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Medical Policy Manual

Tools & Resources

Medical Policy Manual

​This Medical Policy Manual is developed by the Medical Policy Committee of Presbyterian Health Plan and Presbyterian Insurance Company, Inc. to assist in administering plan benefits. Presbyterian Health Plan, Inc. and Presbyterian Insurance Company, Inc. are referred to collectively in this manual as "PHP." The manual contains medical policies that serve as guidelines. These guidelines do not guarantee benefits or constitute medical advice. Coverage determinations and payment of claims are subject to eligibility, coverage, exclusions, limitations, provider contracts, allowable charges, and correct coding/billing practices.

Relationship of Medical Policy Manual with Group Subscriber Agreement or Evidence of Coverage, also referred to as "member's contract"

Not every PHP plan contains the same benefits. Therefore, the member's contract must be reviewed before using this manual, in order to determine if a specific benefit is available to a member. Any information contained in this manual does not replace the member's Evidence of Coverage, Group Subscriber Agreement, or Plan Document. If there is a conflict between the member's contract and the manual, the contract will govern. No additional rights are available to a member because of any statement in or omission from this manual.

Benefit Plans and Prior Authorization Guide

Each member's benefit plan offers coverage for a wide range of healthcare services, and should be reviewed as the first step in determining coverage.

View Information about Group Insurance Plans

Identifies the procedures and services which require pre-authorization.

Prior Authorization Guide

Medical Policies

All services provided must be medically necessary as determined by the member's practitioner or provider in consultation with PHP. Benefit certification decisions are made on a case-by-case basis using the member's contract, the Medical Policies Manual, and the specific facts of the particular situation.

Medical Policy Manual

Behavioral Health Clinical Medical Necessity Criteria (Medicaid Turquoise Care)

Behavioral Health Medical Necessity Criteria (Medicare/Commercial) Magellan NIA Medical Necessity Criteria

Limitations and Exclusions

Benefits listed in the manual are subject to all the limitations and exclusions of the member's contract.

Plan Requirements

The manual assumes that all plan requirements have been followed, such as using in-plan providers, obtaining referrals, obtaining benefit certification as required, etc.

Subject to Change

Medical technology evolves continuously, and these medical policies are subject to change without notice.

Not a Guideline for Medical Practice

This manual is developed to assist PHP Health Services Staff and Medical Directors in determination of coverage. It is not a treatment guide and should not be used as such. For those instances where a member does not meet criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the Medical Director in reviewing the case.

To continue to the MPM Table of Contents, you must acknowledge that you have read and understand the conditions describing the use of the Medical Policy Manual.

I have read and understand ​the above conditions Reviewed and approved on 03/23/2023 by Dr. Gray Clarke, Vice President and Chief Medical Officer, Presbyterian Health Plan.

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