Partners_health_management Coverage Criteria
- Partners_health_management prior authorization
- Partners_health_management contact directory
- All Partners_health_management policy updates
Latest Partners_health_management coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01High Fidelity Wraparound (HFW) — Coverage CriteriaDefines coverage, eligibility, utilization management, service components, and documentation requirements for High Fidelity Wraparound (HFW) for Medicaid-eligible youth and young adults; applies to providers delivering HFW under the Partners Health Management benefit plan.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-14Family Centered Treatment (FCT) — Coverage CriteriaDefines eligibility, utilization management, documentation, service codes, monitoring, and clinical criteria for Family Centered Treatment (an intensive in-home behavioral health service) for children and adolescents and their families.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Acute and Subacute Services Provided in an Institute for Mental Disease (IMD)Defines coverage, utilization management, clinical criteria, and operational requirements for 24-hour acute and subacute psychiatric and substance use inpatient services delivered in an Institute for Mental Disease (IMD) for Medicaid members ages 21-64.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Behavioral Health Urgent Care (BHUC) coverage criteriaDefines Partners Health Management's Behavioral Health Urgent Care (BHUC) service model as an alternative to hospital EDs for urgent behavioral health needs for ages 4 and older, including triage, brief assessment, stabilization, and disposition; covers utilization management parameters and staffing/training requirements.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-04-01In Home Therapy Services (IHTS) - Coverage CriteriaDefines coverage, eligibility, utilization management, staffing, and documentation requirements for In Home Therapy Services (IHTS) for children and adolescents with complex psychosocial needs; applies to Providers seeking Partners Health Management authorization and reimbursement for IHTS in North Carolina.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyBariatric Surgery — Coverage Criteria and Coding UpdatesDefines medical necessity, preoperative requirements, repeat/conversion surgery rules, investigational and not-medically-necessary bariatric procedures for members of plans affiliated with Centene/Partners Health Management.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyBreast SurgeriesMedical necessity criteria and coverage guidance for breast surgeries including mastectomy/breast conserving surgery, male gynecomastia surgery, prophylactic mastectomy, reduction mammoplasty, and breast reconstruction for Partners Health Management members.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyCONCERT INFECTIOUS DISEASE: RESPIRATORY TESTING - Outpatient respiratory pathogen testing coverage criteriaDefines medical necessity criteria for outpatient diagnostic testing for respiratory infections (viral and bacterial panels, influenza, RSV, SARS-CoV-2, Group A streptococcus) and when those tests are considered clinically indicated for plan members.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyCONCERT INFECTIOUS DISEASE: VECTOR-BORNE AND TROPICAL DISEASES TESTINGDefines medical necessity and coverage criteria for outpatient laboratory testing for Lyme disease (Borrelia burgdorferi) and Zika virus using serologic and molecular methods for members of Partners Health Management plans.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyCaudal or Interlaminar Epidural Steroid InjectionsClinical coverage policy defining medical necessity criteria, limits, and coding guidance for caudal and interlaminar epidural steroid injections for members/enrollees of the health plan.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Air AmbulanceMedical necessity criteria and coding guidance for fixed‑wing and rotary‑wing air ambulance transport for members/enrollees of health plans affiliated with Centene (Partners Health Management). Affects providers requesting or billing air medical transports.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Air AmbulanceMedical necessity criteria and coverage guidance for fixed-wing and rotary-wing air ambulance transport for members/enrollees of the Health Plan. Applies to providers requesting air ambulance transport and to claims adjudication.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Fetal Surgery in Utero for Prenatally Diagnosed MalformationsDefines medical necessity criteria and coverage stance for in-utero fetal surgery interventions for specific prenatal malformations and identifies procedures considered not supported; applies to providers submitting claims to Partners Health Management (Carolina Complete Health adaptation).All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: GonioscopyDefines coverage criteria and supporting diagnosis codes for gonioscopy procedures affecting members with relevant ophthalmic conditions; applies to providers submitting claims to Partners Health Management.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Heart-Lung TransplantMedical necessity criteria and contraindications for heart-lung transplantation for members of the health plan, including adult and pediatric indications and disease severity requirements.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Hyperhidrosis TreatmentsDefines medical necessity criteria and coding guidance for treatments of primary hyperhidrosis (iontophoresis, surgical excision of axillary sweat glands, endoscopic thoracic sympathectomy) for members of the Health Plan.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Osteogenic StimulationMedical necessity criteria for electrical (invasive and noninvasive) and ultrasonic osteogenic stimulators to enhance bone healing for covered members/enrollees of Partners Health Management (Centene-affiliated plans). Applies to clinical use indications, exclusions, and coding referenced in the policy.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: PanniculectomyMedical necessity criteria and coding guidance for panniculectomy (surgical removal of a panniculus) for members/enrollees, including indications when performed prior to certain other surgeries.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Spinal Cord Stimulation, Peripheral Nerve and Percutaneous Electrical Nerve StimulationDefines medical necessity and coverage criteria for spinal cord stimulation (SCS) and states coverage stance for peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNFS), percutaneous electrical nerve stimulation (PENS), and percutaneous electrical nerve field stimulation (PENFS) for members of health plans affiliated with Partners Health Management/Carolina Complete Health.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Urodynamic TestingDefines medical necessity criteria, coding, and coverage stance for urodynamic studies used in evaluating voiding dysfunction for members/enrollees of the payer.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyConcert Infectious Disease: Dermatologic TestingOutpatient policy governing medical necessity criteria for laboratory testing to confirm suspected onychomycosis (microscopy/peroxidase, fungal culture, and NAAT/PCR), directed at providers ordering these tests for members/enrollees.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyConcert Infectious Disease: Primary Care & Preventative ScreeningDefines medical necessity criteria for outpatient screening tests for human papillomavirus (HPV), hepatitis C virus (HCV), and group B streptococcus (GBS) for members/enrollees of the payer network.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyDiaphragmatic/Phrenic Nerve StimulationMedical necessity and coverage criteria for diaphragmatic/phrenic nerve stimulation (diaphragm pacing) devices and associated implantation for members of health plans affiliated with Centene Corporation (Partners Health Management). Affects providers requesting coverage for device implantation and use.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyElectric Tumor Treating Fields (Optune)Clinical coverage criteria for use of electric tumor treating fields (Optune) in adults with glioblastoma, including initial and continuation authorization requirements and stated contraindications; affects providers seeking authorization for Optune therapy.All partners_health_management updates
- Coverage CriteriaClinical/Medical PolicyEndometrial AblationMedical necessity guidelines for endometrial ablation for non‑Medicare health plans affiliated with Centene/Partners Health Management, including indications, contraindications, and coding references affecting providers and payers.All partners_health_management updates
1–25 of 49
1 / 2
Tool Description
Search Partners_health_management 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 are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.