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
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)

Multiple Sleep Latency Testing (PDF) Total Artificial Heart (PDF)
Bronchial Thermoplasty (PDF)

Neonatal Abstinence Syndrome Guidelines (PDF) Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Cardiac Biomarker Testing for Acute MI (PDF)

Neonatal Sepsis Management Guidelines (PDF) Transcatheter Closure of Patent Foramen Ovale (PFO) (PDF)
Carrier Screening in Pregnancy (PDF)

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

NICU Apnea Bradycardia Guidelines (PDF) Trigger Point Ingections for Pain Management (PDF)
Cell-free Fetal DNA Testing (PDF)

NICU Discharge Guidelines (PDF) Ultrasound in Pregnancy (PDF)
Clinical Trials (PDF)

Nonmyeloablative allogeneic stem cell transplant (PDF) Urinary Incontinence Devices and Treatments (PDF)
Cochlear Implant Replacements (PDF)

OB Home Health Programs (PDF) Urodynamic Testing (PDF)
Cosmetic and Reconstructive Surgery (PDF)

Optic Nerve Decompression Surgery (PDF) Vagus Nerve Stimulation (PDF)
Dental Anesthesia (PDF)

Outpatient Testing for Drugs of Abuse (PDF) Ventricular Assist Devices (PDF)
Diagnosis of Vaginitis (PDF)

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

Panniculectomy (PDF) Wheelchair Seating (PDF)
Disc Decompression Procedures (PDF)

Pediatric Heart Transplant (PDF) Wireless Motility Capsule (PDF)
Discography (PDF)

Pediatric Liver Transplant (PDF) Zika Virus Testing (PDF)
DNA Analysis of Stool (PDF)

Percutaneous LAAD Stroke Prevention (PDF) Proton and Neutron Beam Therapy (PDF)
Donor Lymphocyte Infusion (PDF)

Posterior Nerve Stimulation for Voiding Dysfunction (PDF)  
Durable Medical Equipment (DME) (PDF)

Preventive Health and Clinical Practice Guideline Policy (PDF)  
EEG in Evaluation of Headache (PDF)

   
Electric Tumor Treating Fields (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.