Clinical Policy Committee Form

Page 1 of 6 Clinical Policy: Physical Health Clinical Policy Committee Reference Number: CP.CPC.01

Date of Last Revision: 10/25 Revision Log

Description
The Clinical Policy Committee ensures that clinical policies provide a guide to medical necessity, are reviewed and approved by appropriately qualified physicians, and are available to all Centene Health Plans.

Clinical policies provide a guide to medical necessity. Benefit determinations should be based in all cases on the applicable contract provisions governing plan benefits (“Benefit Plan Contract”) and applicable state and federal requirements, as well as applicable plan-level administrative policies and procedures. To the extent there are any conflicts between these policies and the Benefit Plan Contract provisions, the Benefit Plan Contract provisions will control.

Clinical policies reflect current scientific research and evidence-based clinical standards.
Clinical policies are not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment given to members. All clinical policies are available to providers in compliance with all federal, statutory, and regulatory requirements and upon request.

I. Purpose A. The Centene Deputy Chief Health Officer (DCHO) or their designee is responsible for establishing and maintaining a Physical Health Clinical Policy Committee (PH CPC) composed of physicians and other medical and operational representatives as appropriate from Corporate Population Health and Clinical Operations (PHCO), and each plan to assist in the identification of need, development, revision, and/or review of clinical policy. All corporate clinical policies require approval by the PH CPC. B. The PH CPC reviews clinical (medical necessity) policies and select rules-based policies with substantial clinical content. These policies include but are not limited to:

1. New and emerging technologies;
2. New uses for existing technologies;
3. Coverage issues relating to new and existing technologies;
4. Clinical guidelines for the evaluation and treatment of specific conditions;

5. Clinical/medical criteria or information used in pre- or post-service review.
   C. The DCHO or designees performs an annual review of all existing corporate clinical policies to determine continued applicability and appropriateness. In connection with annual review, the DCHO or designees are responsible for identifying which policies require revisions on an annual or ad hoc basis. The DCHO or designees shall send such policies to the PH CPC for review and approval.

   II. Membership Medical directors participating in the PH CPC shall be board-certified and shall be licensed in good standing in at least one state. The DCHO or designee recruits and replaces, as needed, PH CPC members to maintain a committee that includes: A. Voting members:

CLINICAL POLICY

Clinical Policy Committee Page 2 of 6

1. One Medical Director from each plan (at minimum)
2. Senior Corporate Medical Directors, to include but not limited to: a. Chief Medical Officer of Physical Health Utilization Management; b. Centralized Medicare Unit Senior Medical Director(s); c. Marketplace Shared Services Senior Medical Director(s). B. Non-voting members:
3. All enterprise Medical Directors, aside from those listed as voting members;
4. PHCO staff representing each region;
5. Corporate clinical policy leadership;
6. Corporate PHCO staff. C. Ad hoc advisors
7. Representatives from Centene subsidiaries;
8. Internal legal counsel;
9. Plan compliance directors;

10. Outside experts and/or relevant interested parties depending upon the specialty area or special needs of the clinical policy.

    III. Committee Maintenance and Oversight A. The DCHO or designee acts as the chairperson for meetings and activities performed by the PH CPC (Committee Chair). The Corporate Director of Clinical Policy reports committee activities to the Committee Chair. B. The Corporate Director of Clinical Policy oversees the Clinical Policy Department which is tasked with the following responsibilities in connection with the development and approval of clinical policies:

11. Coordinating activities of the PH CPC including, but not limited to, annual (at minimum) and ad hoc review, revision, approval, and maintenance processes of all corporate clinical policies. This includes scheduling meetings, sending necessary agendas and attachments, documenting meeting minutes, clinical policy reference number assignment, and the maintenance of such documents in electronic files and within the organizational internal database.
12. Coordinating research and development of new clinical policies or those with requested ad hoc updates, which includes: a. Prioritizing all inquiries for new corporate policies and updates and maintaining an electronic log of all requests for research and new policies with the requestor and subject of review.
    b. Conducting prelimary review of topics as follows: i. A critical appraisal of the current published medical literature from peer- reviewed publications including systematic reviews, randomized controlled trials, cohort studies, case control studies, and diagnostic test studies with statistically sound methods. ii. Evidence-based guidelines developed by national organizations and recognized authorities. iii. Opinions and assessments by nationally recognized medical associations including physician specialty societies, consensus panels, or other nationally recognized research or technology assessment organizations such as Hayes, UpToDate, or ECRI.

