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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 New Jersey Clinical Policy Manual apply to Ambetter from WellCare of New Jersey members. Policies in the Ambetter from WellCare of New Jersey Clinical Policy Manual may have either a Ambetter from WellCare of New Jersey or a “Centene” heading. Ambetter from WellCare of New Jersey utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter from WellCare of New Jersey 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 New Jersey. In addition, Ambetter from WellCare of New Jersey 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 New Jersey.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- Acupuncture (CP.MP.92) (PDF)
- Adopted Clinical Practice and Preventive Health Guidelines (CPG Grid) (PDF)
- Air Ambulance (CP.MP.175) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (CP.MP.108) (PDF)
- Applied Behavior Analysis (CP.BH.104) (PDF)
- Applied Behavioral Analysis Documentation Requirements (CP.BH.105) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Behavioral Health Treatment Documentation Requirements (HIM.CP.BH.500) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Biofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93)(PDF)
- Burn Surgery (CP.MP.186.) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Concert Genetics Genetic Testing: Aortopathies and Connective Tissue Disorders (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Cardiac Disorders (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Dermatologic Conditions (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Eye Disorders (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Gastroenterologic Disorders (non-cancerous) (V1.2024) (PDF)
- Concert Genetic Testing: General Approach to Genetic and Molecular Testing (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Hearing Loss (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Hematologic Condition (non-cancerous) (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Hereditary Cancer Susceptibility (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Kidney Disorders (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Lung Disorders (V1.2024) (PDF)
- Concert Genetics Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Pharmacogenetics (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Preimplantation Genetic Testing (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Prenatal and Preconception Carrier Screening (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Prenatal Diagnosis via Amniocentesis, CVS or PUBS and Pregnancy Loss (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (V2.2024) (PDF)
- Concert Genetics Oncology: Algorithmic Testing (V2.2024) (PDF)
- Concert Genetics Oncology: Cancer Screening (V2.2024) (PDF)
- Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells Liquid Biopsy (V2.2024) (PDF)
- Concert Genetics Oncology: Cytogenetic Testing (V2.2024) (PDF)
- Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (V2.2024) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (CP.BH.201) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Disc Decompression Procedures (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Drugs of Abuse: Definitive Testing (previously Outpatient Testing for Drugs of Abuse) (CP.MP.50) (PDF)
- Durable Medical Equipment and Orthotics and Prosthetics Guidelines (DME) (CP.MP.107) (PDF)
- Electric Tumor Treating Fields (Optune) (CP.MP.145)(PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171) (PDF)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248)(PDF)
- Fecal Incontinence Treatments (CP.MP.137) (PDF)
- Ferriscan R2-MRI (CP.MP.53) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (CP.MP.129) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- H Pylori Testing (CP.MP.153) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Home Births (CP.MP.136) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal or Epidural Pain Pump (PDF) (CP.MP.173)
- Implantable Loop Recorder (CP.MP.243) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF)
- Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (CP.MP.250) (PDF)
- Liposuction for Lipedema (CP.MP.244) (PDF)
- Long Term Care Placement (CP.MP.71) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) (PDF)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Nerve Blocks and Neurolysis for Pain Management (CP.MP.170)(PDF)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (CP.MP.48) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Home Ventilators (CP.MP.184) (PDF)
