Molinalogo

Clinical Policies

Passport by Molina Healthcare (Passport) follows the most current edition of MCG, a nationally recognized set of guidelines.  Passport may employ the Molina Clinical Policies if the MCG guidelines are insufficient. Molina clinical policies are located at www.MolinaClinicalPolicy.com.  Please note, these policies do not constitute plan authorization, an explanation of benefits, or a guarantee of payment.

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.

Breast Cancer Genetic Testing Tier 1 vs Tier 2
Critical Care Codes when Discharged to Home
DRG Clinical Validation
Early Elective Delivery Payment Policy
Facility Emergency Department Evaluation and Management Leveling
High Level E/M with Preventive Medicine Policy
Hospital Routine Supplies Services Reimbursement
Hydrolyzed Enteral Formula Diagnosis
In-Office Lab Policy
Newborn and NICU
Observation Reimbursement Policy
Optum Pause and Pay
Outpatient Definitive Presumptive Drug Testing Medicaid Medicare
Split Night Sleep Study
Sterilization
Therapeutic Behavioral Health Services H2019_H2020
Inpatient Only Procedure Codes