Clinical & Payment Policies | Ambetter de Sunshine Health

 

Políticas clínicas y de pago

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

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

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

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

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30-Day Readmission (PDF)
Effective Date: February 5, 2021
Incidental Diagnostic and Laboratory Tests Billed with Evaluation and Management Services (PDF)
Effective Date: January 1, 2013
Renal Hemodialysis (PDF)
Effective Date: September, 2022
3-Day Payment Window (PDF)
Effective Date:
Inpatient Consultation (PDF)
Effective Date: October 1, 2017
Reporting Global Maternity Package (PDF)
Effective Date: January 1, 2013
Add on Code Billed Without Primary Code (PDF)
Effective Date: January 1, 2013
Inpatient Only Procedures (PDF)
Effective Date: November 30, 2021
Rituximab (PDF)
Effective Date: November 1, 2017
ADHD Assessment and Treatment (PDF)
Effective Date: January 1, 2022
Intravenous Hydration (PDF)
Effective Date: January 1, 2013
Robotic Surgery (PDF)
Effective Date: April 20, 2021
Allergy Testing and Therapy (PDF)
Effective Date: January 1, 2022
Laser Skin Treatment (PDF)
Effective Date: March 31, 2022
Same Day Visits (PDF)
Effective Date: December 1, 2022
Ambulatory EEG (PDF)
Effective Until: September 14, 2020 Ambulatory EEG (PDF)
Effective Date: September 14, 2020
Leveling of Care: Evaluation and Management Overcoding (PDF)
Effective Date: February 5, 2021
Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective Date: January 1, 2022
Assistant Surgeon (PDF)
Effective Date: January 1, 2014
Leveling of Emergency Room Services (PDF)
Effective Date: May 15, 2019
Sepsis Diagnosis (PDF)
Effective Date: October 1, 2020
Bevacizumab (Avastin) (PDF)
Effective Date: August 12, 2016
Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: September 1, 2017
Short Inpatient Hospital Stay (PDF) Effective Date: October 1, 2020
Bilateral Procedures (PDF)
Effective Date: January 1, 2014
Maximum Units of Service (PDF)
Effective Date: January 1, 2013
Sleep Studies Place of Services (PDF)
Effective Date: May 1, 2017
Billing Requirements for Transgender Services (PDF)
Last Review Date: April 17, 2023
  
Bronchial Thermoplasty (PDF) Effective Date: January 15, 2017Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: January 1, 2022
Status "B" Bundled Services (PDF)
Effective Date: January 1, 2014
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: June 1, 2018
Mechanical Stretch Devices (PDF)
Effective Date: September 1, 2017
Status "P" Bundled Services (PDF)
Effective Date: April 1, 2017
Cerumen Removal (PDF)
Effective Date: January 1, 2014
Moderate Conscious Sedation (PDF)
Date of Last Revision: June 26, 2023
Supplies Billed On Same Day as Surgery (PDF)
Effective Date: January 1, 2013
Clean Claims (PDF)
Effective Date:
Modifier DOS Validation (PDF)
Effective Date: January 1, 2013
Testing for Rupture of Fetal Membranes (PDF)
Effective Date: Retired
Clean Claim Reviews (PDF)
Effective Date: November 1, 2012
Modifier to Procedure Code Validation (PDF)
Effective Date: January 1, 2013
Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF)
Effective Date: January 1, 2022
Clinical Validation of Modifier 25 (PDF)
Effective Date: January 1, 2013
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: March 1, 2019Testing of Select GU Conditions (PDF) Effective Date: March 31, 2022
CMS Correct Coding Initiative Unbundling Edits (PDF)
Effective Date:
 Thryoid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: October 31, 2021
Code Editing Overview (PDF)
Effective Date: January 1, 2013
Multiple CPT Code Replacement (PDF)
Effective Date: January 1, 2014
 
