Molinalogo

• Clinical Policies
  • Medical
    Clinical Payment Policy F2019 Flow Cytometry
    Clinical Payment Policy G2002 Cervical Cancer Screening
    Clinical Payment Policy G2005 Vitamin D Testing
    Clinical Payment Policy G2006 Hemoglobin A1c
    Clinical Payment Policy G2007 Prostate Biopsies
    Clinical Payment Policy G2008 Prostate Specific Antigen (PSA) Testing
    Clinical Payment Policy G2009 Preventive Screening in Adults
    Clinical Payment Policy G2011 Diagnostic Testing of Iron Homeostasis and Metabolism
    Clinical Payment Policy G2013 Testosterone Testing
    Clinical Payment Policy G2014 Vitamin B12 and Methylmalonic Acid Testing
    Clinical Payment Policy G2022 ANA ENA Testing
    Clinical Payment Policy G2031 Allergen Testing
    Clinical Payment Policy G2036 Hepatitis C
    Clinical Payment Policy G2042 Pediatric Preventive Screening
    Clinical Payment Policy G2043 Celiac Disease Testing
    Clinical Payment Policy G2044 Helicobacter pylori Testing
    Clinical Payment Policy G2045 Thyroid Disease Testing
    Clinical Payment Policy G2048 Biochemical Markers of Alzheimer Disease and Dementia
    Clinical Payment Policy G2050 Cardiovascular Disease Risk Assessment
    Clinical Payment Policy G2051 Bone Turnover Markers Testing
    Clinical Payment Policy G2056 Diagnosis of Idiopathic Environmental Intolerance
    Clinical Payment Policy G2059 Epithelial Cell Cytology In Breast Cancer Risk Assessment
    Clinical Payment Policy G2060 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing
    Clinical Payment Policy G2061 Fecal Calprotectin Testing in Adults
    Clinical Payment Policy G2063 Testing for Diagnosis of Active or Latent Tuberculosis
    Clinical Payment Policy G2098 Immune Cell Function Assay
    Clinical Payment Policy G2099 Intracellular Micronutrient Analysis
    Clinical Payment Policy G2100 In Vitro Chemoresistance and Chemosensitivity Assays
    Clinical Payment Policy G2105 Immunopharmacologic Monitoring of Therapeutic Serum Antibodies
    Clinical Payment Policy G2107 Measurement of Thromboxane Metabolites for ASA Resistance
    Clinical Payment Policy G2110 Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
    Clinical Payment Policy G2113 Oral Screening Lesion Identification Systems and Genetic Screening
    Clinical Payment Policy G2115 Metabolite Markers of Thiopurines Testing
    Clinical Payment Policy G2119 Diagnostic Testing of Influenza
    Clinical Payment Policy G2120 Salivary Hormone Testing
    Clinical Payment Policy G2121 Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease
    Clinical Payment Policy G2123 Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases
    Clinical Payment Policy G2124 Serum Tumor Markers for Malignancies
    Clinical Payment Policy G2125 Urinary Tumor Markers For Bladder Cancer
    Clinical Payment Policy G2127 Vectra DA Blood Test for Rheumatoid Arthritis
    Clinical Payment Policy G2130 ST2 Assay for Chronic Heart Failure
    Clinical Payment Policy G2132 Erectile Dysfunction
    Clinical Payment Policy G2133 ZIKA Virus Risk Assessment
    Clinical Payment Policy G2138 Evaluation of Dry Eyes
    Clinical Payment Policy G2143 Lyme Disease
    Clinical Payment Policy G2149 Pathogen Panel Testing
    Clinical Payment Policy G2150 Cardiac Biomarkers for Myocardial Infarction
    Clinical Payment Policy G2153 Pancreatic Enzyme Testing for Acute Pancreatitis
    Clinical Payment Policy G2154 Folate Testing
    Clinical Payment Policy G2155 General Inflammation Testing
    Clinical Payment Policy G2156 Urine Culture Testing For Bacteria
    Clinical Payment Policy G2157 Diagnostic Testing of Common Sexually Transmitted Infections
    Clinical Payment Policy G2158 Testing for Mosquito or Tick-Related Infections
    Clinical Payment Policy G2159 BHemolytic Streptococcus Testing
    Clinical Payment Policy G2164 Parathyroid Hormone Phosphorus Calcium and Magnesium Testing
    Clinical Payment Policy G2173 Gamma-Glutamyl Transferase
    Clinical Payment Policy M2041 Venous and Arterial Thrombosis Risk Testing
    Clinical Payment Policy M2057 Diagnosis of Vaginitis Including Multi Target PCR Testing
    Clinical Payment Policy M2058 Genetic Testing for Adolescent Idiopathic Scoliosis
    Clinical Payment Policy M2068 Testing for Alpha 1 Antitrypsin Deficiency
    Clinical Payment Policy M2091 Transplant Rejection Testing
    Clinical Payment Policy M2093 HIV Genotyping and Phenotyping
    Clinical Payment Policy M2097 Identification Of Microorganisms Using Nucleic Acid Probes
    Clinical Payment Policy M2112 Nerve Fiber Density Testing
    Clinical Payment Policy M2116 Plasma HIV1 and HIV2 RNA Quantification for HIV Infection
    Clinical Payment Policy M2136 DNA Ploidy Cell Cycle Analysis
    Clinical Payment Policy M2172 Onychomycosis Testing
    Clinical Payment Policy P2018 Immunohistochemistry
    Clinical Payment Policy R2162 Avalon Laboratory Procedures Reimbursement Policy
    Clinical Payment Policy UM XRT 2009 External Beam Teletherapy Brachytherapy
    Clinical Payment Policy UM XRT 2010 Neutron and Proton Beam Policy
  • Behavioral Health
  • Oncology & Radiology

    Passport partners with New Century Health to administer cardiology and oncology services for members age 18+. For clinical policies related to cardiology and oncology, please visit New Century’s websitewww.NewCenturyHEalth.com or click the following link: Compliance and Regulatory Information - New Century Health. Clinical policies are also housed within the provider portal at my.newcenturyhealth.com.

     

     

     

  • Pharmacy

    MedImpact administers pharmacy benefits for Kentucky Medicaid Members. For information regarding Kentucky Medicaid Single PDL Prior Authorization Criteria please click here.

   

   

   

• Payment Policies

Please note that the effective date of any payment policy, and any subsequent revision to a payment policy, shall not be less than 30 days following the date of publication of that revision, pursuant to Section 27.12 of the Kentucky Managed Care Contract.

Inpatient Only Procedure Codes