CLINICAL POLICY

Clinical Policy Committee Page 3 of 6 iv. Reports and publications of government agencies such as the Food and Drug, Administration (FDA), Centers for Disease Control (CDC), or National Institutes of Health (NIH).
v. External review organization recommendations. c. Conveying the findings of the preliminary review to the requestor within the priority-based time frame. Preliminary review findings are saved in an electronic file for potential future policy development. d. For new policy topics requested through medical management needs, if a possible policy need is identified, prior authorization volume and paid claims data are reviewed, and a formal medical policy may be developed. The Clinical and Payment Policy Advisory Committee (CPPAC) will review and advise on any new policy topic requests prior to policy development. If the CPPAC supports the development of a new policy, the following steps are completed:
i. The clinical policy staff utilizes the preliminary research to draft a policy.
Relevant CPT, HCPCS and ICD-10-CM codes are identified and included in the policy. A review of historical handling and/or payment of the policy topic is also conducted to share with the PH CPC as appropriate. ii. Opinions from internal and external clinicians are solicited as appropriate, including behavioral health clinicians.
iii. The policy is sent for PH CPC review and approval.
iv. Subsequent to each new policy approval, the clinical policy staff sends a notice to all medical directors and PHCO leadership to inform them of new policies that have been approved by the PH CPC.
e. For changes to existing policies requested through medical management needs, prior authorization volume and paid claims data are reviewed, and a policy may be revised. The CPPAC may review and advise on policy revision requests for topics that are controversial or complex. The following steps may be completed as relevant:
i. The clinical policy staff utilizes the preliminary research to draft a policy.
Relevant CPT, HPCPCS and ICD-10-CM codes are identified and included in the policy. A review of historical handling and/or payment of the policy topic is also conducted to share with the PH CPC as appropriate. ii. Opinions from internal and external clinicians are solicited as appropriate, including behavioral health clinicians.
iii. The policy is sent for PH CPC review and approval.
iv. Subsequent to each new policy approval, the clinical policy staff sends a notice to all medical directors and PHCO leadership to inform them of new policies that have been approved by the PH CPC.
f. Communication of these policies to provider networks is arranged by the plan marketing or provider network department.

3. Generating reports reflecting PH CPC activity on a quarterly basis, or more frequently as needed, for the Committee Chair.
4. Notifying all relevant persons/departments and health plans regarding approved policies and related materials through email, including: a. PH CPC members, PHCO VPs and directors, and other health plan contacts for dissemination to their plan UM personnel. This includes notification to plan

CLINICAL POLICY

Clinical Policy Committee Page 4 of 6 respresentatives for inclusion in the plan UM or QI committee responsible for plan-level policy approval. Marketing and/or provider relations are included for appropriate provider notification of policy changes.
b. Corporate VPs of PHCO and Corporate medical auditing and training teams for dissemination and auditing. c. Payment Integrity for implementation and configuration updates, as applicable.

5. Facilitating training, as needed, with the corporate PHCO Training Department.

   IV. Meeting Frequency: PH CPC meetings are held, at minimum, on a quarterly basis. Frequency is dependent upon clinical policy revision cycles and/or clinical policy need (as determined by the DCHO or designee).

