Mga Tagapagbigay
Updated Clinical and Payment policies: Effective April 1, 2026
Detailed policy revisions and summaries that affect Meridian and its family of plans—including Meridian Medicaid Plan, Wellcare By Meridian, YouthCare, Ambetter, and Wellcare—are included below.
The intent of this notice is to inform you of revisions to existing policies that Meridian and its family of plans will be implementing effective April 1, 2026. A summary of the revisions is also included in a separate table.
| Policy Number | Policy Name | Policy Summary |
|---|---|---|
| CG.CP.MP.01 | Infectious Disease: Respiratory Lab Testing | This policy outlines criteria for Syndromic/Multiplex Respiratory Panels with 6 or More Targets, SARS-CoV-2, RSV, or Influenza A/B, OR Multiplex Respiratory Viral Panels with 5 or Fewer Targets, Bacterial Respiratory Infection/Pneumonia Panels, Influenza A and B Antibody Tests, Group A Streptococcus Pharyngitis Tests, Group A Streptococcus Pharyngitis Cultures, and Group A Streptococcus Antibody Tests. |
| CG.CP.MP.02 | Infectious Disease: Multi-System Lab Testing | This policy outlines the appropriate use of tests for pathogens that can cause multisystem symptoms and/or infections. Tests for pathogens that infect multiple body systems can be targeted to detect a specific pathogen(s) or non-targeted to broadly detect nucleic acid from any potential pathogen. |
| CG.CP.MP.03 | Infectious Disease: Dermatologic Testing | This policy outlines the appropriate use of Microscopy/Peroxidase Tests, Fungal Culture, and Culture-Independent Molecular Tests (NAAT/PCR) for Onychomycosis. |
| CG.CP.MP.04 | Infectious Disease: Gastroenterologic Lab Testing | This policy outlines appropriate use of multi-pathogen panels, as well as diagnostic assays targeted at Helicobacter pylori (H. pylori). |
| CG.CP.MP.05 | Infectious Disease Primary Care and Preventive Lab Screening | This policy outlines criteria for human papillomavirus (HPV), hepatitis C virus (HCV), and group B streptococcus (GBS). |
| CG.CP.MP.06 | Infectious Disease: Vector-Borne and Tropical Diseases Lab Testing | This policy outlines criteria for Lyme disease and Zika virus testing via serologic and molecular methods. |
| CG.CP.MP.07 | Infectious Disease: Genitourinary Lab Testing | This policy outlines criteria for Targeted Vaginitis/Vaginosis Pathogen Testing, Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels, Urine Culture for Asymptomatic Bacteriuria, and Molecular/Multiplex UTI Panels. |
| CG.PP.551A | Genetic and Molecular Testing-Version A | This payment policy is supporting the entire Concert genetic testing QAI program. Concert outreaches to labs that have not already registered with them to inform them of the GTU and which codes are assigned to their tests as payable (never more than 5 per test), but registration is not required for them to have claims edited upon. This version (A) requires Concert’s unique genetic test identifier, the GTU, on every genetic testing claim. |
| CG.PP.551C | Genetic and Molecular Testing-Version C | This payment policy is supporting the entire Concert genetic testing QAI program. Concert outreaches to labs that have not already registered with them to inform them of the GTU and which codes are assigned to their tests as payable (never more than 5 per test), but registration is not required for them to have claims edited upon. This version (B) only requires a procedure code description (recommended to use the GTU but test name would also suffice) for the non-specific codes, 81479, 81599 and Tier 2 Codes. |
| Policy Name | Revision Log Details | Applicable Lines of Business |
|---|---|---|
| Infectious Disease Respiratory Testing- CG.CP.MP.01 | Annual review. Changed verbiage in applicable policy statements from “may be considered medically necessary” to “are considered medically necessary.” References reviewed and updated. For Group A Streptococcus Pharyngitis Cultures: Expanded coverage criteria to include patients up to 18 years old (was previously up to 14 years old); updated background and rationale to include language from the updated 2024 American Academy of Family Physicians evidence review. Added 0528U as an in-scope CPT code. Removed deleted codes U0003, U0004, and U0005. Reordered codes in CPT code table numerically. References reviewed and updated. |
|
| Infectious Disease Multisystem Lab Testing-CG.CP.MP.02 | Annual Review. In policy statements for the following criteria sections, changed policy to note that tests “are considered medically necessary” from the previous statement that they “may be considered medically necessary”: Cytomegalovirus (CMV) Nucleic Acid/PCR or Antigen Detection Tests; Cytomegalovirus (CMV) Antibody Tests. For Untargeted Metagenomic Sequencing Tests for Pathogen Detection: Added Bacteria, Viruses, Fungus, and Parasite Metagenomic Sequencing, Spinal Fluid (MSCSF) (Mayo Clinic) to the Policy Reference Table and updated related background. References reviewed and updated. |
|
