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.
Tethered Cord Policy Effective Date May 4,2025
H2027 Psychoeducational Service Effective Date September 1, 2025
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 website www.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.
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.
Assistant at Surgery Effective Date June 17, 2024
Breast Cancer Genetic Testing Tier 1 vs Tier 2 Effective Date November 5, 2023
Corrected Claims Effective Date July 18, 2025
Critical Care Codes when Discharged to Home Effective Date November 5, 2023
DRG Clinical Validation Effective Date August 25, 2023
Duplicate Claim Reimbursement Policy Effective Date July 18, 2025
Early Elective Delivery Payment Policy Effective Date June 20, 2024
Facility Emergency Department Evaluation and Management Leveling Effective Date January 5, 2025
High Level E/M with Preventive Medicine Policy Effective Date November 5, 2023
Hospital Routine Supplies Services Reimbursement Effective Date December 13, 2023
Hydrolyzed Enteral Formula Diagnosis Effective Date November 20, 2023
In-Office Lab Policy Effective Date June 1, 2024
Inpatient Only Procedure Codes Effective Date April 1, 2024
Newborn and NICU Effective Date August 25, 2023
Observation Reimbursement Policy Effective Date June 17, 2024
Optum Pause and Pay Effective Date February 22, 2024
Outpatient Definitive Presumptive Drug Testing Medicaid Medicare Effective Date August 12, 2023
Split Night Sleep Study Effective Date November 5, 2023
Sterilization Effective Date July 18,2025
Therapeutic Behavioral Health Services H2019_H2020 Effective Date September 10, 2023
Timely Filing Reimbursement Policy Effective Date December 26, 2024
Vitamin D Assay Testing Effective Date July 18,2025