Clinical Payment Policies | Ambetter of North Carolina

 

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.

For a list of all active clinical policies, see below. For any upcoming policy changes, view the Clinical Policy Updates list.

POLICY TITLE
POLICY NUMBER
25-hydroxyvitamin D Testing in Chldren and Adolescents (PDF)CP.MP.157
Acupuncture (PDF)CP.MP.92
Adopted Clinical Practice and Preventive Health Guidelines (PDF)CPG Grid
Air Ambulance (PDF)CP.MP.175
Allergy Testing and Therapy (PDF)
CP.MP.100
Allogeneic Hematopoietic Cell Transplants For Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108
Applied Behavior Analysis (PDF)CP.BH.104
Articular Cartilage Defect Repairs (PDF)CP.MP.26
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF) CP.BH.124
Bariatric Surgery (PDF)CP.MP.37
Behavioral Health Treatment Documentation Requirements (PDF)CP.BH.500
Biofeedback (PDF)CP.MP.168
Biofeedback for Behavioral Health Disorders (PDF)CP.BH.300
Bone-Anchored Hearing Aid (PDF)CP.MP.93
Bronchial Thermoplasty (PDF)CP.MP.110
Burn Surgery (PDF)CP.MP.186
Cardiac Biomarker Testing (PDF)CP.MP.156
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164
Clinical Trials (PDF)CP.MP.94
Cochlear Implant Replacements (PDF)CP.MP.14
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V1.2024
Concert Genetic Testing: Cardiac Disorders (PDF)V1.2024
Concert Genetic Testing: Dermatologic Conditions (PDF)V1.2024
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders (PDF)V1.2024
Concert Genetics Genetic Testing: Eye Disorders (PDF)V1.2024
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V1.2024
Concert Genetic Testing: Gastroenterologic Disorders (Non-Cancerous) (PDF)V1.2024
Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)V1.2024
Concert Genetic Testing: Hearing Loss (PDF)V2.2023
Concert Genetic Testing: Hematologic Conditions (Non-Cancerous) (PDF)V1.2024
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V1.2024
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V1.2024
Concert Genetic Testing: Kidney Disorders (PDF)V1.2024
Concert Genetics Genetic Testing: Lung Disorders (PDF)V1.2024
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V1.2024
Concert Genetic Testing: Multisystem Inherited Disorders Intellectual Disability (PDF)V2.2023
Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)V2.2023
Concert Genetic Testing: Pharmacogenetics (PDF)V2.2023
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V2.2023
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V2.2023
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)V1.2024
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V1.2024
Concert Genetics Oncology: Cytogenetic Testing (PDF)V1.2024
Concert Genetics Oncology: Algorithmic Testing (PDF)V1.2024
Concert Genetics Oncology: Cancer Screening (PDF)V1.2024
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)V1.2024
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V1.2024
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31
Deep Transcranial Magnetic Stimulation for Treatment of Obsessive Compulsive Disorder  (PDF)CP.BH.201
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203
Digital EEG Spike Analysis (PDF)CP.MP.105
Disc Decompression Procedures (PDF)CP.MP.114
Discography (PDF)CP.MP.115
Donor Lymphocyte Infusion (PDF)CP.MP.101
Drugs of Abuse Definitive Testing (PDF) CP.MP.50
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)CP.MP.107
EEG in the Evaluation of Headache (PDF)CP.MP.155
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.145
Endometrial Ablation (PDF)CP.MP.106
Evoked Potential Testing (PDF)CP.MP.134
Experimental Technologies (PDF)CP.MP.36
Facet Joint Interventions (PDF)CP.MP.171
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248
Fecal Incontinence Treatments (PDF)CP.MP.137
Ferriscan R2-MRI (PDF)CP.MP.53
Fertility Preservation (PDF)CP.MP.130
Fetal Surgery in Utero for Prenatally Diagnosed Malfunctions (PDF)CP.MP.129
Functional MRI (PDF)CP.MP.43
Gastric Electrical Stimulation (PDF)CP.MP.40
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)CP.MP.209
Gender-Affirming Procedures (PDF)CP.MP.95
Heart-Lung Transplant (PDF)CP.MP.132
Helicopacter Pylori (H Pylori) Serology Testing (PDF)CP.MP.153
Holter Monitors (PDF)CP.MP.113
Home Births (PDF)CP.MP.136
Home Ventilators (PDF)CP.MP.184
Homocysteine Testing (PDF)CP.MP.121
Hospice Services (PDF)CP.MP.54
Hyperhidrosis Treatments (PDF)CP.MP.62
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173
Implantable Loop Recorder (PDF)CP.MP.243
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.160
Intensity-Modulated Radiotherapy (PDF)CP.MP.69
Intestinal and Multivisceral Transplant (PDF)CP.MP.58
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.167
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61
Lantidra (Donislecel): Allogenic Pancreatic Islet Cellular Therapy (PDF)CP.MP.250
Laser Therapy for Skin Conditions (PDF)CP.MP.123
Liposuction for Lipedema (PDF)CP.MP.244
Long Term Care Placement (PDF)CP.MP.71
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.139
Lung Transplantation (PDF)CP.MP.57
Lysis of Epidural Lesions (PDF)CP.MP.116
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.144
Multiple Sleep Latency Testing (PDF)CP.MP.24
Neonatal Abstinence Syndrome Guidelines (PDF)CP.MP.86
Neonatal Sepsis Management (PDF)CP.MP.85
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.170
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.48
NICU Apnea Bradycardia Guidelines (PDF)CP.MP.82
NICU Discharge Guidelines (PDF)CP.MP.81
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.141
Obstetrical Home Care Programs (PDF)CP.MP.91
Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249
Orthognathic Surgery (PDF)CP.MP.202
Osteogenic Stimulation (PDF)CP.MP.194
Outpatient Cardiac Rehabilitation (PDF)CP.MP.176
Outpatient Oxygen Use (PDF)CP.MP.190
Paclitaxel, Protein-Bound (PDF)CP.PHAR.176
Pancreas Transplantation (PDF)CP.MP.102
Panniculectomy (PDF)CP.MP.109
Pediatric Heart Transplant (PDF)CP.MP.138
Pediatric Kidney Transplant (PDF)CP.MP.246
Pediatric Liver Transplant (PDF)CP.MP.120
Pediatric Oral Function Therapy (PDF)CP.MP.188
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.147
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.150
Physical Occupational and Speech Therapy Services (PDF)CP.MP.49
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)CP.MP.181
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133
Proton and Neutron Beam Therapies (PDF)CP.MP.70
Pulmonary Function Testing (PDF)CP.MP.242
Reduction Mammoplasty and Gyncomastia Surgery (PDF)CP.MP.51
Repair of Nasal Valve Compromise (PDF)CP.MP.210
Sacroilic Joint Infusion (PDF)CP.MP.126
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)CP.MP.165
Short Inpatient Hospital Stay (PDF)CP.MP.182
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117
Stereotactic Body Radiation Therapy (PDF)CP.MP.22
Tandem Transplant (PDF)CP.MP.162
Testing for Select Genitourinary Conditions (PDF)CP.MP.97
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)CP.MP.154
Total Artificial Heart (PDF)CP.MP.127
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163
Transcatheter Closure of Patent Foramen Ovale (PDF)CP.MP.151
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression  (PDF)CP.BH.200
Transplant Service Documentation Requirements (PDF)CP.MP.247
Trigger Point Injections for Pain Management (PDF)CP.MP.169
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142
Urodynamic Testing (PDF)CP.MP.98
Vagus Nerve Stimulation (PDF)CP.MP.12
Ventricular Assist Devices (PDF)CP.MP.46
Wireless Motility Capsule (PDF)CP.MP.143

