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-ABH-233 Opioid Use Disorder 1/24/20 3/9/20 Pending Opioid Use Disorder
2020-HBL-320 Emergency and Post Stabilization Services 1/24/20 3/9/20 Pending Emergency and Post Stabilization Services
2020-LHCC-237 Opioid Use Disorder Treatment in Opioid Treatment Programs 1/24/20 3/9/20 Pending Opioid Use Disorder Treatment in Opioid Treatment Programs
2020-ACLA-236 Opioid Use Disorder Treatment in Opioid Treatment Programs 1/23/20 3/8/20 Pending Covered Benefits and Services
Standard and Urgent Prior Authorization
2020-HBL-235 Reimbursement in Opioid Treatment Programs 1/23/20 3/8/20 Pending Reimbursement in Opioid Treatment Programs
2020-LHCC-249

Ambulatory Insulin Pump

1/23/20 3/8/20 Pending Ambulatory Insulin Pump
2020-UHC-234 Opioid Use Disorder Treatment in Opioid Treatment Programs 1/23/20 3/8/20 Pending Opioid Use Disorder Treatment in Opioid Treatment Programs
2020-PHARM-1 Pharmacy Lock-In Program 1/17/20 3/2/20 Pending Pharmacy Lock-In Program
2020-HBL-244 Assertive Community Treatment Billing 1/16/20 3/1/20 Pending Assertive Community Treatment Billing
2020-UHC-248 Vertebral Tethering for Scoliosis 1/15/20 2/29/20 Pending Vertebral Tethering for Scoliosis
2020-HBL-121 POA HCAC Article 1/15/20 2/29/20 Pending POA HCAC Article
2020-ABA-1 ABA Required Documentation per Codes 1/14/20 2/28/20 Pending ABA Required Documentation per Codes
2020-ABA-2 ABA Audit Tool Overview 1/14/20 2/28/20 Pending ABA Audit Tool Overview
2020-ABA-3 Record Keeping Provider Training 1/14/20 2/28/20 Pending Record Keeping Provider Training
2019-PHARM-15 Spinraza Single PDL 1/14/20 2/28/20 Pending Spinraza Single PDL
2020-SCG-1 Change Disposition of Edit 202 from “E” to “D” 1/7/20 2/21/20 Pending MCO System Companion Guide, pg. 125
2019-LHCC-53 Homebuilders Services 1/7/20 2/21/20 Pending Homebuilders Services
2020-HBL-258 Health Care Management Denial 1/7/20 2/21/20 Pending Health Care Management Denial
2020-LHCC-106 Coordinated System of Care (CSoC) 1/6/20 2/20/20 Pending Coordinated System of Care (CSoC)
2020-LHCC-232 Referrals to SHC Services 1/2/20 2/16/20 Pending Referrals to SHC Services
2019-LHCC-45 Court Ordered Services 12/27/19 2/10/20 Pending Court Ordered Services
2019-LHCC-48 EPSDT Personal Care Services 12/26/19 2/9/20 Pending EPSDT Personal Care Services
2019-UHC-200 Ablative Treatment for Spinal Pain (for Louisiana Only) 12/23/19 2/6/20 Pending Ablative Treatment for Spinal Pain (for Louisiana Only)
2019-UHC-201 Apheresis (for Louisiana Only) 12/23/19 2/6/20 Pending Apheresis (for Louisiana Only)
2019-UHC-202 Balloon Sinus Ostial Dilation (for Louisiana Only) 12/23/19 2/6/20 Pending Balloon Sinus Ostial Dilation (for Louisiana Only)
2019-UHC-203 Breast Reduction Surgery (for Louisiana Only) 12/23/19  2/6/20   Pending Breast Reduction Surgery (for Louisiana Only)
2019-UHC-204 Cardiac Event Monitoring 12/23/19 2/6/20 Pending Cardiac Event Monitoring
2019-UHC-205 Computed Tomographic Colonography 12/23/19 2/6/20 Pending Computed Tomographic Colonography
2019-UHC-206 Electric Tumor Treatment Field Therapy 12/23/19 2/6/20 Pending Electric Tumor Treatment Field Therapy
2019-UHC-207 Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation 12/23/19 2/6/20 Pending Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
2019-UHC-208 Epidural Steroid and Facet Injections for Spinal Pain 12/23/19 2/6/20 Pending Epidural Steroid and Facet Injections for Spinal Pain
2019-UHC-210 Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography (for Louisiana Only) 12/23/19 2/6/20 Pending Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography (for Louisiana Only)
2019-UHC-211 Fecal Calprotectin Testing (for Louisiana Only) 12/23/19 2/6/20 Pending Fecal Calprotectin Testing (for Louisiana Only)
2019-UHC-212 Functional Endoscopic Sinus Surgery (FESS) (for Louisiana Only) 12/23/19 2/6/20 Pending Functional Endoscopic Sinus Surgery (FESS) (for Louisiana Only)
