Providers
Policy Bulletin Library

Policy bulletins are complementary to our provider manual. They communicate our medical, claim payment reimbursement and drug positions for services administered to members.

Sections for medical policies, claim payment policies and drug policies are below.

Contents:

Medical Policy Bulletins

Our medical policy bulletins define medical necessity criteria and coverage positions on topics such as medical services, procedures, durable medical equipment and therapies.

MN.004.C - New Technology
Documents coverage for new technology
Reviewed Date: 5/20/2026

MN.005.D - Experimental and Investigational (E&I) Services, Investigational Device Exemption (IDE), and Coverage with Evidence Development (CED) Documents our coverage position for E&I Services, IDEs, and CEDs
Reviewed Date: 6/17/2026

MN.006.I - Cosmetic & Reconstructive Services
Documents our coverage position for cosmetic and reconstructive services
Reviewed Date: 4/15/2026

MN.008.C - Genetic Testing
Documents our coverage position on genetic testing
Reviewed Date: 2/18/2026

MN.010.I - Gender-Affirming Surgery
Documents our position on gender-affirming surgery
Reviewed Date: 12/17/2025

MN.011.E - Whole Genome Sequencing (WGS)/Whole Exome Sequencing (WES)
Documents our coverage position on WGS and WES
Reviewed Date: 9/17/2025

MN.013.E - Shift Nursing, Personal Care, and Medical Daycare
Documents our position on the shift care, personal care, and medical daycare
Reviewed Date: 11/20/2025

MN.015.C - Standards of Medical Necessity
Documents our position related to medical necessity
Reviewed Date: 9/17/2025

MN.016.A - Injectable/Specialty Drugs Prior Authorization Requirements
Documents our prior authorization requirements for injectable/specialty drugs
Reviewed Date: 2/18/2026

MN.018.A - Medical Nutritional Support
Documents our policies on enteral nutrition
Reviewed Date: 10/15/2025

MN.020.C - Peroral Endoscopic Myotomy (POEM)
Documents our position related to POEM
Reviewed Date: 1/21/2026

MN.021.B - Panniculectomy and Abdominoplasty
Documents our position related to panniculectomy and abdominoplasty
Reviewed Date: 7/16/2025

MN.022.C - Reduction Mammoplasty
Documents our position related to reduction mammoplasty
Reviewed Date: 7/16/2025

MN.024.B - Relizorb (Immobilized Lipase Cartridge)
Documents our position related to Relizorb
Reviewed Date: 2/18/2026

MN.025.C - Speech Generating Devices
Documents our position related to Speech Generating Devices
Reviewed Date: 2/18/2026

MN.026.A - Continuous Glucose Monitors
Documents our position related to Continuous Glucose Monitors
Reviewed Date: 8/20/2025

MN.027.A - External Infusion Pump, Insulin
Documents our position related to External Infusion Pump, Insulin
Reviewed Date: 9/18/2025

MN.028.A - Inhaled Nitric Oxide
Documents our position related to Inhaled Nitric Oxide
Reviewed Date: 12/17/2025

MN.029.A - Autism Screening, Evaluation and Diagnosis
Reviewed Date: 2/18/2026

Claim Payment Policy Bulletins

Our claim payment policy bulletins provide reimbursement rules and billing guidelines necessary to ensure timely and appropriate payment.

RB.001.D - Ambulance Ground Mileage Claim
Documents our reimbursement rules for ambulance ground mileage and ambulance services
Reviewed Date: 4/28/2026

RB.004.A - Modifier 50, Bilateral Procedure
Documents our position on modifier 50, bilateral procedure
Reviewed Date: 2/2/2026

RB.005.A - Modifier 25
Documents our position on Modifier 25
Reviewed Date: 2/2/2026

RB.006.D - STAT Labs
Provides reporting requirements and reimbursement rules for STAT laboratory tests (a.k.a. labs)
Reviewed Date: 8/13/2025

RB.007.D - Durable Medical Equipment (DME) Rental Payment)
Documents our position on DME rentals
Reviewed Date: 3/5/2025

RB.014.C - Observation Care
Documents our position on Observation Care servicesProvides answers to common questions
Reviewed Date: 1/30/2025

