Managed Care Policies & Procedures

COVID-19 Update: Changes to Medicaid policy and procedure deemed of an imminent peril to the public health, safety, or welfare and requiring immediate approval, such as those related to COVID-19, are exempt from the legislative requirement to publish the proposed policy or procedure for public comment prior to implementation. To keep abreast of these exempted changes to policy and procedure related to COVID-19, refer to the Coronavirus (COVID-19) Medicaid Information website. Here you will find guidance to Medicaid providers, guidance for MCOs via Health Plan Advisories, emergency rules and requests the Department has submitted to the Centers for Medicare & Medicaid Services (CMS). Broader information related to COVID-19 can be found at

"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


Scenesse 9/28/20 11/12/20 Pending Scenesse
2020-UHC-PHARM-2 Uplizna 9/28/20 11/12/20 Pending Uplizna
2020-UHC-PHARM-3 Viltepso 9/28/20 11/12/20 Pending Viltepso
2020-ACLA-PHARM-4 Specialty Drugs PA Criteria 9/15/20 10/30/20 Pending Specialty Drugs PA Criteria
2020-ACLA-PHARM-3 Oncology Drugs PA Criteria 9/8/20 10/24/20 Pending Oncology Drugs PA Criteria
2020-ACLA-PHARM-1 Remdesivir 9/1/20 10/16/20 Pending Remdesivir
2020-ACLA-PHARM-2 Diabetic Testing Supplies 9/1/20 10/16/20 Pending Diabetic Testing Supplies
2020-LHCC-817 Crisis Intervention Policy 8/28/20 10/12/20 Pending Crisis Intervention Policy
2020-LHCC-817 Vitamin D Testing Policy 8/28/20 10/12/20 Pending Vitamin D Testing Policy
2020-ABH-PHARM-2 Compounds 8/25/20 10/9/20 Pending Compounds
2020-ABH-PHARM-1 Quantity Level Limit 8/19/20 10/3/20 Pending Quantity Level Limit
2020-HBL-816 Vitamin D Policy 8/18/20 10/2/20 Pending Vitamin D Policy
2020-ACLA-815 Vitamin D Policy 8/14/20 9/28/20 Pending Vitamin D Policy
2020-ABH-813 Vitamin D Policy 8/14/20 9/28/20 Pending Vitamin D Policy