Managed Care Policies & Procedures

"Policy or procedure" shall mean a requirement governing the administration of managed care organizations specific to billing guidelines, medical management and utilization review guidelines, case management guidelines, claims processing guidelines and edits, grievance and appeals procedures and process, other guidelines or manuals containing pertinent information related to operations and pre-processing claims, and core benefits and services.

Below are the changes to the managed care policies and procedures beginning August 1, 2019. To provide feedback, please complete this form.

Item Number Policy/Procedure Date Posted Public Comments Due By Status Document Links
2020-PHARM-20 POS DUR May 2020 Posting  3/13/20 4/27/20 Pending POS DUR May 2020 Posting
2020-PHARM-19 POS Document for January 2020 May Implementation  3/13/20 4/27/20 Pending POS Document for January 2020 May Implementation 
2020-PHARM-18 Oral Glucocorticoids  3/13/20 4/27/20 Pending Oral Glucocorticoids 
2020-PHARM-17 Miscellaneous Agents with POS Req  3/13/20  4/27/20 Pending Miscellaneous Agents with POS Req  
2020-PHARM-16 Other Behavioral Health Under 6  3/13/20 4/27/20 Pending Other Behavioral Health Under 6
2020-PHARM-15 Kalydeco  3/13/20 4/27/20 Pending Kalydeco
2020-PHARM-14 Symdeko  3/13/20 4/27/20 Pending Symdeko
2020-PHARM-13 Orkambi  3/13/20 4/27/20 Pending Orkambi
2020-PHARM-12 Exondys  3/13/20 4/27/20 Pending Exondys
2020-PHARM-11 Cytokine and CAM Antagonists  3/13/20 4/27/20 Pending Cytokine and CAM Antagonists 
2020-PHARM-10 Hepatitis C DAA  3/13/20 4/27/20 Pending Hepatitis C DAA
2020-PHARM-9 Mytesi  3/13/20 4/27/20 Pending Mytesi
2020-PHARM-8 Samsca  3/13/20 4/27/20 Pending Samsca
2020-PHARM-7 Jynarque  3/13/20 4/27/20 Pending Jynarque 
2020-PHARM-6 Penicillamine  3/13/20 4/27/20 Pending Penicillamine
2020-PHARM-5 Buphenyl Carbaglu Ravicti 3/13/20   4/27/20 Pending Buphenyl Carbaglu Ravicti
2020-PHARM-4 Vyondys 3/13/20 4/27/20 Pending Vyondys
2020-PHARM-3 Trikafta 3/13/20 4/27/20 Pending Trikafta
2020-PHARM-2 Zulresso 3/13/20 4/27/20 Pending Zulresso
2020-UHC-126 Behavior Health Supportive Criteria 3/13/20 4/27/20 Pending Behavior Health Supportive Criteria
2020-SCG-2 Addition of new codes to Evidence Based Practice Codes:  EB06 and EB07 3/6/20 4/20/20 Pending MCO SCG v 57
2020-HBL-357 Non-Par Opioid Policy 3/6/20 4/20/20 Pending Non-Par Opioid Policy
2020 HBL-333 Medical Transportation 3/4/20 4/18/20 Pending Medical Transportation
2020-HPA-1 Revised Hysterectomy Acknowledgement Form 3/3/20 4/17/20 Pending HPA Hysterectomy Acknowledgement Form
2020-IB-1 Revised Hysterectomy Acknowledgement Form 3/3/20 4/17/20 Pending IB Hysterectomy Acknowledgement Form
2020-HBL-121 POA HCAC Article and Policy 2/26/20 4/11/20 Pending POA HCAC Article and Policy
2020-HBL-321 Behavioral Health Adverse Incidents Monitoring and Reporting 2/26/20 4/11/20 Pending Behavioral Health Adverse Incidents Monitoring and Reporting
2020-HBL-332 Prior Authorization Liaison (PAL) Policy 2/26/20 4/11/20 Pending Prior Authorization Liaison (PAL) Policy
2020-HBL-358 Behavioral Health – Nursing Facility Services 2/26//20 4/11/20 Pending Behavioral Health – Nursing Facility Services
2020-LHCC-339 Network Adequacy 2/17/20 4/2/20 Pending Network Adequacy
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