2019-UHC-213 Genetic Testing for Hereditary Cancer (for Louisiana Only) 12/23/19 2/6/20 Pending Genetic Testing for Hereditary Cancer (for Louisiana Only)
2019-UHC-214 Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions (for Louisiana Only) 12/23/19 2/6/20 Pending Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions (for Louisiana Only)
2019-UHC-215 Bone or Soft Tissue Healing and Fusion Enhancement Products 12/23/19 2/6/20 Pending Bone or Soft Tissue Healing and Fusion Enhancement Products
2019-UHC-216 DME 12/23/19 2/6/20 Pending DME
2019-UHC-217 Omnibus Codes 12/23/19 2/6/20 Pending Omnibus Codes
2019-UHC-218 Pharmacogenetic Testing 12/23/19 2/6/20 Pending Pharmacogenetic Testing
2019-UHC-219 Articular Defect Repairs 12/23/19 2/6/20 Pending Articular Defect Repairs
2019-UHC-220 Prolotherapy and Platelet Rich Plasma Therapies 12/23/19 2/6/20 Pending Prolotherapy and Platelet Rich Plasma Therapies
2019-UHC-221 Prosthetic Devices, Specialized, Microprocessor or Myoelectric Limbs 12/23/19 2/6/20 Pending Prosthetic Devices, Specialized, Microprocessor or Myoelectric Limbs
2019-UHC-222 Skin and Soft Tissue Substitutes (for Louisiana Only) 12/23/19 2/6/20 Pending Skin and Soft Tissue Substitutes (for Louisiana Only)
2019-UHC-223 Vagus and Trigeminal Nerve Stimulation 12/23/19 2/6/20 Pending Vagus and Trigeminal Nerve Stimulation
2019-UHC-224 Visual Information Processing Evaluation and Orthoptic and Vision Therapy 12/23/19 2/6/20 Pending Visual Information Processing Evaluation and Orthoptic and Vision Therapy
2019-UHC-247 Negative Pressure Wound Therapy 12/23/19 2/6/20 Pending Negative Pressure Wound Therapy
2019-ABH-118 Prior Authorization of PDHC 12/18/19 2/1/20 Pending Prior Authorization of PDHC
2019-ABH-117 Multi-Systemic Therapy 12/18/19 2/1/20 Pending Multi-Systemic Therapy
2019-ABH-116 Crisis Intervention Services 12/18/19 2/1/20 Pending Crisis Intervention Services
2019-HBL-128 Continuing Crisis Intervention Services 12/18/19 2/1/20 Pending Continuing Crisis Intervention Services
2019-UHC-125 Certification of Need for PRTFs 12/16/19 1/30/20 Pending Certification of Need for PRTFs
2019-PHARM-3 Mayzent 12/12/19 1/26/20 Pending Mayzent
2019-PHARM-4 Reclast 12/12/19 1/26/20 Pending Reclast
2019-PHARM-5 Vyndaquel Criteria 12/12/19 1/26/20 Pending Vyndaquel Criteria
2019-PHARM-6 Spinraza PA Form 12/12/19 1/26/20 Pending Spinraza PA Form
2019-PHARM-7 Rinvoq 12/12/19 1/26/20 Pending Rinvoq
2019-PHARM-8 Pamidronate Disodium 12/12/19 1/26/20 Pending Pamidronate Disodium
2019-PHARM-9 Neudexta 12/12/19 1/26/20 Pending Neudexta
2019-PHARM-10 Gattex 12/12/19 1/26/20 Pending Gattex
2019-PHARM-11 Epidiolex 12/12/19 1/26/20 Pending Epidiolex
2019-PHARM-12 Enzyme Replacement Therapy 12/12/19 1/26/20 Pending Enzyme Replacement Therapy
2019-PHARM-13 Cablivi Criteria 12/12/19 1/26/20 Pending Cablivi Criteria
2019-PHARM-14 Acthar Gel Criteria 12/12/19 1/26/20 Pending Acthar Gel Criteria
2019-PHARM-16 Nucala 12/12/19 1/26/20 Pending Nucala
2019-PHARM-17 POS Posting for November 2019 DUR 12/12/19 1/26/20 Pending POS Posting for November 2019 DUR
2019-ABH-122 Out of State Outpatient CCR 12/11/19 1/25/20 Pending Out of State Outpatient CCR
2019-UHC-123 Prior Authorization FAQ 2019 12/11/19 1/25/20 Pending Prior Authorization FAQ 2019
2019-LHCC-111 Functional Family Therapy – Child Welfare 12/11/19 1/25/20 Pending Functional Family Therapy – Child Welfare
2019-HBL-142 Med CAT II Changes Provider Letter 12/11/19 1/25/20 Pending Med CAT II Changes Provider Letter
2019-UHC-124 Intensive Outpatient Process Change Proposal 12/11/19 1/25/20 Pending Intensive Outpatient Process Change Proposal
2019-LHCC-138 Appropriate UM Professionals 12/27/19 2/10/20 Pending Appropriate UM Professionals
2019-LHCC-139 UM Program Description 12/27/19 2/10/20 Pending UM Program Description

 

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