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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.B 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 7/18/2018
MN.006.F Cosmetic & Reconstructive Services Documents our coverage position for cosmetic and reconstructive services 5/1/2020
MN.008.C Genetic Testing Documents our coverage position on genetic testing 7/1/2020
MN.010.D Gender Confirmation Surgery Documents our position on gender confirmation surgery 7/1/2021
MN.011.C Whole Genome Sequencing/Whole Exome Sequencing Documents our coverage position on WGS and WES 12/1/2019
MN.012.B LINX™ Reflux Management System Documents our position on the LINX™ Reflux Management System 12/1/2018
MN.013.B Shift Nursing, Personal Care, and Medical Daycare Documents our position on the shift care, personal care, and medical daycare 1/1/2019
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.A Peroral Endoscopic Myotomy (POEM) Documents our position related to Peroral Endoscopic Myotomy (POEM) 11/1/2019

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.B Ambulance Ground Mileage Claim Documents our reimbursement rules for ambulance ground mileage and ambulance services 6/1/2020
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.A STAT Labs Provides reporting requirements and reimbursement rules for STAT laboratory tests (a.k.a. labs) 7/1/2016
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 3/1/2020
RB.012.A Professional Telehealth Services Documents our coverage position on professional telehealth services 12/1/2019
RB.014.B Observation Care


Documents our position on Observation Care services

Provides answers to common questions

RB.015.A Cataract Removal and Related Ophthalmologic Testing Documents our position on cataract removal and related ophthalmologic testing 5/1/2020
RB.017.B Continuous Glucose Monitors Documents our position on continuous glucose monitors 3/19/2021
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

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


Intravenous Immune Globulin (IVIG)

Documents our position regarding IVIG Therapy.


DR.003.C Ocrevus (Ocrelizumab)

Documents our position on Ocrevus (Ocrelizumab).

DR.004.C Spinraza (Nusinersen)

Documents our position on Spinraza (Nusinersen).


DR.005.A Zolgensma (onasemnogene abeparvovec-xioi)

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


DR.006.A Complement Inhibitors: Eculizumab (Soliris) & Ravulizumab(Ultomiris)

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


DR.007.B Adakveo (Crizanlizumab-tcma)

Documents our position on Adakveo (Crizanlizumab-tcma).

DR.008.A Sandostatin LAR Depot (octreotide acetate)

Documents our position on Sandostatin LAR Depot (octreotide acetate).

DR.009.A TEPEZZA® (teprotumumab-trbw)

Documents our position on TEPEZZA (teprotumumab-trbw).

DR.010.A Xiaflex (Collagenase clostridium histolyticum)

Documents our position on Xiaflex (Collagenase clostridium histolyticum).


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.