RB.018.B - Medicare Readmissions
Documents our position on Medicare readmissions
Reviewed Date: 10/21/2025

RB.019.A - Health Care Acquired Conditions (HCAC) and Preventable Serious Adverse Events (PSAE)
Documents our position on HCAC and PSAE
Reviewed Date: 4/8/2025

RB.020.A - Obstetric Anesthesia Services
Documents our position on obstetric anesthesia services
Reviewed Date: 4/8/2025

RB.021.C - Professional Telehealth Services (Medicare)
Updates our policy on telehealth services, specifically for Medicare members
Reviewed Date: 2/12/2026

RB.022.C - Rapid Hemoglobin A1c (HbA1c) Testing
Documents our position on rapid HbA1c testing
Reviewed Date: 2/24/2025

RB.023.B - Diabetic Retinopathy Screening and Fundus Photography
Documents our position on diabetic retinopathy screening and fundus photography
Reviewed Date: 2/9/2026

RB.024.C - Professional Telehealth Services (Medicaid and CHIP)
Updates our policy on telehealth services for Medicaid and CHIP members
Reviewed Date: 3/5/2026

RB.025.E - 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
Reviewed Date: 5/28/2025

RB.026.A - Remote Patient Monitoring
Provides information on remote patient monitoring
Reviewed Date: 2/2/2026

RB.027.B - Tobacco Cessation Program
Provides information on tobacco cessation certification
Reviewed Date: 6/11/2026

RB.028.C - CMS and DHS Payment Systems Update and Maintenance Payment Policy
Provides information on CMS and DHS policies
Reviewed Date: 1/12/2026

RB.029.C - Diabetes Prevention Program
Provides information on the Diabetes Prevention Program
Reviewed Date: 2/1/2025

RB.030.C - Newborn Authorizations
Provides information on authorizations for newborns
Reviewed Date: 1/31/2025

RB.031.A - Maternity Billing and Reimbursement Guidelines
Provides information on authorizations for maternity billing and reimbursement
Reviewed Date: 4/8/2025

RB.032.A - Adjudication of Claims from Non-Participating Providers - Medicaid & CHIP
Documents our coverage position for adjudication of claims for non-participating providers
Reviewed Date: 9/22/2025

RB.033.B - Vaccine Coding and Reimbursement
Provides information on vaccine coding and administration
Reviewed Date: 9/22/2025

RB.034.A - Adjudication of Claims from Non-Participating Providers - Medicare
Documents our coverage position for adjudication of claims for non-participating providers
Reviewed Date: 9/22/2025

RB.035.B - Preventive Care Services - Individual and Family Plan
Documents our policies on preventive care services for Individual and Family Plans
Reviewed Date: 11/12/2025

RB.037.B - Readmissions - Individual & Family Plan
Documents our position on Individual & Family Plan readmissions
Reviewed Date: 11/13/2025

RB.038.B - Professional Telehealth Services - Individual and Family Plan
Updates our policy on telehealth services for Individual & Family Plan members
Reviewed Date: 4/8/2025

RB.039.A - Reporting Requirements for Anesthesia Services
Documents our reporting requirements for anesthesia services
Reviewed Date: 8/3/2026

RB.042.A - NDC Billing Requirements for Medical Drugs
Updates our NDC billing requirements for medical drugs
Reviewed Date: 12/19/2025

RB.044.A - Urine Drug Testing
Documents our coverage for urine drug testing
Reviewed Date: 4/9/2026

RB.046.A - Home Infusion Billing Requirements
Documents home infusion billing requirements
Reviewed Date: 4/28/2026

RB.047.A - STI Laboratory Testing
Documents our coverage for STI testing
Reviewed Date: 4/9/2026

RB.048.A - Readmissions - Medicaid and CHIP
Establishes readmission billing requirements
Reviewed Date: 6/11/2026

RB.049.A - Respiratory Panel Laboratory Testing
Documents our policy on coverage for respiratory pathogen panel (RPP) laboratory testing
Reviewed Date: 6/25/2026

RB.050.A - Urgent Care Center Services
Establishes urgent care center billing requirements
Reviewed Date: 6/11/2026

RB.051.A - Community Health Workers Services
Guidelines for the coverage and reimbursement for Community Health Workers (CHW) services for eligible members
Reviewed Date: 6/30/2026

Drug Policy Bulletins

Our drug policy bulletins document our position on pharmaceutical topics and drugs.

