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Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the PA Health and Wellness Clinical Policy Manual apply to PA Health and Wellness members. Policies in the PA Health and Wellness Clinical Policy Manual may have either a PA Health and Wellness or a “Centene” heading. PA Health and Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a PA Health and Wellness clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling PA Health and Wellness. In addition, PA Health and Wellness may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria is payable by PA Health and Wellness.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Pharmacy Policies

Pennsylvania Medical Assistance Program's Statewide Preferred Drug List (PDL) Pharmacy Policies

PHW Supplemental Drug List Pharmacy Policies

Archived Policies