- Nonmyeloablative Allogeneic Stem Cell Transplants (CP.MP.141.) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Omisirge (omidubicel): Nicotinamide-modified Allogeneic Hematopoietic Progenitor Cell Therapy (CP.MP.249) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Osteogenic Stimulation (CP.MP.194) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Outpatient Oxygen Use (CP.MP.190) (PDF)
- Pancreas Transplantation (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF)
- Pediatric Kidney Transplant (CP.MP.246) (PDF)
- Pediatric Liver Transplant (CP.MP.120)(PDF)
- Pediatric Oral Function Therapy (CP.MP.188) (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (CP.MP.147) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Pulmonary Function Testing (CP.MP.242) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
- Sacroiliac Joint Fusion (CP.MP.126) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (CP.MP.165) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Skin and Soft Tissue Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Testing for Select Genitourinary Conditions (previously Diagnosis of Vaginitis) (CP.MP.97) (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF)
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (CP.BH.200) (PDF)
- Transplant Service Documentation Requirements (CP.MP.247) (PDF)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
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 New Jersey Payment Policy Manual apply with respect to Ambetter from WellCare of New Jersey members. Policies in the Ambetter from WellCare of New Jersey Payment Policy Manual may have either a Ambetter from WellCare of New Jersey or a “Centene” heading. In addition, Ambetter from WellCare of New Jersey 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 New Jersey
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- 25-hydroxyvitamin D Testing in Children and Adolescents (PDF) Effective Date: 1/1/2022
- 3 Day Payment Window (PDF) Effective Date: 6/30/2022
- 30 Day Readmission (PDF) Effective Date: 6/30/2022
- Allergy Testing (PDF) Effective Date: 1/1/2022
- Bronchial Thermoplasty (PDF) Effective Date: 1/1/2022
- Cardiac Biomarker Testing for Acute MI (PDF) Effective Date: 1/1/2022
- Digital EEG Analysis (PDF) Effective Date: 1/1/2022
- EEG in Evaluation of Headache (PDF) Effective Date: 1/1/2022
- Endometrial Ablation (PDF) Effective Date: 1/1/2022
- Extended Ophthalmoscopy (PDF) Effective Date: 1/1/2022
- External Ocular Photography (PDF) Effective Date: 1/1/2022
- Evoked Potential Testing (PDF) Effective Date: 1/1/2022
- Fluorescein Angiography (PDF) Effective Date: 1/1/2022
- Fundus Photography (PDF) Effective Date: 1/1/2022
- GI Pathogen Nucleic Acid DPT (PDF) Effective Date: 1/1/2022
- Gonioscopy (PDF) Effective Date: 1/1/2022
- Holter Monitors (PDF) Effective Date: 1/1/2022
- Homocysteine Testing (PDF) Effective Date: 1/1/2022
- Intravenous Hydration (PDF) Effective Date: 1/1/2013
- Laser Skin Treatment (PDF) Effective Date: 1/1/2022
- Leveling of Care: Evaluation and Management Overcoding (PDF) Effective Date: 1/1/2022
- Low-Frequency Ultrasound Wound Therapy (PDF) Effective Date: 1/1/2022
- Measurement of Serum 1,25 - dihydroxyvitamin D (PDF) Effective Date: 1/1/2022
- Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) Effective Date: 5/30/2022
- Multiple Procedure Payment Reduction for Therapeutic Services (PDF) Effective Date: 5/30/2022
- Multiple Procedure Payment Reduction Ophthalmology Procedures (PDF) Effective Date: 5/30/2022
- Non-Emergent ER Services (Leveling of ER) (PDF) Effective Date: 5/30/2022
- Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF) Effective Date: 5/30/2022
- Office Visits Billed with Treatment Rooms (PDF) Effective Date: 6/30/2022
- Optum Comprehensive Payment Integrity (CPI) (PDF) Effective Date: 4/1/2023
- Physician's Consultation Services (PDF) Effective Date: 6/30/2022
- Physician's Office Lab Testing (POLT) (PDF) Effective Date: 6/30/2022
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) Effective Date: 1/1/2022
- Problem-Oriented Visits with Preventative Visits (PDF) Effective Date: 6/30/2022
- Problem-Oriented Visits with Surgical Procedures (PDF) Effective Date: 6/30/2022
- Renal Hemodialysis (PDF) Effective Date: 5/30/2022
- Robotic Surgery (PDF) Effective Date: 6/30/2023
- Scan Comp Oph Diag Imaging (PDF) Effective Date: 1/1/2022
- Skilled Nursing Facility Leveling (CC.PP.206) (PDF) Effective Date: 7/8/2024
- Sleep Studies Place of Service (PDF) Effective Date: 6/30/2022
- Thyroid Hormones and Insulin Testing in Pediatrics (PDF) Effective Date: 1/1/2022
- Ultrasound in Pregnancy (PDF) Effective Date: 1/1/2022
- Urine Specimen Validity Testing (PDF) Effective Date: 6/30/2022
- Urodynamic Testing (PDF) Effective Date: 1/1/2022
- Visual Field Testing (PDF) Effective Date: 1/1/2022
- Wheelchairs and Accessories (PDF) Effective Date: 6/30/2022
- Wheelchair Seating (PDF) Effective Date: 1/1/2022