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 Health Clinical Policy Manual apply to Ambetter Health members. Policies in the Ambetter Health Clinical Policy Manual may have either a Ambetter Health or a “Centene” heading. Ambetter Health utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter Health 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 Health. In addition, Ambetter Health 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 Health.   

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

POLICY TITLEPOLICY NUMBER
Adopted Clinical Practice and Preventive Health Guidelines (PDF)CPG Grid
Air Ambulance (PDF)CP.MP.175
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108
Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249
Applied Behavior Analysis (PDF)CP.BH.104
Applied Behavioral Analysis Documentation Requirements (PDF)CP.BH.105
Assisted Reproductive Technology (PDF)CP.MP.55
Bariatric Surgery (PDF)CP.MP.37
Behavioral Health Treatment Documentation Requirements (PDF)HIM.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
Burn Surgery (PDF)CP.MP.186
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 Oncology: Algorithmic Testing (PDF)V1.2025
Concert Genetic Oncology: Cancer Screening (PDF)V1.2025
Concert Genetic Oncology: Circulating Tumor Cells (Liquid Biopsy) (PDF)V1.2025
Concert Genetic Oncology: Cytogenetic Testing (PDF)V1.2025
Concert Genetic Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V1.2025
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V1.2025
Concert Genetic Testing: Cardiac Disorders (PDF)V1.2025
Concert Genetic Testing: Dermatologic Conditions (PDF)V1.2025
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V1.2025
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V1.2025
Concert Genetic Testing: Eye Disorders (PDF)V1.2025
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)V1.2025
Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)V1.2025
Concert Genetic Testing: Hearing Loss (PDF)V1.2025
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)V1.2025
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V1.2025
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V1.2025
Concert Genetic Testing: Kidney Disorders (PDF)V1.2025
Concert Genetic Testing: Lung Disorders (PDF)V1.2025
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V1.2025
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V1.2025
Concert Genetic Testing: Pharmacogenetics (Version B) (PDF)V1.2025
Concert Genetic Testing: Preimplantation Genetic Testing  (PDF)V1.2025
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V1.2025
Concert Genetic Testing: Prenatal Cell-Free DNA Testing (PDF)V1.2025
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss  (PDF)V1.2025
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V1.2025
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.201
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203
Disc Decompression Procedures (PDF)CP.MP.114
Discography (PDF)CP.MP.115
Donor Lymphocyte Infusion (PDF)CP.MP.101
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)CP.MP.107
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.145
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
Fertility Preservation (PDF)CP.MP.130
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129
Gastric Electrical Stimulation (PDF)CP.MP.40
Gender-Affirming Procedures (PDF)CP.MP.95
Heart-Lung Transplant (PDF)CP.MP.132
Home Births (PDF)CP.MP.136
Home Ventilators (PDF)CP.MP.184
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): Allogeneic Pancreatic Islet Cellular Therapy (PDF)CP.MP.250
Liposuction for Lipedema (PDF)CP.MP.244
Long Term Care Placement (PDF)CP.MP.71
Lung Transplantation (PDF)CP.MP.57
Lysis of Epidural Lesions (PDF)CP.MP.116
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
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
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 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
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133
Proton and Neutron Beam Therapies (PDF)CP.MP.70
Radiation Therapy for Skin Cancer (PDF)CP.MP.251
Reduction Mammoplasty and Gynecomastia Surgery (PDF)CP.MP.51
Repair of Nasal Valve Compromise (PDF)CP.MP.210
Sacroiliac Joint Fusion (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
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87
Total Artificial Heart (PDF)CP.MP.127
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163
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
Vagus Nerve Stimulation (PDF)CP.MP.12
Ventricular Assist Devices (PDF)CP.MP.46

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 Health Payment Policy Manual apply with respect to Ambetter Health members. Policies in the Ambetter Health Payment Policy Manual may have either a Ambetter Health or a “Centene” heading.  In addition, Ambetter Health 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 Health.     

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

Pharmacy Policies