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.

Policy TitleEffective Date
Add on Code Billed Without Primary Code (PDF)1/1/2019
Clean Claim Reviews (PDF)9/11/2020
Clinical Validation of Modifier 25 (PDF)1/1/2019
Clinical Validation of Modifier 59 (PDF)1/1/2019
Cost to Charge Adjustments on Clean Claim Reviews (PDF)9/11/2020
Evaluation and Management Services Billed with Treatment Rooms (PDF)5/1/2022
Facility Charges for Hospital-Based Outpatient Clinics  (PDF)5/8/2018
Infectious Disease: Respiratory Lab Testing (PDF)8/1/2024
Leveling of Emergency Room Services (PDF)10/1/2017
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)2/6/2020
Multiple Procedure Payment Reduction for Therapeutic Services (PDF)8/23/2020
Multiple Procedure Reduction: Ophthalmology (PDF)8/23/2020
Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)9/1/2019
Physician's Consultation Services (PDF)11/1/2017
Physician's Office Lab Testing (PDF)1/1/2024
Problem Oriented Visits Billed with Preventative Visits (PDF)11/1/2017
Problem Oriented Visits Billed with Surgical Procedures (PDF) 11/1/2017
Professional Services (Visit Codes) Billed With Labs (PDF) 1/1/2019
Robotic Surgery (PDF)8/1/2017
Sepsis Diagnosis (PDF)1/1/2024
Severe Malnutrition (PDF)1/1/2024
Skilled Nursing Facility Leveling (PDF)1/1/2019
Supplies Billed on Same Day As Surgery (PDF)1/1/2019
Unbundling Adjustments on Clean Claim Reviews (PDF)9/11/2020
Unbundled Professional Services (PDF)1/1/2019
Unbundled Surgical Procedures (PDF)1/1/2019
Visits On Same Day As Surgery (PDF)1/1/2019
Wheelchair Seating (PDF)8/1/2024
3-Day Payment Window (PDF)7/1/2014
30 Day Readmission (PDF)1/1/2015