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Políticas clínicas y de pago
Medical 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 Absolute Total Care Clinical Policy Manual apply to Absolute Total Care members. Policies in the Absolute Total Care Clinical Policy Manual may have either an Absolute Total Care or a “Centene” heading. Absolute Total Care utilizes InterQual® criteria for those medical technologies, procedures, or pharmaceutical treatments for which an Absolute Total Care 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 in to the Secure Provider Portal or by calling Absolute Total Care.
In addition, Absolute Total Care 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 Absolute Total Care.
If you have any questions regarding these policies, please contact Provider Services at 1-866-433-6041 and ask to be directed to the Medical Management Department.
Navigate directory by letter:
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | #
A
- Acupuncture CP.MP.92 (PDF)
- ADHD Assessment and Treatment CP.MP.124 (PDF)
- Air Ambulance CP.MP.175 (PDF)
- Allergy Testing and Therapy CP.MP.100 (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia CP.MP.108 (PDF)
- Articular Cartilage Defect Repairs CP.MP.26 (PDF)
B
- Bariatric Surgery CP.MP.37 (PDF)
- Biofeedback CP.MP.168 (PDF)
- Bone-Anchored Hearing Aid CP.MP.93 (PDF)
- Bronchial Thermoplasty CP.MP.110 (PDF)
- Burn Surgery CP.MP.186 (PDF)
C
- Cardiac Biomarker Testing CP.MP.156 (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 Genetic Testing: Aortopathies and Connective Tissue Disorders V2.2024 (PDF)
- Concert Genetic Testing: Cardiac Disorders V2.2024 (PDF)
- Concert Genetic Testing: Dermatologic Conditions V2.2024 (PDF)
- Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions V2.2024 (PDF)
- Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders V2.2024 (PDF)
- Concert Genetic Testing: Eye Disorders V2.2024 (PDF)
- Concert Genetic Testing: Gastroenterologic Disorders (Non-Cancerous) V2.2024 (PDF)
- Concert Genetic Testing: General Approach to Genetic and Molecular Testing V2.2024 (PDF)
- Concert Genetic Testing: Hearing Loss V2.2024 (PDF)
- Concert Genetic Testing: Hematologic Conditions (Non-Cancerous) V2.2024 (PDF)
- Concert Genetic Testing: Hereditary Cancer Susceptibility V2.2024 (PDF)
- Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders V2.2024 (PDF)
- Concert Genetic Testing: Kidney Disorders V2.2024 (PDF)
- Concert Genetic Testing: Lung Disorders V2.2024 (PDF)
- Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders V2.2024 (PDF)
- Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay V1.2024 (PDF)
- Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) V2.2024 (PDF)
- Concert Genetic Testing: Pharmacogenetics V2.2024 (PDF)
- Concert Genetic Testing: Preimplantation Genetic Testing V2.2024 (PDF)
- Concert Genetic Testing: Prenatal and Preconception Carrier Screening V2.2024 (PDF)
- Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss V1.2024 (PDF)
- Concert 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 Surgery CP.MP.31 (PDF)
- CPG Grid Adopted Clinical Practice and Preventive Health Guidelines (PDF)
D
- Diaphragmatic/Phrenic Nerve Stimulation CP.MP.203 (PDF)
- Digital EEG Spike Analysis CP.MP.105 (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 CP.MP.50 (PDF)
- Durable Medical Equipment (DME) CP.MP.107 (PDF)
E
- EEG in the Evaluation of Headache CP.MP.155 (PDF)
- Electric Tumor Treating Fields (Optune) CP.MP.145 (PDF)
- Endometrial Ablation CP.MP.106 (PDF)
- Evoked Potential Testing CP.MP.134 (PDF)
- Experimental Technologies CP.MP.36 (PDF)
F
- 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)
G
- Gastric Electrical Stimulation CP.MP.40 (PDF)
- Gender Affirming Procedures CP.MP.95 (PDF)
- GI Pathogen Nucleic Acid Detection Panel Testing CP.MP.209 (PDF)
H
- Heart-Lung Transplant CP.MP.132 (PDF)
- Helicobacter Pylori Serology Testing CP.MP.153 (PDF)
- Holter Monitors CP.MP.113 (PDF)
- Home Births CP.MP.136 (PDF)
- Home Ventilators CP.MP.184 (PDF)
- Homocysteine Testing CP.MP.121 (PDF)
- Hyperhidrosis Treatments CP.MP.62 (PDF)
I
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea CP.MP.180 (PDF)
- Implantable Intrathecal or Epidural Pain Pump CP.MP.173 (PDF)
- Implantable Loop Recorder CP.MP.243 (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring CP.MP.160 (PDF)
- Intestinal and Multivisceral Transplant CP.MP.58 (PDF)
- Intensity-Modulated Radiotherapy CP.MP.69 (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)