Cosmetic Procedures (PDF)
Effective Date: January 1, 2014
Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (PDF) Effective Date: February 6, 2021Ultrasound in Pregnancy (PDF)
Effective Date: March 31, 2022
Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: August 23, 2021
Unbundled Professional Services (PDF)
Effective Date: January 1, 2014
Diagnosis of Vaginitis (PDF)
Effective Date: January 15, 2017 - September 30, 2017
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective Date: August 23, 2021
Unbundled Surgical Procedures (PDF)
Effective Date:
Diagnosis of Vaginitis (PDF) Effective Date: October 1, 2017 - December 31, 2017NCCI Unbundling (PDF)
Effective Date:
Unbundling Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
Digital Analysis of EEGs (PDF)
Effective Date: October 31, 2021
Never Paid Events (PDF)
Effective Date: January 1, 2013
Unlisted Procedure Codes (PDF)
Effective Date: January 1, 2013
Digital Breast Tomosynthesis (PDF)
Effective Date: December 1, 2016 - December 31, 2017
New Patient (PDF)
Effective Date: January 1, 2014
Urine Specimen Validity Testing (PDF)
Effective Date: April 20, 2021
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)
Effective Date: January 1, 2013
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: March 1, 2019Urodynamic Testing (PDF)
Effective Date: March 31, 2022
Distinct Procedural Service: Modifier 59 (PDF)
Effective Date: January 1, 2013
Outpatient Consultation (PDF)
Effective Date: January 1, 2014
Visual Field Testing (PDF)
Effective Date: January 1, 2022
Duplicate Primary Code Billing (PDF)
Effective Date: January 1, 2014
Paclitaxel Protein Bound (PDF)
Effective Date: January 1, 2022
Vitamin D Testing in Children and Adolescents (PDF)
Effective Date: June 1, 2018
EEG in the Evaluation of Headache (PDF)
Effective Date: January 1, 2022
Physician Visit Codes Billed with Labs (PDF)
Effective Date:
Wheelchair and Accessories (PDF)
Effective Date: August 12, 2016
Endometrial Ablation (PDF)
Effective Date: April 30, 2022
Physician's Consultation Services (PDF)
Effective Date: December 1, 2017
Wheelchair Seating (PDF)
Effective Date: March 31, 2022
EpiFix Wound Treatment (PDF)
Effective Date: September 1, 2017
Physician's Office Lab Testing (PDF)
Effective Date: January 1, 2022
Wireless Motility Capsule (PDF)
Effective Date: September 1, 2017
Evaluation and Management Services Billed with Treatment Rooms (PDF)
Effective Date: January 1, 2022
Place of Service Mismatch (PDF) Effective Date: March 1, 2019 
Evoked Potentials (PDF)
Effective Date: January 1, 2022
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) Effective Date: March 31, 2022 
Extended Ophthalmoscopy (PDF) Effective Date: May 15, 2021Post-Operative Visits (PDF)
Effective Date: January 1, 2014
 
External Ocular Photography (PDF)
Effective Date: January 1, 2022
Pre-Operative Visits (PDF)
Effective Date: January 1, 2014
 
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)Problem Oriented Visits Billed with Preventative Visits (PDF)
Effective Date: September 2, 2022
 
Facility Charges for Hospital-Based Outpatient Clinics (PDF)
Effective: September 2022
Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: December 1, 2017
 
Fecal Calprotectin Assay (PDF)
Effective Date: May 1, 2017
Professional Component Modifier 26 (PDF)
Effective Date: January 1, 2013
 
Fluorescein Angiography (PDF) Effective Date: January 1, 2022Professional Services (Visit Codes) Billed With Labs (PDF)
Effective Date: January 1, 2013
 
Fundus Photography (PDF)
Effective Date: February 5, 2021
PROM Testing (PDF)
Effective Date: December 1, 2017
 
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
Effective Date: January 1, 2022
Proton and Neutron Beam Therapy (PDF)
Effective Date: December 1, 2016
 
Gonioscopy (PDF) Effective Date: January 1, 2022Pulse Oximetry with Evaluation & Management Services (PDF)
Effective Date: January 1, 2014
 
High Complexity Medical Decision-Making (PDF)
Effective Date: June 2017
  
Holter Monitors (PDF)
Effective Date: December 31, 2021
  
Homocysteine Testing (PDF)
Effective Date: March 31, 2022


 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: January 1, 2013