Our 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, one for medical policies, one for claim payment polices, and one for drug policies.

All policy documents are considered complimentary 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 #	Title	Summary	Version Date
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.C	Gender Confirmation Surgery	Documents our position on gender confirmation surgery	9/1/2020
MN.011.C	Whole Genome Sequencing/Whole Exome Sequencing	Updates 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, personcal care, and medical daycare	1/1/2019
MN.015.A	Standards of Medical Necessity	Documents our position related to medical necessity	12/1/2018
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 #	Title	Summary	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 (aka, 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	30 day notification of 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   FAQ	Documents our position on Observation Care services Provides answers to common questions	12/4/2019
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 30-day notification	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 #	Title	Summary	Version Date
DR.002.B	Intravenous Immune Globulin (IVIG)	Documents our position regarding IVIG Therapy	8/1/2020
DR.003.B	Ocrevus (Ocrelizumab)	Documents our position on Ocrevus (Ocrelizumab).	5/1/2020
DR.004.B	Spinraza (Nusinersen)	Documents our position on Spinraza (Nusinersen).	6/1/2020
DR.005.A	Zolgensma (onasemnogene abeparvovec-xioi)	Documents our position on Zolgensma (onasemnogene abeparvovec-xioi).	3/1/2020
DR.006.A	Complement Inhibitors: Eculizumab (Soliris) & Ravulizumab(Ultomiris)	Documents our position on Eculizumab (Soliris) and Ravulizumab(Ultomiris).	7/1/2020
DR.007.B	Adakveo (Crizanlizumab-tcma)	Documents our position on Adakveo (Crizanlizumab-tcma).	1/1/2021
DR.008.A	Sandostatin LAR Depot (octreotide acetate)	Documents our position on Sandostatin LAR Depot (octreotide acetate).	10/1/2020
DR.009.A	TEPEZZA® (teprotumumab-trbw)	Documents our position on TEPEZZA® (teprotumumab-trbw).	11/1/2020

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.