Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.

All policies found in the Ambetter of North Carolina Inc. Clinical Policy Manual apply to Ambetter of North Carolina Inc. members. Policies in the Ambetter of North Carolina Inc. Clinical Policy Manual may have either a Ambetter of North Carolina Inc. or a “Centene” heading. Ambetter of North Carolina Inc. utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter of North Carolina Inc. clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Ambetter of North Carolina Inc.. In addition, Ambetter of North Carolina Inc. may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria is payable by Ambetter of North Carolina Inc..

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Clinical Policy List
A-G	H-P	Q-Z
Allergy Testing and Therapy (PDF) Effective Date: 1/31/2018	Heart-Lung Transplant (PDF) Effective Date: 4/30/2018	Paclitaxel, Protein-Bound (PDF) Effective Date: 7/01/2015
Applied Behavioral Analysis for Autism (PDF) Effective Date: 1/31/2018	Hospice Services (PDF) Effective Date: 4/30/2018	Pancreas transplant (PDF) Effective Date: 2/28/2018
Assisted Reproductive Technology (PDF) Effective Date: 3/31/2018	Hyperemesis gravidarum treatment (PDF) Effective Date: 3/30/2018	Pediatric Liver Transplant (PDF) Effective Date: 4/30/2018
Bariatric Surgery (PDF) Effective Date: 6/30/2018	Medical Necessity Criteria (PDF) Effective Date: 6/30/2018	Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) Effective Date: 08/01/2020
Biofeedback (PDF) Effective Date: 5/31/2018	NICU discharge guidelines (PDF) Effective Date: 8/31/2018	PROM Testing (PDF) Effective Date: 4/1/2021
Bronchial Thermoplasty (PDF) Effective Date: 4/202	Outpatient Testing for Drugs of Abuse (PDF) Effective Date: 1/15/2021	Short Inpatient Hospital Stay (PDF) Effectie Date: 3/01/2020
Cell-free Fetal DNA Testing (PDF) Effective Date: 4/30/2018		Therapy Services (PT/OT/ST) (PDF) Effective Date: 6/22/2018
Clinical Trials (PDF) Effective Date: 11/1/2022		Testing for Select Genitourinary Conditions (PDF) Effective Date: 8/2019
Cosmetic and Reconstructive Surgery (PDF) Effective Date: 3/31/2018		Wheelchair Seating (PDF) Effective Date: 9/2020
Dental Anesthesia (PDF) Effective Date: 4/30/2018		Ultrasound in Pregnancy (PDF) Effective Date: 6/30/2018
Digital EEG Spike Analysis (PDF) Effective Date: 1/2020
Durable Medical Equipment (DME) (PDF) Effective Date: 7/31/2018
Endometrial Ablation (PDF) Effective Date: 7/2019
Functional MRI (PDF) Effective Date: 9/30/2018
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) Effective Date: 3/01/2022

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Ambetter of North Carolina Inc. Payment Policy Manual apply with respect to Ambetter of North Carolina Inc. members. Policies in the Ambetter of North Carolina Inc. Payment Policy Manual may have either a Ambetter of North Carolina Inc. or a “Centene” heading. In addition, Ambetter of North Carolina Inc. may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Ambetter of North Carolina Inc.

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Payment Policy List
A-G	H-P	Q-Z
Clean Claim Reviews (PDF) Effectice Date: 9/11/2020	Leveling of Emergency Room Services (PDF) Effective Date: 10/01/2017	Physician's Consultation Services (PDF) Effective Date: 11/01/2017
Cost to Charge Adjustments on Clean Claim Reviews (PDF) Effective Date: 9/11/2020	Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) Effective Date: 2/6/2020	Physician's Office Lab Testing (PDF) Effective Date: 11/01/2017
Evaluation and Management Services Billed with Treatment Rooms (PDF) Effective Date: 5/01/2022	Multiple Procedure Payment Reduction for Therapeutic Services (PDF) Effective Date: 8/23/2020	Problem Oriented Visits Billed with Preventative Visits (PDF) Effective Date: 11/1/2017
Facility Charges for Hospital-Based Outpatient Clinics (PDF) Effective Date: 5/8/2018	Multiple Procedure Reduction: Ophthalmology (PDF) Effective Date: 8/23/2020	Problem Oriented Visits Billed with Surgical Procedures (PDF) Effective Date: 11/1/2017
	Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: 09/01/2019	Robotic Surgery (PDF) Effective Date: 8/2017Sepsis Diagnosis (PDF)
		Sepsis Diagnosis (PDF) Effective Date: 2/1/2021
		Unbundling Adjustments on Clean Claim Reviews (PDF) Effective Date: 9/11/2020
		3-Day Payment Window (PDF) Effective Date: 7/01/2014
		30 Day Readmission (PDF) Effective Date: 1/01/2015

Clinical Payment Policies | Ambetter of North Carolina

Clinical & Payment Policies

Clinical Policies

Clinical Policies

Payment Policies

Payment Policies