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Clinical and 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 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.

 
A-H I-Q R-Z
Abortions (PDF) Intradiscal Steroid Injections for Pain Management (PDF) Retrospective Review for Services Requiring Authorization (PDF)
ADHD Assessment and Treatment (PDF) Laser Skin Treatment (PDF) Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF)
Allergy Testing and Therapy (PDF) Low-Frequency Ultrasound Wound Therapy (PDF) Single Case Agreements (PDF)
Ambulatory EEG (PDF) Measure Serum 1,25 Vitamin D (PDF) Sterilization and Hysterectomies (PDF)
Bariatric Surgery (PDF) Mechanical Stretch Devices (PDF) Sacroiliac Joint Interventions for Pain Management (PDF)
Bronchial Thermoplasty (PDF) Medical Mgmt Physician Peer-To-Peer Delegation Policy (PDF) Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Cardiac Biomarker Testing for Acute MI (PDF) Nerve Blocks for Pain Management (PDF) Short Inpatient Hospital Stay (PDF)
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) Out-of-Network Referrals (PDF) Testing for Select Genitourinary Conditions (PDF)
Clinical Information & Documentation (PDF) Paclitaxel, Protein-Bound (Abraxane) (PDF) Thyroid Testing in Pediatrics (PDF)
Diagnosis of Vaginitis (PDF) Physical, Occupational, Speech Therapy (PDF) Timeliness of UM Decisions and Notifications (PDF)
Digital Analysis of EEGs (PDF) Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) - Effective 1/1/2021 Tracking Disclosure of InterQual Criteria (PDF)
DNA Analysis of Stool (PDF) PROM Testing (PDF) Transcranial Magnetic Stimulation (PDF)
EEG in Evaluation of Headache (PDF) Proton and Neutron Beam Therapy (PDF) Transition of Care (PDF)
Emergency Services (PDF)   Trigger Point Ingections for Pain Management (PDF)
Endometrial Ablation (EA) (PDF)   Ultrasound in Pregnancy (PDF)
EpiFix Wound Treatment (PDF)   Urodynamic Testing (PDF)
Evoked Potential Testing (PDF)   Visual Field Testing (PDF)
Extended Opthalmoscopy (PDF)   Vitamin D Testing in Children (PDF)
External Ocular Photography (PDF)   Wheelchair Seating (PDF)
Facet Joint Interventions for Pain Management (PDF)   Wireless Motility Capsule (PDF)
Fecal Calprotectin Assay (PDF)    
FeNo Testing (PDF)    
Fluorescein Angiography (PDF)    
Fundus Photography (PDF)    
Gonioscopy (PDF)    
H Pylori Testing (PDF)    
Holter Monitors (PDF)    
Homocysteine Testing (PDF)    
 
A-H I-Q R-Z
ADHD Assessment and Treatment (PDF) Intradiscal Steroid Injections for Pain Management (PDF) Sacroiliac Joint Interventions for Pain Management (PDF)
Allergy Testing and Therapy (PDF) Laser Skin Treatment (PDF) Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Ambulatory EEG (PDF) Low-Frequency Ultrasound Wound Therapy (PDF) Short Inpatient Hospital Stay (PDF)
Bronchial Thermoplasty (PDF) Measure Serum 1,25 Vitamin D (PDF) Transcranial Magnetic Stimulation (PDF)
Cardiac Biomarker Testing for Acute MI (PDF) Mechanical Stretch Devices (PDF) Trigger Point Ingections for Pain Management (PDF)
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) Nerve Blocks for Pain Management (PDF) Ultrasound in Pregnancy (PDF)
Diagnosis of Vaginitis (PDF) Paclitaxel, Protein-Bound (Abraxane) (PDF) Urodynamic Testing (PDF)
Digital Analysis of EEGs (PDF) Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) - Effective 1/1/2021 Wheelchair Seating (PDF)
DNA Analysis of Stool (PDF) PROM Testing (PDF) Wireless Motility Capsule (PDF)
EEG in Evaluation of Headache (PDF) Proton and Neutron Beam Therapy (PDF)  
Endometrial Ablation (EA) (PDF)    
EpiFix Wound Treatment (PDF)    
Evoked Potential Testing (PDF)    
Facet Joint Interventions for Pain Management (PDF)    
Fecal Calprotectin Assay (PDF)    
FeNo Testing (PDF)    
H Pylori Testing (PDF)    
Holter Monitors (PDF)    
Homocysteine Testing (PDF)    
 
