/1/2023

Drug Policy Type Key: DR = Drug

Please note:

  • The effective date of select policy bulletins found in the Policy Bulletin Library above may considerably pre-date the actual date of their availability on this Policy Bulletin Library web page. This is because the Policy Bulletin Library will include PDFs of policies that have been in effect for many years, but have not been previously published on our website.
  • New and updated policy bulletins will typically be published in the Policy Bulletin Library 30 to 60 days prior to their implementation date, ensuring that your office is given appropriate notification of changes and updates that may affect your office.