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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 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 into 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 Member Services 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) Single Case Agreements (PDF)
Allergy Testing (PDF) Low-Frequency Ultrasound Wound Therapy (PDF) Sterilization and Hysterectomies (PDF)
Ambulatory EEG (PDF) Measure Serum 1,25 Vitamin D (PDF) Sacroiliac Joint Interventions for Pain Management (PDF)
Bariatric Surgery (PDF) Mechanical Stretch Devices (PDF) Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Bronchial Thermoplasty (PDF) Medical Mgmt Physician Peer-To-Peer Delegation Policy (PDF) Timeliness of UM Decisions and Notifications (PDF)
Cardiac Biomarker Testing for Acute MI (PDF) Monitored Anesthesia (PDF) Tracking Disclosure of InterQual Criteria (PDF)
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) Nerve Blocks for Pain Management (PDF) Transcranial Magnetic Stimulation (PDF)
Clinical Information & Documentation (PDF) Out of Network Referrals (PDF) Transition of Care (PDF)
Diagnosis of Vaginitis (PDF) Physical, Occupational, Speech Therapy (PDF) Trigger Point Ingections for Pain Management (PDF)
Digital Analysis of EEGs (PDF) Proton and Neutron Beam Therapy (PDF) Ultrasound in Pregnancy (PDF)
DNA Analysis of Stool (PDF)   Urodynamic Testing (PDF)
EEG in Evaluation of Headache (PDF)   Wheelchair Seating (PDF)
Emergency Services (PDF)   Wireless Motility Capsule (PDF)
Endometrial Ablation (EA) (PDF)    
EpiFix Wound Treatment (PDF)    
Evoked Potentials (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
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 (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)

Sclerotherapy for Varicose Veins (PDF)
Ambulatory EEG (PDF)

Laser Skin Treatment (PDF)

Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Ambulatory Surgery Center Optimization (PDF)

Long Term Care Placement Criteria (PDF)

Sickle Cell Disease Observation (PDF)
Applied Behavioral Analysis for Autism (PDF)

Low-Frequency Ultrasound Wound Therapy (PDF)

Spinal Cord Stimulation (PDF)
Articular Cartilage Defect Repairs (PDF)

Lung Transplantation (PDF)

Stereotactic Body Radiation Therapy (PDF)
Assisted Reproductive Technology (PDF)

Lysis of Epidural Lesions (PDF)

Tandem Transplant (PDF)
Balloon Sinus Ostial Dilation (PDF)

Measure Serum 1,25 Vitamin D (PDF)

Testing for rupture of fetal membranes (PDF)
Bariatric Surgery (PDF)

Mechanical Stretch Devices (PDF)

Therapy Services (PTOTST) (PDF)
Biofeedback (PDF)

Medical Necessity Criteria (PDF)

Thyroid hormones and insulin testing in pediatrics (PDF)
Bone-anchored Hearing Aid (PDF)

Monitored Anesthesia (PDF)

Total Artificial Heart (PDF)
Bronchial Thermoplasty (PDF)

Multiple Sleep Latency Testing (PDF)

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Cardiac Biomarker Testing for Acute MI (PDF)

Neonatal Abstinence Syndrome Guidelines (PDF)

Transcatheter Closure of Patent Foramen Ovale (PFO) (PDF)
Carrier Screening in Pregnancy (PDF)

Neonatal Sepsis Management Guidelines (PDF)

Transcranial Magnetic Stimulation (PDF)
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)

Nerve Blocks for Pain Management (PDF)

Trigger Point Ingections for Pain Management (PDF)
Cell-free Fetal DNA Testing (PDF)

NICU Apnea Bradycardia Guidelines (PDF)

Ultrasound in Pregnancy (PDF)
Clinical Trials (PDF)

NICU Discharge Guidelines (PDF)

Urinary Incontinence Devices and Treatments (PDF)
Cochlear Implant Replacements (PDF)

Nonmyeloablative allogeneic stem cell transplant (PDF)

Urodynamic Testing (PDF)
Cosmetic and Reconstructive Surgery (PDF)

OB Home Health Programs (PDF)

Vagus Nerve Stimulation (PDF)
Dental Anesthesia (PDF)

Optic Nerve Decompression Surgery (PDF)

Ventricular Assist Devices (PDF)
Diagnosis of Vaginitis (PDF)

Outpatient Testing for Drugs of Abuse (PDF)

Ventriculectomy and Cardiomyoplasty (PDF)
Digital Analysis of EEGs (PDF)

Pancreas Transplantation (PDF)

Wheelchair Seating (PDF)
Disc Decompression Procedures (PDF)

Panniculectomy (PDF)

Wireless Motility Capsule (PDF)
Discography (PDF)

Pediatric Heart Transplant (PDF)

Zika Virus Testing (PDF)
DNA Analysis of Stool (PDF)

Pediatric Liver Transplant (PDF)

 
Donor Lymphocyte Infusion (PDF)

Percutaneous LAAD Stroke Prevention (PDF)

 
Durable Medical Equipment (DME) (PDF)

Posterior Nerve Stimulation for Voiding Dysfunction (PDF)

 
EEG in Evaluation of Headache (PDF)

Preventive Health and Clinical Practice Guideline Policy (PDF)

 
Electric Tumor Treating Fields (PDF)

Proton and Neutron Beam Therapy (PDF)
 
Endometrial Ablation (EA) (PDF)

   
EpiFix Wound Treatment (PDF)

   
Essure Removal (PDF)

   
Evoked Potentials (PDF)

   
Experimental Technologies (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)

   
Functional MRI (PDF)

   
Gastric Electrical Stimulation (PDF)

   
Gender Reassignment Surgery (PDF)

   
Genetic Testing (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

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 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 Member Services and ask to be directed to the Medical Management department.

A-H I-Q R-Z
3-Day Payment Window (PDF) Inpatient Consultation (PDF) Same Day Visits (PDF)
Add on Code Billed Without Primary Code (PDF) Inpatient Only Procedures (PDF) Status "B" Bundled Services (PDF)
Assistant Surgeon (PDF) IV Hydration (PDF) Status P Bundled Services (PDF)
Bilateral Procedures (PDF)
Maximum Units (PDF) Supplies Billed on Same Day as Surgery (PDF)
Cerumen Removal (PDF)
Modifier -25 clinical validation Transgender Related Services (PDF)
CLIA Number (PDF)
Modifier -59 clinical validation (PDF) Unbundled Professional Services (PDF)
Cosmetic Procedures (PDF) Modifier DOS Validation (PDF) Unbundled Surgical Procedures (PDF)
Distinct Procedural Modifiers (PDF) Modifier to Procedure Code Validation (PDF) Unlisted Procedure Codes (PDF)
Duplicate Primary Code Billing (PDF) Multiple CPT Code Replacement (PDF) Urine Specimen Validity Testing (PDF)
EM Bundling Edits (PDF) NCCI Unbundling (PDF) Wheelchair Accessories (PDF)
Global Maternity Billing (PDF) Never Paid Events (PDF)  
Hospital Visit Codes Billed with Labs (PDF) New Patient (PDF)  
  Outpatient Consultation (PDF)  
  Pelvic and Transabdominal US (PDF)  
  Physician Visit Codes Billed with Labs (PDF)  
  Physician's Office Lab Testing  
  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)