A-H I-Q R-Z
ADHD Assessment and Treatment (PDF) Intradiscal Steroid Injections for Pain Management (PDF) Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF)
Allergy Testing and Therapy (PDF) Laser Skin Treatment (PDF) Sacroiliac Joint Interventions for Pain Management (PDF)
Ambulatory EEG (PDF) Low-Frequency Ultrasound Wound Therapy (PDF) Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Bronchial Thermoplasty (PDF) Measure Serum 1,25 Vitamin D (PDF) Short Inpatient Hospital Stay (PDF)
Cardiac Biomarker Testing for Acute MI (PDF) Mechanical Stretch Devices (PDF) Testing for Select Genitourinary Conditions (PDF)
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) Nerve Blocks for Pain Management (PDF) Thyroid Testing in Pediatrics (PDF)
Diagnosis of Vaginitis (PDF) Paclitaxel, Protein-Bound (Abraxane) (PDF) Transcranial Magnetic Stimulation (PDF)
Digital Analysis of EEGs (PDF) Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) - Effective 1/1/2021 Trigger Point Ingections for Pain Management (PDF)
DNA Analysis of Stool (PDF) Proton and Neutron Beam Therapy (PDF) Ultrasound in Pregnancy (PDF)
EEG in Evaluation of Headache (PDF)   Urodynamic Testing (PDF)
Endometrial Ablation (EA) (PDF)   Visual Field Testing (PDF)
EpiFix Wound Treatment (PDF)   Vitamin D Testing in Children (PDF)
Evoked Potential Testing (PDF)   Wheelchair Seating (PDF)
Extended Opthalmoscopy (PDF)   Wireless Motility Capsule (PDF)
External Ocular Photography (PDF)    
Facet Joint Interventions for Pain Management (PDF)    
Fecal Calprotectin Assay (PDF)    
FeNo Testing (PDF)    
Fluorescein Angiography (PDF)    
Fundus Photography (PDF)    
Gonioscopy (PDF)    
H Pylori Testing (PDF)    
Holter Monitors (PDF)    
Homocysteine Testing (PDF)    
A-H I-Q R-Z
25-Hydroxyvitamin D Testing (PDF) Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) Radial Head Implant (PDF)
Acupuncture (PDF)
Inhaled Nitric Oxide (PDF)
Reduction Mammoplasty and Gynecomastia Surgery (PDF)
ADHD Assessment and Treatment (PDF)

Intensity-Modulated Radiotherapy (PDF)

Sacroiliac Joint Fusion (PDF)
Allergy Testing and Therapy (PDF) Intestinal and multivisceral transplant (PDF)
Sacroiliac Joint Interventions for Pain Management (PDF)
Allogeneic Hematopoietic Cell Transplants (PDF)
Intradiscal Steroid Injections for Pain Management (PDF)
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF)
Ambulatory EEG (PDF)
Laser Skin Treatment (PDF)
Sclerotherapy for Varicose Veins (PDF)
Ambulatory Surgery Center Optimization (PDF)
Long-Term Care Placement Criteria (PDF)
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Applied Behavioral Analysis for Autism (PDF)
Low-Frequency Ultrasound Wound Therapy (PDF)
Short Inpatient Hospital Stay (PDF)
Articular Cartilage Defect Repairs (PDF)
Lung Transplantation (PDF)
Sickle Cell Disease Observation (PDF)
Assisted Reproductive Technology (PDF)
Lysis of Epidural Lesions (PDF)
Spinal Cord Stimulation (PDF)
Balloon Sinus Ostial Dilation (PDF)
Measure Serum 1,25 Vitamin D (PDF)
Stereotactic Body Radiation Therapy (PDF)
Bariatric Surgery (PDF)
Mechanical Stretch Devices (PDF)

