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.

Clinical Policy List
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
Leveling of Emergency Room Services (PDF)
Effective Date: 10/01/2017
Physician's Consultation Services (PDF)
Effective Date: 11/01/2017
Biofeedback (PDF)
Effective Date: 5/31/2018
Medical Necessity Criteria (PDF)
Effective Date: 6/30/2018
Physician's Office Lab Testing (PDF)
Effective Date: 11/01/2017

Bronchial Thermoplasty (PDF)

Date: 4/2020

Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)

Effective Date:


Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)

Effective Date:


Carrier Screening in Pregnancy (PDF)
Effective Date: 5/31/2018
Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
Effective Date: 8/23/2020
Preventive Health and Clinical Practice Guideline Policy (PDF)
Effective Date: 9/19/2018
Cell-free Fetal DNA Testing (PDF)
Effective Date: 4/30/2018

Multiple Procedure Reduction: Ophthalmology (PDF)

Effective Date: 8/23/2020

Problem Oriented Visits Billed with Preventative Visits (PDF)
Effective Date: 11/1/2017
Clinical Policy Committee (PDF)
Effective Date: 7/31/2018
NICU discharge guidelines (PDF)
Effective Date: 8/31/2018
Problem Oriented Visits Billed with Surgical Procedures (PDF)
Effective Date: 11/1/2017
Clinical Policy Web Posting (PDF)
Effective Date: 8/24/2018
Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Date: 09/01/2019

Robotic Surgery (PDF)

Effective Date: 8/2017

Cosmetic and Reconstructive Surgery (PDF)
Effective Date: 3/31/2018
Outpatient testing for drugs of abuse (PDF)
Effective Date: 8/1/2021
Sepsis (PDF)
Effective Date: 1/1/2020
Dental Anesthesia (PDF)
Effective Date: 4/30/2018
Therapy Services (PT/OT/ST) (PDF)
Effective Date: 6/22/2018
Short Inpatient Hospital Stay (PDF)
Effectie Date: 3/01/2020
Diagnostic Testing Guidelines for 2019-Novel Coronavirus (PDF)
Date: 3/2020
  Therapy Services (PT/OT/ST) (PDF)
Effective Date: 6/22/2018

Digital EEG Spike Analysis (PDF)

Date: 1/2020

  Testing for Rupture of Fetal Membranes (PDF)
Effective Date: 6/2020
Durable Medical Equipment (DME) (PDF)
Effective Date: 7/31/2018
  Testing for Select Genitourinary Conditions (PDF)
Date: 8/2019
Endometrial Ablation (PDF)
Date: 7/2019
  Wheelchair Seating (PDF)
Effective Date: 9/2020
Evaluation and Management Services Billed with Treatment Rooms (PDF)
Effective Date: 5/01/2022
  Ultrasound in Pregnancy (PDF)
Effective Date: 6/30/2018
Functional MRI (PDF)
Effective Date: 9/30/2018
  3-Day Payment Window (PDF)
Effective Date: 7/01/2014
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
Effective Date: 3/01/2022
Genetic Testing (PDF)
Effective Date: 4/30/2018
  30 Day Readmission (PDF)
Effective Date: 1/01/2015