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-O P-Z
Allergy Testing and Therapy (PDF)
Effective Date: 1/31/2018
 Heart-Lung Transplant (PDF)
Effective Date: 4/30/2018		 Pancreas transplant (PDF)
Effective Date: 2/28/2018
Applied Behavioral Analysis for Autism (PDF)
Effective Date: 1/31/2018		 Holter Monitors (PDF)
Effective Date: 6/30/2018		 Pediatric Liver Transplant (PDF)
Effective Date: 4/30/2018
Assisted Reproductive Technology (PDF)
Effective Date: 3/31/2018		 Hospice Services (PDF)
Effective Date: 4/30/2018		 Preventive Health and Clinical Practice Guideline Policy (PDF)
Effective Date: 9/19/2018
Bariatric Surgery (PDF)
Effective Date: 6/30/2018
 Hyperemesis gravidarum treatment (PDF)
Effective Date: 3/30/2018		 Therapy Services (PT/OT/ST) (PDF)
Effective Date: 6/22/2018
Biofeedback (PDF)
Effective Date: 5/31/2018		 Measurement of serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: 12/29/2017		 Ultrasound in Pregnancy (PDF)
Effective Date: 6/30/2018
Carrier Screening in Pregnancy (PDF)
Effective Date: 5/31/2018		 Medical Necessity Criteria (PDF)
Effective Date: 6/30/2018		 Wheelchair seating (PDF)
Effective Date: 9/30/2018
Cell-free Fetal DNA Testing (PDF)
Effective Date: 4/30/2018		 NICU discharge guidelines (PDF)
Effective Date: 8/31/2018		  
Clinical Policy Committee (PDF)
Effective Date: 7/31/2018		 Outpatient testing for drugs of abuse (PDF)
Effective Date: 7/31/2018		  
Clinical Policy Web Posting (PDF)
Effective Date: 8/24/2018		    
Cosmetic and Reconstructive Surgery (PDF)
Effective Date: 3/31/2018		    
Dental Anesthesia (PDF)
Effective Date: 4/30/2018		    
DNA analysis of stool to screen for colorectal cancer (PDF)
Effective Date: 7/31/2018		    
Durable Medical Equipment (DME) (PDF)
Effective Date: 7/31/2018		    
Functional MRI (PDF)
Effective Date: 9/30/2018		    
Genetic Testing (PDF)
Effective Date: 4/30/2018