Tandem Transplant (PDF)
Biofeedback (PDF)
Medical Necessity Criteria (PDF)
Testing for Rupture of Fetal Membranes (PDF)
Bone-anchored Hearing Aid (PDF)
Multiple Sleep Latency Testing (PDF) Testing for Select Genitourinary Conditions (PDF)
Bronchial Thermoplasty (PDF)
Neonatal Abstinence Syndrome Guidelines (PDF) Therapy Services (PTOTST) (PDF)
Cardiac Biomarker Testing for Acute MI (PDF)
Neonatal Sepsis Management Guidelines (PDF) Thyroid Testing in Pediatrics (PDF)
Carrier Screening in Pregnancy (PDF)
Nerve Blocks for Pain Management (PDF) Total Artificial Heart (PDF)
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)
NICU Apnea Bradycardia Guidelines (PDF) Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Cell-free Fetal DNA Testing (PDF)
NICU Discharge Guidelines (PDF) Transcatheter Closure of Patent Foramen Ovale (PFO) (PDF)
Clinical Trials (PDF)
Nonmyeloablative allogeneic stem cell transplant (PDF) Transcranial Magnetic Stimulation (PDF)
Cochlear Implant Replacements (PDF)
OB Home Health Programs (PDF) Trigger Point Ingections for Pain Management (PDF)
Cosmetic and Reconstructive Surgery (PDF)
Optic Nerve Decompression Surgery (PDF) Ultrasound in Pregnancy (PDF)
Dental Anesthesia (PDF)
Outpatient Testing for Drugs of Abuse (PDF) Urinary Incontinence Devices and Treatments (PDF)
Diagnosis of Vaginitis (PDF)
Paclitaxel, Protein-Bound (Abraxane) (PDF) Urodynamic Testing (PDF)
Digital Analysis of EEGs (PDF)
Pancreas Transplantation (PDF) Vagus Nerve Stimulation (PDF)
Disc Decompression Procedures (PDF)
Panniculectomy (PDF) Ventricular Assist Devices (PDF)
Discography (PDF)
Pediatric Heart Transplant (PDF) Ventriculectomy and Cardiomyoplasty (PDF)
DNA Analysis of Stool (PDF)
Pediatric Liver Transplant (PDF) Visual Field Testing (PDF)
Donor Lymphocyte Infusion (PDF)
Percutaneous LAAD Stroke Prevention (PDF) Vitamin D Testing in Children (PDF)
Durable Medical Equipment (DME) (PDF)
Posterior Nerve Stimulation for Voiding Dysfunction (PDF) Wheelchair Seating (PDF)
EEG in Evaluation of Headache (PDF)
Preventive Health and Clinical Practice Guideline Policy (PDF) Wireless Motility Capsule (PDF)
Electric Tumor Treating Fields (PDF)
PROM Testing (PDF) Zika Virus Testing (PDF)
Endometrial Ablation (EA) (PDF)
Proton and Neutron Beam Therapy (PDF)  
EpiFix Wound Treatment (PDF)
   
Essure Removal (PDF)
   
Evoked Potential Testing (PDF)
   
Experimental Technologies (PDF)
   
Extended Opthalmoscopy (PDF)    
External Ocular Photography (PDF)    
Facet Joint Interventions for Pain Management (PDF)
   
Fecal Calprotectin Assay (PDF)
   
Fecal Incontinence Treatments (PDF)
   
Ferriscan R2-MRI (PDF)
   
Fertility Preservation (PDF)
   
Fetal Surgery In Utero (PDF)
   
FeNo Testing (PDF)
   
Fluorescein Angiography (PDF)    
Functional MRI (PDF)    
Fundus Photography (PDF)    
Gastric Electrical Stimulation (PDF)
   
Gender Reassignment Surgery (PDF)
   
Genetic Testing (PDF)
   
Gonioscopy (PDF)    
H Pylori Testing (PDF)
   
Heart-Lung Transplant (PDF)
   
Holter Monitors (PDF)
   
Home Birth (PDF)
   
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)
   
Homocysteine Testing (PDF)
   
Hospice Services (PDF)
   
Hyperbaric Oxygen Therapy (PDF)
   
Hyperemesis Gravidarum Treatment (PDF)
   
Hyperhidrosis Treatments (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.

A-H I-Q R-Z
3-Day Payment Window (PDF) Inpatient Consultation (PDF) Review of Acute Care Readmissions within 30 Calendar Days (PDF)
30-Day Readmission (PDF) Inpatient Only Procedures (PDF) Renal Hemodialysis (PDF) - Effective 1/1/2021
Add on Code Billed Without Primary Code (PDF) IV Hydration (PDF) Robotic Surgery (PDF)
Assistant Surgeon (PDF) Lab Quantity Limits (PDF) Same Day Visits (PDF)
Cerumen Removal (PDF) Maximum Units (PDF) Sleep Studies Place of Service (PDF)
Code Editing Overview (PDF) Modifier -25 clinical validation Status "B" Bundled Services (PDF)
Cosmetic Procedures (PDF) Modifier -59 clinical validation (PDF) Status P Bundled Services (PDF)
Distinct Procedural Modifiers (PDF) Modifier DOS Validation (PDF) Supplies Billed on Same Day as Surgery (PDF)
Duplicate Primary Code Billing (PDF) Multiple CPT Code Replacement (PDF) Transgender Related Services (PDF)
EM Bundling Edits (PDF) Modifier to Procedure Code Validation (PDF) Unbundled Professional Services (PDF)
Global Maternity Billing (PDF) Multiple Procedure Reduction: Ophthalmology (PDF) - Effective 1/1/2021 Unbundled Surgical Procedures (PDF)
Hospital Visit Codes Billed with Labs (PDF) Multiple Procedure Payment Reduction for Diagnostic Cardiovascular Procedures (PDF) Unlisted Procedure Codes (PDF)
  Multiple Procedure Payment Reduction for Therapeutic Services (PDF) - Effective 1/1/2021 Urine Specimen Validity Testing (PDF)
  NCCI Unbundling (PDF) Wheelchair Accessories (PDF)
  Never Paid Events (PDF)  
  New Patient (PDF)  
  Non-Emergent ER Services (PDF)  
  Outpatient Consultation (PDF)  
  Pelvic and Transabdominal US (PDF)  
  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)  
 