   V. Committee Member Activities and Responsibilities: A. Identification of new subjects to consider for clinical policy development can occur in the following ways:

6. Through UM authorization requests;
7. New technologies identified through trade publications;
8. Inquiries from providers and vendors;
9. Review of appeals cases;
10. Suggestion of the Clinical and Payment Policy Advisory Committee; B. Review of clinical policies which includes:
11. New clinical policy drafts;
12. Policies due for scheduled annual review;
13. Ad hoc updates or revisions to existing policies outside of the scheduled review due to advances or changes in standards of care, new information, missing information or content error;
14. Updates regarding the status of any policies under review;
15. Policy and prioritization requests for new clinical policies; C. Electronic approval of clinical policies Policies will be reviewed and approved through an electronic web poll process.
16. All draft clinical policies are loaded into the Qualtrics survey tool.
17. An email notification is sent to each of the PH CPC members with a link for the current survey with policies due for review as well as the required completion date for review. Standard surveys allow one week for review of clinical policies.
18. The survey directs PH CPC members to indicate if the policy meets their approval with a vote stating either (a) “yes,” (b) “yes, with comments,” (c) “no,” or (d) “abstain.” “Yes, with comments” and “no” votes require feedback to be supplied before the reviewer can complete the survey.
19. The Committee Chair determines, based on voting feedback, whether an issue identified during the voting process will be included on the agenda for discussion at the following PH CPC meeting. If so, the feedback will be distributed with the agenda for consideration prior to the meeting.
20. In the context of the electronic approval process, PH CPC actions are determined by a majority vote of the voting members responding. A majority of the voting committee members must respond to the review request to be considered a quorum. If a quorum does not respond, a follow-up email is sent to request additional members to respond.

CLINICAL POLICY

Clinical Policy Committee Page 5 of 6

6. Survey results are maintained electronically in the folder dated with the survey fielded date, along with all the policies that were submitted for approval at that time.
   D. Attendance and Participation
7. Committee members are expected to attend all scheduled meetings and participate in the review of documents forwarded electronically for review and consensus.
8. The Committee Chair has the right to replace a committee member who does not participate in two or more consecutive committee meetings.
9. In the context of PH CPC surveys, PH CPC actions are determined by a majority vote of the voting members present. A majority of the voting committee members must participate to constitute a quorum.
10. A corporate designee will document meeting minutes. Meeting minutes include the agenda topic, pertinent discussion, proposed changes submitted/discussed, and any action taken, or consensus reached with respect to the proposed changes. E. Approvals The DCHO or designee approves all clinical policies. The Committee Chair is authorized to act as the DCHO designee for the purpose of approving clinical policies.
11. Within 14 business days of the survey poll close date or PH CPC meeting date, the Corporate Clinical Policy team incorporates any agreed changes and finalizes all survey policies.

12. The DCHO designee uploads approved policies to the Clinical Policy SharePoint Dashboard and in Adobe Experience Manager for linking to plan websites and distributes all policies by email to the health plans for review and plan level approval.

    Reviews, Revisions, and Approvals Approval Date Policy developed 09/08 Added that new policy requests may come through the Medical Policy Governance Team. Removed mention of BH voters on the CPC, and BH policy topics. Specified throughout the policy that the CPC addresses corporate clinical policies. 03/20 Restricted voting privileges for corporate MDs to senior MDs only. 04/20 Annual review. 02/21 Annual review. 02/22 Annual review. Updated policy processing and posting timeframe post- CPC approval to 14 business days from 10. Noted in V.E.2. Approvals section that all policies are distributed by email to the health plans for review and plan level approval. 02/23 Annual review. Replaced all instances of Chief Medical Officer with Deputy Chief Health Officer. Changed references to the medical management department to Population Health and Clinical Operations (PHCO). Changed II.B.1. to note PHCO representation for each region. 01/24 Annual review. Changed title to “Physical Health Clinical Policy Committee” and changed “CPC” to “PH CPC” throughout. Moved participating physician requirements statement from I.A. to II. Added clarifying language to I.B. and C. Added additional member details to II.A.2. and II.B.1. Revised and added detailed lists to section III. regarding 10/24

CLINICAL POLICY

Clinical Policy Committee Page 6 of 6 Reviews, Revisions, and Approvals Approval Date established policies, new policies, and ad hoc reviewed policies as well as information on policy dissemination; removed Claims as an area that receives policy update. Removed details about meeting location from IV. Updated language for clarity in section V. and updated process in V.E. Annual review. Revised section III.B.2.d. and e. by updating all instances of “Clinical and Payment policy Governance Committee” to “Clinical and Payment Policy Advisory Committee” and removing the responsibility of voting on policy topics. Minor rewording throughout. 10/25