Archived Policies

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A

• Air Ambulance Transportation
• Air Ambulance Transportation - Archive effective 5/15/2026

C

• COVID-19 Testing
• COVID-19 Vaccine and Administration
• COVID-19 Therapeutic Treatment Therapies

E

• Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
• Early and Periodic Screening, Diagnostic and Treatment (EPSDT) - Archive effective 6/18/2026

G

• Gold Card Program

H

• Hospital Readmission Occurring within 30 Days of an Index Admission

N

• Never Events, Adverse Events, Hospital Acquired Conditions, Serious Reportable Conditions & Provider Preventable Conditions  
• Non-Covered / Non-Reimbursable Codes
• Non-Covered / Non-Reimbursable Codes - Archive effective 7/3/2026

O

• Outpatient Hospital Laboratory Pass Through Billing 

R

• Robot Assisted Surgery