Políticas clínicas y de pago

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

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

Clinical Policy List
A-GH-PQ-Z
Allergy Testing and Therapy (PDF)
Effective Date: 8/1/2023
Heart-Lung Transplant (PDF)
Effective Date: 4/30/2018		Paclitaxel, Protein-Bound (PDF)
Effective Date: 7/01/2015
Applied Behavioral Analysis for Autism (PDF)
Effective Date: 1/31/2018		Hospice Services (PDF)
Effective Date: 4/30/2018		Pancreas transplant (PDF)
Effective Date: 2/28/2018
Assisted Reproductive Technology (PDF)
Effective Date: 3/31/2018		Hyperemesis gravidarum treatment (PDF)
Effective Date: 3/30/2018		Pediatric Liver Transplant (PDF)
Effective Date: 4/30/2018
Bariatric Surgery (PDF)
Effective Date: 6/30/2018
Medical Necessity Criteria (PDF)
Effective Date: 6/30/2018		Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
Effective Date: 08/01/2020
Biofeedback (PDF)
Effective Date: 5/31/2018		NICU discharge guidelines (PDF)
Effective Date: 8/31/2018		PROM Testing (PDF)
Effective Date: 4/1/2021
Bronchial Thermoplasty (PDF)
Effective Date: 4/202
Outpatient Testing for Drugs of Abuse (PDF)
Effective Date: 1/15/2021
Short Inpatient Hospital Stay (PDF)
Effectie Date: 3/01/2020
Cell-free Fetal DNA Testing (PDF)
Effective Date: 4/30/2018
 Therapy Services (PT/OT/ST) (PDF)
Effective Date: 6/22/2018
Clinical Trials (PDF)
Effective Date: 11/1/2022
 Testing for Select Genitourinary Conditions (PDF)
Effective Date: 8/1/2023
Cosmetic and Reconstructive Surgery (PDF)
Effective Date: 3/31/2018
 Wheelchair Seating (PDF)
Effective Date: 9/2020
Dental Anesthesia (PDF)
Effective Date: 4/30/2018
 Ultrasound in Pregnancy (PDF)
Effective Date: 6/30/2018
Digital EEG Spike Analysis (PDF)
Effective Date: 1/2020		  
Durable Medical Equipment (DME) (PDF)
Effective Date: 7/31/2018		  
Endometrial Ablation (PDF)
Effective Date: 7/2019		  
Functional MRI (PDF)
Effective Date: 9/30/2018		  
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
Effective Date: 3/01/2022		  

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 of North Carolina Inc. Payment Policy Manual apply with respect to Ambetter of North Carolina Inc. members. Policies in the Ambetter of North Carolina Inc. Payment Policy Manual may have either a Ambetter of North Carolina Inc. or a “Centene” heading.  In addition, Ambetter of North Carolina Inc. 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 of North Carolina Inc.

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

Payment Policy List
A-GH-PQ-Z
Add on Code Billed Without Primary Code (PDF)
Effective Date: 1/1/2019		Leveling of Emergency Room Services (PDF)
Effective Date: 10/01/2017		Physician's Consultation Services (PDF)
Effective Date: 11/01/2017
Clean Claim Reviews (PDF)
Effectice Date: 9/11/2020
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)
Effective Date: 2/6/2020		Physician's Office Lab Testing (PDF)
Effective Date: 11/01/2017
Clinical Validation of Modifier 25 (PDF)
Effective Date: 1/1/2019		Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
Effective Date: 8/23/2020		Problem Oriented Visits Billed with Preventative Visits (PDF)
Effective Date: 11/1/2017
Clinical Validation of Modifier 59 (PDF)
Effective Date: 1/1/2019		Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: 8/23/2020		Problem Oriented Visits Billed with Surgical Procedures (PDF)
Effective Date: 11/1/2017
Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: 9/11/2020
Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 09/01/2019		Professional Services (Visit Codes) Billed With Labs (PDF) 
Effective Date: 1/1/2019
Evaluation and Management Services Billed with Treatment Rooms (PDF)
Effective Date: 5/01/2022
 Robotic Surgery (PDF)
Effective Date: 8/2017
Facility Charges for Hospital-Based Outpatient Clinics  (PDF)
Effective Date: 5/8/2018

 

Sepsis
Diagnosis (PDF)
Effective Date: 2/1/2021
  Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/2019
  Unbundling Adjustments on Clean Claim Reviews (PDF)
Effective Date: 9/11/2020
  Unbundled Professional Services (PDF) Effective Date: 1/1/2019
  Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/2019
  Visits On Same Day As Surgery (PDF)
Effective Date: 1/1/2019
  3-Day Payment Window (PDF)
Effective Date: 7/01/2014
  30 Day Readmission (PDF)
Effective Date: 1/01/2015