Effective May 22, 2024: Clinical Policies

Date: 05/22/24

Superior HealthPlan has updated certain clinical policies to ensure medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result, the following policies are effective on May 22, 2024, at 12:00AM.

Changes in these policies reflect preauthorization requirement amendments that are less burdensome to insureds, physicians, or health care providers.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Diabetic Supplies (TX.CP.MP.526)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP	Policy updates include: Section II added for blood ketone test/strips (A4252) criteria and added to HCPCS table
Enteral Nutrition and Supplies (TX.CP.MP.550)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP	Policy updates include: Changed Policy Name to include “and Supplies” Added III. D. 2. B9998 with modifier U3 for over allowable of 4 units per g-tube/j-peg site Added section III F for sterile water A4217 with criteria and limitations Updated HCPCS table with A4217

To review all policies, please visit Superior’s Clinical, Payment & Pharmacy Policies webpage.

Prior to updates, Medical Clinical policies are reviewed and approved by the Utilization Management Committee.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.