| Infectious Disease Dermatologic Testing- CG.CP.MP.03 | Annual review. For Fungal Culture for Onychomycosis and Microscopy/Peroxidase Tests for Onychomycosis, reworded policy statements from “may be considered medically necessary” to “are considered medically necessary.” |
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| Infectious Disease Gastroenterological Lab Testing- CG.CP.MP.04 | Annual review. Minor rewording with no clinical significance. For Syndromic/Multiplex Gastrointestinal Pathogen Panels with 11 or Fewer Targets: Changed policy statement from “may be considered medically necessary” to " are considered medically necessary.” Added 87650 and 0369U to Coding Table. |
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| Infectious Disease Primary Care & Preventive Lab Screening- CG.CP.MP.05 | Annual review. Changed policy statement verbiage from " may be considered medically necessary" to "are considered medically necessary" for the following criteria sections: Group B Streptococcus Screening Tests of Vaginal-Rectal Specimens, Genotyping of High-Risk Human Papillomavirus (HPV) Types for Cervical Cancer Screening, and Hepatitis C Nucleic Acid/PCR Tests. For Hepatitis C Nucleic Acid/PCR Tests, added the following criteria option: "The member was exposed to HCV perinatally and is between 2 months and 17 months of age". Background updated. Codes added to CPT Coding table: 0500T, 87626. Code added to new HCPCS table: G0476. References updated. |
|
| Infectious Disease Vector-borne and Tropical Disease Testing- CG.CP.MP.06 | Annual review. Corrected 03/24 revision log to note that 86353 was removed from the CPT table. Minor rewording and formatting with no clinical significance. Reworded policy statements from “may be considered medically necessary” to “are considered medically necessary” for the following criteria sections: Lyme Disease (Borrelia burgdorferi) Serum Antibody Tests, Lyme Disease (Borrelia burgdorferi) Nucleic Acid/PCR Tests, Zika Virus Antibody Tests, and Zika Virus Nucleic Acid/PCR Tests. References updated. |
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| Infectious Disease Genitourinary Lab Testing- CG.CP.MP.07 | Annual review. Minor rewording without clinical significance. For Urine Culture for Asymptomatic Bacteriuria: Addition of Urinary Tract Infection Testing (NxGen MDx, LLC) to Policy Reference Table. Changed policy statements for the following criteria sections from “may be considered medically necessary” to “are considered medically necessary”: Targeted Vaginitis/Vaginosis Pathogen Testing, For Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels: Addition of Vaginal Infection Testing (NxGen MDx, LLC) to Policy Reference Table. Additional codes added to coding table: 87510, 87660, 87808, 87810, 87850, 0371U, 0372U, 0374U, 0504U, 81515, 87528, 87529, 87530, 87531, 87532, 87533, 87534, 87535, 87536, 87537, 87538, 87539, 87901, 87903, 87904, 87906. Removed deleted code 0352U.Background and references updated. |
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| Genetic and Molecular Testing- Version A ---CG.PP.551A | Annual Review. Minor rewording throughout. Removed “Policy Description” header. In Policy Overview, updated vendor name to “Concert”. In “Application”: replaced first sentence regarding “molecular pathology, genomic sequencing…” with Pathology and Laboratory Procedures (80000 Codes), Category III Multianalyte Assays with Algorithmic Analyses (MAAA) (M codes), Proprietary Lab Analysis (PLA) (U codes), Level II Healthcare Common Procedure Coding System (HCPCS);” updated URL to https://www.concertgenetics.com/join-centene. In the Reimbursement section reworded “Laboratories should adhere…” to “All providers of genetic and molecular testing services…”. |
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| Concert Laboratory Payment Policy CG.CC.PP.01 | Annual review. Added “Application” and “Reimbursement” section headers, with other restructuring. In applicable code ranges at the beginning of the policy, replaced “HCPCS level I codes for lab tests (G codes and S codes)” with Level II HCPCS and specified that in-scope codes are those unrelated to genetic and molecular tests, which are addressed by CG.PP.551. Combined AMA and NCCI coding requirements into one section and added details regarding NCCI manual instructions for billing panel codes. |
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We continually review and update our payment and utilization policies to ensure that they comply with industry standards, while delivering the best patient experience to our members.
For detailed policy information, refer to our websites:
- Meridian Medicaid Plan Clinical & Payment Policies
- Wellcare.ILmeridian.com/for-providers.html
- YouthCare Clinical & Payment Policies
- Ambetter Health Clinical & Payment Policies
Please contact your Provider Engagement representative or Meridian Provider Services at 866-606-3700, TTY: 711, Wellcare By Meridian Provider Services at 844-536-2175, TTY: 711, Wellcare Provider Services at 866-822-1339, TTY: 711, YouthCare Provider Services at 844-289-2264, TTY: 711, or Ambetter Provider Services at 855-745-5507, TTY: 844-517-3431 for assistance.