J
K
L
- Lantidra (Donislecel): Allogenic Pancreatic Islet Cellular Therapy CP.MP.250 (PDF)
- Laser Therapy for Skin Conditions CP.MP.123 (PDF)
- Liposuction for Lipedema CP.MP.244 (PDF)
- Long Term Care Placement CP.MP.71 (PDF)
- Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy CP.MP.139 (PDF)
- Lung Transplantation CP.MP.57 (PDF)
- Lysis of Epidural Lesions CP.MP.116 (PDF)
M
- Mechanical Stretching Devices for Joint Stiffness and Contracture CP.MP.144 (PDF)
- Measurement of Serum 1,25-dihydroxyvitamin D CP.MP.152 (PDF)
N
- 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)
- Nonmyeloablative Allogeneic Stem Cell Transplants CP.MP.141 (PDF)
O
- Obstetrical Home Care Programs CP.MP.91 (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)
P
- 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)
- Polymerase Chain Reaction Respiratory Viral Panel Testing CP.MP.181 (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)
Q
R
- Reduction Mammoplasty and Gynecomastia Surgery CP.MP.51 (PDF)
- Repair of Nasal Valve Compromise CP.MP.210 (PDF)
S
- 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)
- Skilled Nursing Facility Leveling CC.PP.206 (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)
T
- Tandem Transplant CP.MP.162 (PDF)
- Testing for Select Genitourinary Conditions CP.MP.97 (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide CP.MP.87 (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics CP.MP.154 (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)
- Transplant Service Documentation Requirements CP.MP.247 (PDF)
- Trigger Point Injections for Pain Management CP.MP.169 (PDF)
U
- Ultrasound in Pregnancy CP.MP.38 (PDF)
- Urinary Incontinence Devices and Treatments CP.MP.142 (PDF)
- Urodynamic Testing CP.MP.98 (PDF)
V
W
X
Y
Z
#
- Applied Behavior Analysis CP.BH.104 (PDF)
- Applied Behavioral Analysis Documentation Requirements CP.BH.105 (PDF)
- Behavioral Health Treatment Documentation Requirements HIM.CP.BH.500 (PDF)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder CP.BH.201 (PDF)
- Experimental Technologies CP.MP.36 (PDF)
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression CP.BH.200 (PDF)
Payment Policies
Healthcare 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 healthcare 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 healthcare and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the Absolute Total Care Payment Policy Manual apply with respect to Absolute Total Care members. Policies in the Absolute Total Care Payment Policy Manual may have either an Absolute Total Care or a “Centene” heading. In addition, Absolute Total Care 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 Absolute Total Care.
If you have any questions regarding these policies, please contact Provider Services at 1-866-433-6041 and ask to be directed to the Medical Management Department.
Navigate directory by letter:
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | #
A
B
C
- Cerumen Removal (PDF)
- Clean Claim Reviews (PDF)
- Code Editing Overview (PDF)
- Cosmetic Procedures (PDF)
- Cost to Charge Adjustments on Clean Claim Reviews (PDF)
D
E
- EM Bundling Edits (PDF)
- Emergency Department (ED) Evaluation and Management (E/M) Coding for Facility Claims (PDF)
F
G
H
I
J
K
L
M
- Maximum Units (PDF)
- Modifier -25 clinical validation
- Modifier -59 clinical validation (PDF)
- Modifier DOS Validation (PDF)
- Modifier to Procedure Code Validation (PDF)
- Multiple CPT Code Replacement (PDF)
- Multiple Procedure Payment Reduction for Diagnostic Cardiovascular Procedures (PDF)
N
- NCCI Unbundling (PDF)
- Never Paid Events (PDF)
- Non-Emergent ER Services (PDF)
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
O
P
- Physician's Consultation Services (PDF)
- Physician's Office Lab Testing (PDF)
- Physician Visit Codes Billed with Labs (PDF)
- Place of Service Mismatch (PDF)
- Post-Operative Visits (PDF)
- Pre-Operative Visits (PDF)
- Problem-Oriented Visits with Preventative Visits (PDF)
- Problem-Oriented Visits with Surgical Procedures (PDF)
- Professional Component (PDF)
- Pulse Oximetry (PDF)
Q
R
S
- Same Day Visits (PDF)
- Sleep Studies Place of Service (PDF)
- Status "B" Bundled Services (PDF)
- Status "P" Bundled Services (PDF)
- Supplies Billed on Same Day as Surgery (PDF)
T
U
- Unbundling Adjustments on Clean Claim Reviews (PDF)
- Unbundled Professional Services (PDF)
- Unbundled Surgical Procedures (PDF)
- Unlisted Procedure Codes (PDF)
- Urine Specimen Validity Testing (PDF)