Communityhealthchoice Coverage Criteria
Latest Communityhealthchoice coverage criteria updates4
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-01Prior Authorization Criteria for KisunlaThis policy governs Medicaid and CHIP prior authorization for Kisunla infusion therapy for clients with Alzheimer's disease in Texas. It establishes initial approval, treatment monitoring, and renewal requirements for providers.All communityhealthchoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01SevenFact Criteria for CoverageThis policy governs medical-necessity review and prior authorization for SevenFact in Community Health Choice members with hemophilia A or B and high-titer factor inhibitors, including bleeding-episode treatment, control, and perioperative bleeding management.All communityhealthchoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-05-01Trogarzo (ibalizumab-uiyk) Coverage CriteriaMedical-necessity and prior-authorization criteria for Trogarzo used with an optimized background antiretroviral regimen in members with HIV-1 infection.All communityhealthchoice updates
- Coverage CriteriaClinical/Medical PolicyTocilizumab Preferred Product PolicyThis Medical Review Guideline governs medical-necessity review and preferred-product requirements for tocilizumab products, including Actemra, Tofidence, Tyenne, and future tocilizumab biosimilars. It is intended for Community Health Choice clinical staff reviewing requests and does not determine member eligibility or benefit coverage.All communityhealthchoice updates
Tool Description
Search Communityhealthchoice coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage Criteria by Payer
Go deeper
Explore OpenPayer Data
Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Billing Code Reimbursement RatesBuild a reimbursement rate report across any mix of billing codes and states, comparing commercial payers against Medicare.
- Payer Comparison DashboardPick 2-5 payers to compare market share, premium, and membership by region, all at once.
- Facility Comparison DashboardPick 2-6 hospital facility types (or add a specific hospital) to compare facility count, revenue, net income, and Medicare/Medicaid payer mix by region, all at once.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Prior Authorization LookupSearch payer prior authorization policies by drug, procedure, or policy name.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.