DR.002.G - Intravenous Immune Globulin (IVIG)
Documents our position regarding IVIG Therapy
Reviewed Date: 8/20/2025

DR.003.D - Ocrevus (Ocrelizumab)
Documents our position on Ocrevus (Ocrelizumab)
Reviewed Date: 10/15/2025

DR.004.F - Spinraza (Nusinersen)
Documents our position on Spinraza (Nusinersen)
Reviewed Date: 3/18/2026

DR.005.F - Zolgensma (onasemnogene abeparvovec-xioi)
Documents our position on Zolgensma (onasemnogene abeparvovec-xioi)
Reviewed Date: 4/15/2026

DR.006.G - Complement Inhibitors: Eculizumab (Soliris) & Ravulizumab (Ultomiris)
Documents our position on Eculizumab (Soliris) and Ravulizumab (Ultomiris)
Reviewed Date: 12/17/2025

DR.007.E - Adakveo (Crizanlizumab-tcma)
Documents our position on Adakveo (Crizanlizumab-tcma)
Reviewed Date: 3/9/2026

DR.008.D - Sandostatin LAR Depot (octreotide acetate)
Documents our position on Sandostatin LAR Depot (octreotide acetate)
Reviewed Date: 5/20/2026

DR.009.E - TEPEZZA® (teprotumumab-trbw)
Documents our position on TEPEZZA (teprotumumab-trbw)
Reviewed Date: 7/16/2025

DR.010.D - Xiaflex (Collagenase clostridium histolyticum)
Documents our position on Xiaflex (Collagenase clostridium histolyticum)
Reviewed Date: 9/17/2025

DR.011.E - IgG1 Monoclonal Antibodies for Alzheimer’s
Documents our position on IgG1 Monoclonal Antibodies for Alzheimer’s
Reviewed Date: 12/17/2025

DR.015.B - ROCTAVIAN® (valoctocogene roxaparvovec-rvox)
Documents our position on ROCTAVIAN® (valoctocogene roxaparvovec-rvox)
Reviewed Date: 5/20/2026

DR.016.C - ELEVIDYS® (Delandistrogene moxeparvovec-rokl)
Documents our position on ELEVIDYS® (Delandistrogene moxeparvovec-rokl)
Reviewed Date: 1/21/2026

DR.017.C - Adstiladrin® (Nadofaragene firadenovec-vncg)
Documents our position on Adstiladrin® (Nadofaragene firadenovec-vncg)
Reviewed Date: 6/17/2026

DR.018.C - Viltepso® (Viltolarsen)
Documents our position on Viltepso® (Viltolarsen)
Reviewed Date: 6/17/2026

DR.019.C - Hemgenix® (Etranacogene dezaparvovec-drlb)
Documents our position on Hemgenix® (Etranacogene dezaparvovec-drlb)
Reviewed Date: 6/17/2026

DR.020.C - Casgevy® (Exagamglogene autotemcel)
Documents our position on Casgevy®
Reviewed Date: 12/17/2025

DR.021.C - Lyfgenia™ (Lovotibeglogene autotemcel)
Documents our position on Lyfgenia™
Reviewed Date: 12/17/2025

DR.022.B - Zynteglo™ (Betibeglogene autotemcel)
Documents our position on Zynteglo™
Reviewed Date: 8/20/2025

DR.023.A - Vyvgart (Efgartigimod alfa-fcab)
Documents our position on Vyvgart
Reviewed Date: 9/18/2025

DR.024.A - Encelto (revakinagene taroretcel lwey)
Documents our position on Encelto
Reviewed Date: 12/17/2025

DR.025.A - Amvuttra® (vutrisiran)
Documents our position on Amvuttra
Reviewed Date: 7/15/2026

Frequently Asked Questions

The effective date of select policy bulletins found above may considerably pre-date the actual date of their availability on this page. The current policy bulletin library includes PDFs of policies that have been in effect for many years but were not 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.