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

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

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

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-GH-PQ-Z
3 Day Payment Window (PDF)
Effective Date: 1/1/2022		Leveling of Care: Evaluation and Management Overcoding (PDF)
Effective Date: 1/1/2022
Scanning computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF)
Effective Date: 1/1/2022
30 Day Readmission (PDF)
Effective Date: 1/1/2022
 		Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)
Effective Date: 1/1/2022		Sleep Studies Place of Service (PDF)
Effective Date: 1/1/2022
340B Drug Payment Reduction (PDF)
Effective Date: 1/1/2022
Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
Effective Date: 1/1/2022		Skilled Nursing Facility Leveling (PDF)
Effective Date: 4/28/2025
Extended Ophthalmoscopy (PDF)
Effective Date: 1/1/2022
Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: 1/1/2022		Urine Specimen Validity Testing (PDF)
Effective Date: 1/1/2022
External Ocular Photography (PDF)
Effective Date: 1/1/2022		Non-Emergent ER Services (fka Leveling of ER Services) (PDF)
Effective Date: 1/1/2022
Visual Field Testing (PDF)
Effective Date: 1/1/2022
Fluorescein Angiography (PDF)
Effective Date: 1/1/2022		Non-Obstetrical and OB Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 1/1/2022
Wheelchair Accessories (PDF)
Effective Date: 1/1/2022
Fundus Photography (PDF)
Effective Date: 1/1/2022		Physician's Consultation Services (PDF)
Effective Date: 1/1/2022		 
Gonioscopy (PDF)
Effective Date: 1/1/2022		Problem-Oriented Visits with Preventative Visits (PDF)
Effective Date: 1/1/2022		 
 Problem-Oriented Visits with Surgical Procedures (PDF)
Effective Date: 1/1/2022