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 #	Title	Summary	Version Date
MN.004.C	New Technology	Documents our coverage position for new technologies	6/3/2024
MN.005.D	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	8/21/2024
MN.006.I	Cosmetic & Reconstructive Services	Documents our coverage position for cosmetic and reconstructive services	4/17/2024
MN.008.C	Genetic Testing	Documents our coverage position on genetic testing	7/1/2020
MN.010.G	Gender Confirmation Surgery	Documents our position on gender confirmation surgery	7/18/2024
MN.011.D	Whole Genome Sequencing/Whole Exome Sequencing	Documents our coverage position on WGS and WES	12/1/2023
MN.013.D	Shift Nursing, Personal Care, and Medical Daycare	Documents our position on the shift care, personal care, and medical daycare	11/1/2023
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.B	Peroral Endoscopic Myotomy (POEM)	Documents our position related to Peroral Endoscopic Myotomy (POEM)	3/1/2022
MN.021.A	Panniculectomy and Abdominoplasty	Documents our position related to panniculectomy and abdominoplasty	2/1/2023
MN.022.A	Reduction Mammoplasty	Documents our position related to reduction mammoplasty	8/1/2023

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.D	Ambulance Ground Mileage Claim	Documents our reimbursement rules for ambulance ground mileage and ambulance services	7/1/2024
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.C	STAT Labs	Provides reporting requirements and reimbursement rules for STAT laboratory tests (a.k.a. labs)	1/1/2023
RB.007.C	DME Continuous Rental	Documents our position on durable medical equipment (DME) rentals	6/1/2024
RB.009.A	Sepsis and Severe Sepsis DRG Clinical Validation Review	Documents our position on Sepsis and Severe Sepsis DRG Clinical Validation review	4/1/2020
RB.014.C	Observation Care   FAQ	Documents our position on Observation Care services Provides answers to common questions	2/1/2022
RB.015.C	Cataract Removal and Related Ophthalmologic Testing	Documents our position on cataract removal and related ophthalmologic testing	5/1/2022
RB.017.C	Continuous Glucose Monitors	Documents our position on continuous glucose monitors	12/9/2022
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
RB.020.A	Obstetric Anesthesia Services	Documents our position on obstetric anesthesia services.	12/1/2021
RB.021.A	Professional Telehealth Services (Medicare)	Updates our policy on telehealth services, specifically for Medicare members.	1/1/2022
RB.022.C	Rapid Hemoglobin A1c (HbA1c) Testing	Documents our position on rapid hemoglobin A1c (HbA1c) testing.	3/13/2023
RB.023.B	Diabetic Retinopathy Screening and Fundus Photography	Documents our position on diabetic retinopathy screening and fundus photography.	12/9/2022
RB.024.A	Professional Telehealth Services (Medicaid and CHIP)	Updates our policy on telehealth services for Medicaid and CHIP members.	8/1/2022
RB.025.D	Pediatric Shift Care When Multiple Members in a Household Are Receiving Care	Documents our position on pediatric shift care when multiple members in a household are receiving care.	11/1/2023
RB.026.A	Remote Patient Monitoring	Provides information on remote patient monitoring.	10/14/2022
RB.027.A	Tobacco Cessation Program	Provides information on tobacco cessation certification.	7/1/2022
RB.028.A	CMS and DHS Payment Systems Update and Maintenance Payment Policy	Provides information on CMS and DHS policies.	3/1/2022
RB.029.B	Diabetes Prevention Program	Provides information on the Diabetes Prevention Program	5/8/2023
RB.030.B	Newborn Authorizations	Provides information on authorizations for newborns	9/18/2024
RB.031.A	Maternity Billing and Reimbursement Guidelines	Provides information on authorizations for maternity billing and reimbursement	5/15/2023
RB.032.A	Adjudication of Claims from Non-Participating Providers	Documents our coverage position for Adjudication of claims for non participating providers	9/29/2023
RB.033.B	Vaccine Coding and Reimbursement	Provides information on vaccine coding and administration	12/20/2023
RB.034.A	Adjudication of Medicare Claims from Non-Participating Providers	Provides our policy on claims process	1/1/2024
RB.035.A	Preventive Care Services (Individual and Family Plans)	Provides our position on preventative care services	1/1/2024
RB.037.A	Readmissions (Individual and Family Plans)	Updates our policy on readmissions.	1/1/2024
RB.038.A	Professional Telehealth Services (Individual and Family Plans)	Updates our policy on telehealth services, specifically for IFP members.	1/1/2024
RB.039.A	Reporting Requirements for Anesthesia Services	Updates our policy on requirements for anesthesia services.	10/16/2024

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.F	Intravenous Immune Globulin (IVIG)	Documents our position regarding IVIG Therapy.	9/18/2023
DR.003.D	Ocrevus (Ocrelizumab)	Documents our position on Ocrevus (Ocrelizumab).	4/24/2023
DR.004.E	Spinraza (Nusinersen)	Documents our position on Spinraza (Nusinersen).	4/24/2023
DR.005.D	Zolgensma (onasemnogene abeparvovec-xioi)	Documents our position on Zolgensma (onasemnogene abeparvovec-xioi).	4/17/2024
DR.006.D	Complement Inhibitors: Eculizumab (Soliris) & Ravulizumab (Ultomiris)	Documents our position on Eculizumab (Soliris) and Ravulizumab (Ultomiris).	12/1/2023
DR.007.C	Adakveo (Crizanlizumab-tcma)	Documents our position on Adakveo (Crizanlizumab-tcma).	11/1/2023
DR.008.B	Sandostatin LAR Depot (octreotide acetate)	Documents our position on Sandostatin LAR Depot (octreotide acetate).	9/1/2023
DR.009.C	TEPEZZA® (teprotumumab-trbw)	Documents our position on TEPEZZA (teprotumumab-trbw).	8/21/2024
DR.010.C	Xiaflex (Collagenase clostridium histolyticum)	Documents our position on Xiaflex (Collagenase clostridium histolyticum).	9/1/2023
DR.011.D	IgG1 Monoclonal Antibodies for Alzheimer’s	Documents our position on IgG1 Monoclonal Antibodies for Alzheimer’s	5/15/2024
DR.013.B	Relizorb (immobilized lipase) Cartridge	Documents our position on Relizorb (immobilized lipase).	3/20/2024
DR.015.A	ROCTAVIAN™ (valoctocogene roxaparvovec-rvox)	Documents our position on ROCTAVIAN (valoctocogene roxaparvovec-rvox).	5/15/2024
DR.016.A	ELEVIDYS® (Delandistrogene moxeparvovec-rokl)	Documents our position on RELEVIDYS.	7/1/2024
DR.017.A	Adstiladrin® (Nadofaragene firadenovec-vncg)	Documents our position on Adstiladrin (Nadofaragene firadenovec-vncg).	7/1/2024
DR.018.A	Viltepso® (Viltolarsen)	Documents our position on Viltepso (Viltolarsen).	7/1/2024
DR.019.A	Hemgenix® (Etranacogene dezaparvovec-drlb)	Documents our position on Hemgenix (Etranacogene dezaparvovec-drlb).	7/1/2024
DR.020.A	Casgevy® (exagamglogene autotemcel)	Documents our position on Casgevy (exagamglogene autotemcel).	8/21/2024
DR.021.A	Lyfgenia™ (lovotibeglogene autotemcel)	Documents our position on Lyfgenia (lovotibeglogene autotemcel).	8/21/2024
DR.022.A	Zynteglo™ (betibeglogene autotemcel)	Documents our position on Zynteglo(betibeglogene autotemcel).	8/21/2024

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.