A-H I-Q R-Z
3-Day Payment Window (PDF) Inpatient Consultation (PDF) Renal Hemodialysis (PDF) - Effective 1/1/2021
30-Day Readmission (PDF) Inpatient Only Procedures (PDF) Robotic Surgery (PDF)
Add on Code Billed Without Primary Code (PDF) IV Hydration (PDF) Same Day Visits (PDF)
Assistant Surgeon (PDF) Lab Quantity Limits (PDF) Sleep Studies Place of Service (PDF)
Bilateral Procedures (PDF) Maximum Units (PDF) Status "B" Bundled Services (PDF)
Cerumen Removal (PDF) Modifier -25 clinical validation Status P Bundled Services (PDF)
Code Editing Overview (PDF) Modifier -59 clinical validation (PDF) Supplies Billed on Same Day as Surgery (PDF)
Cosmetic Procedures (PDF) Modifier DOS Validation (PDF) Transgender Related Services (PDF)
Distinct Procedural Modifiers (PDF) Modifier to Procedure Code Validation (PDF) Unbundled Professional Services (PDF)
Duplicate Primary Code Billing (PDF) Multiple CPT Code Replacement (PDF) Unbundled Surgical Procedures (PDF)
EM Bundling Edits (PDF)

Multiple Procedure Payment Reduction for Therapeutic Services (PDF) - Effective 1/1/2021 Unlisted Procedure Codes (PDF)
Global Maternity Billing (PDF) Multiple Procedure Payment Reduction for Diagnostic Cardiovascular Procedures (PDF) Urine Specimen Validity Testing (PDF)
Hospital Visit Codes Billed with Labs (PDF) Multiple Procedure Reduction: Ophthalmology (PDF) - Effective 1/1/2021 Wheelchair Accessories (PDF)
  NCCI Unbundling (PDF)  
  Never Paid Events (PDF)  
  New Patient (PDF)  
  Non-Emergent ER Services (PDF)  
  Outpatient Consultation (PDF)  
  Pelvic and Transabdominal US (PDF)  
  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)  
A-H I-Q R-Z
30-Day Readmission (PDF) Inpatient Consultation (PDF) Robotic Surgery (PDF)
Add on Code Billed Without Primary Code (PDF)
Inpatient Only Procedures (PDF) Review of Acute Care Readmissions within 30 Calendar Days (PDF)
Assistant Surgeon (PDF) IV Hydration (PDF) Same Day Visits (PDF)
Bilateral Procedures (PDF) Lab Quantity Limits (PDF) Sleep Studies Place of Service (PDF)
Cerumen Removal (PDF) Maximum Units (PDF) Status "B" Bundled Services (PDF)
Code Editing Overview (PDF) Modifier -25 clinical validation Status "P" Bundled Services (PDF)
Cosmetic Procedures (PDF) Modifier -59 clinical validation (PDF) Supplies Billed on Same Day as Surgery (PDF)
Distinct Procedural Modifiers (PDF) Modifier DOS Validation (PDF) Transgender Related Services (PDF)
Duplicate Primary Code Billing (PDF) Modifier to Procedure Code Validation (PDF) Unbundled Professional Services (PDF)
EM Bundling Edits (PDF)

Multiple CPT Code Replacement (PDF)

Unbundled Surgical Procedures (PDF)
Global Maternity Billing (PDF) Multiple Procedure Payment Reduction for Diagnostic Cardiovascular Procedures (PDF) Unlisted Procedure Codes (PDF)
Hospital Visit Codes Billed with Labs (PDF) NCCI Unbundling (PDF) Urine Specimen Validity Testing (PDF)
  Never Paid Events (PDF) Wheelchair Accessories (PDF)
  New Patient (PDF)  
  Non-Emergent ER Services (PDF)  
  Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)  
  Outpatient Consultation (PDF)  
  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)  
  Professional Component (PDF)  
  Problem-Oriented Visits with Preventative Visits (PDF)  
  Problem-Oriented Visits with Surgical Procedures (PDF)  
  Pulse Oximetry (PDF)