HAVE AN ENROLLMENT NEED? SHOP OUR PLANS
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 Ambetter of Alabama Clinical Policy Manual apply to Ambetter of Alabama members. Policies in the Ambetter of Alabama Clinical Policy Manual may have either a Ambetter of Alabama or a “Centene” heading. Ambetter of Alabama utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter of Alabama 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 Alabama. In addition, Ambetter of Alabama 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 Alabama.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- Acupuncture (PDF) Effective Date: 1/1/2023
- ADHD Assessment and Treatment (PDF) Effective Date: 1/1/2023
- Air Ambulance (PDF) Effective Date: 1/1/2023
- Allergy Testing and Therapy (PDF) Effective Date: 1/1/2023
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (PDF) Effective Date: 1/1/2023
- Ambulatory Surgery Center Optimization (PDF) Effective Date: 1/1/2023
- Applied Behavior Analysis (PDF) Effective Date: 1/1/2023
- Articular Cartilage Defect Repairs (PDF) Effective Date: 1/1/2023
- Assisted Reproductive Technology (PDF) Effective Date: 1/1/2023
- Bariatric Surgery (PDF) Effective Date: 1/1/2023
- Behavioral Health Treatment Documentation Requirements (PDF) Effective Date: 1/1/2023
- Biofeedback (PDF) Effective Date: 1/1/2023
- Biofeedback for Behavioral Health Disorders (PDF) Effective Date: 1/1/2023
- Bone-Anchored Hearing Aid (PDF) Effective Date: 1/1/2023
- Bronchial Thermoplasty (PDF) Effective Date: 1/1/2023
- Burn Surgery (PDF) Effective Date: 1/1/2023
- Cardiac Biomarker Testing (PDF) Effective Date: 1/1/2023
- Caudal or Interlaminar Epidural Steroid Injections (PDF) Effective Date: 1/1/2023
- Clinical Practice and Preventive Health Guidelines (CPG Grid) (PDF) Effective Date: 1/1/2023
- Clinical Trials (PDF) Effective Date: 1/1/2023
- Cochlear Implant Replacements (PDF) Effective Date: 1/1/2023
- Cosmetic and Reconstructive Surgery (PDF) Effective Date: 1/1/2023
- Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF) Effective Date: 1/1/2023
- Dental Anesthesia (PDF) Effective Date: 1/1/2023
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) Effective Date: 1/1/2023
- Digital Electroencephalography Spike Analysis (PDF) Effective Date: 1/1/2023
- Disc Decompression Procedures (PDF) Effective Date: 1/1/2023
- Discography (PDF) Effective Date: 1/1/2023
- Donor Lymphocyte Infusion (PDF) Effective Date: 1/1/2023
- Drugs of Abuse, Definitive Testing (PDF) Effective Date: 1/1/2023
- Durable Medical Equipment (DME) (PDF) Effective Date: 1/1/2023
- Electroencephalography in the Evaluation of Headache (PDF) Effective Date: 1/1/2023
- Electric Tumor Treating Fields (PDF) Effective Date: 1/1/2023
- Endometrial Ablation (PDF) Effective Date: 1/1/2023
- Essure Removal (PDF) Effective Date: 1/1/2023
- Evoked Potential Testing (PDF) Effective Date: 1/1/2023
- Experimental Technologies (PDF) Effective Date: 1/1/2023
- Facet Joint Interventions (PDF) Effective Date: 1/1/2023
- Fecal Incontinence Treatments (PDF) Effective Date: 1/1/2023
- Ferriscan R2-MRI (PDF) Effective Date: 1/1/2023
- Fertility Preservation (PDF) Effective Date: 1/1/2023
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) Effective Date: 1/1/2023
- Functional MRI (PDF) Effective Date: 1/1/2023
- Gastric Electrical Stimulation (PDF) Effective Date: 1/1/2023
- Gender Affirming Procedures (PDF) Effective Date: 1/1/2023
- Genetic Testing Aortopathies and Connective Tissue Disorders (PDF) Effective Date: 1/1/2023
- Genetic Testing Cardiac Disorders (PDF) Effective Date: 1/1/2023
- Genetic Testing Dermatologic Conditions (PDF) Effective Date: 1/1/2023
- Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Disorders (PDF) Effective Date: 1/1/2023
- Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF) Effective Date: 1/1/2023
- Genetic Testing Eye Disorders (PDF) Effective Date: 1/1/2023
- Genetic Testing for Non-Invasive Prenatal Screening (NIPS) (PDF) Effective Date: 1/1/2023
- Genetic Testing Gastroenterologic Disorders (non-cancerous) (PDF) Effective Date: 1/1/2023
- Genetic Testing General Approach to Genetic Testing (PDF) Effective Date: 1/1/2023
- Genetic Testing Hearing Loss (PDF) Effective Date: 1/1/2023
- Genetic Testing Hematologic Condition (non-cancerous) (PDF) Effective Date: 1/1/2023
- Genetic Testing Hereditary Cancer Susceptibility (PDF) Effective Date: 1/1/2023
- Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders (PDF) Effective Date: 1/1/2023
- Genetic Testing Kidney Disorders (PDF) Effective Date: 1/1/2023
- Genetic Testing Lung Disorders (PDF) Effective Date: 1/1/2023
- Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (PDF) Effective Date: 1/1/2023
- Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF) Effective Date: 1/1/2023
- Genetic Testing Oncology Algorithmic Testing (PDF) Effective Date: 1/1/2023
- Genetic Testing Oncology Cancer Screening (PDF) Effective Date: 1/1/2023
- Genetic Testing Oncology Cytogenetic Testing (PDF) Effective Date: 1/1/2023
- Genetic Testing Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) Effective Date: 1/1/2023
- Genetic Testing Pharmacogenetics (PDF) Effective Date: 1/1/2023
- Genetic Testing Preimplantation Genetic Testing (PDF) Effective Date: 1/1/2023
- Genetic Testing Prenatal and Preconception Carrier Screening (PDF) Effective Date: 1/1/2023
- Genetic Testing Prenatal Diagnosis (PDF) Effective Date: 1/1/2023
- Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (PDF) Effective Date: 1/1/2023
- GI Pathogen Nucleic Acid Detection Panel Testing (PDF) Effective Date: 1/1/2023
- Heart-Lung Transplant (PDF) Effective Date: 1/1/2023
- Home Birth (PDF) Effective Date: 1/1/2023
- Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) Effective Date: 1/1/2023
- Home Ventilators (PDF) Effective Date: 1/1/2023
- H. Pylori Serology Testing (PDF) Effective Date: 1/1/2023
- Holter Monitors (PDF) Effective Date: 1/1/2023
- Homocysteine Testing (PDF) Effective Date: 1/1/2023
- Hospice Services (PDF) Effective Date: 1/1/2023
- Hyperemesis Gravidarum Treatment (PDF) Effective Date: 1/1/2023
- Hyperhidrosis Treatments (PDF) Effective Date: 1/1/2023
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) Effective Date: 1/1/2023
- Implantable Intrathecal Pain Pump (PDF) Effective Date: 1/1/2023
- Implantable Loop Recorder (PDF) Effective Date: 1/1/2023
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) Effective Date: 1/1/2023
- Inhaled Nitric Oxide (PDF) Effective Date: 1/1/2023
- Intensity-Modulated Radiotherapy (PDF) Effective Date: 1/1/2023
- Intestinal and Multivisceral Transplant (PDF) Effective Date: 1/1/2023
- Intradiscal Steroid Injections for Pain Management (PDF) Effective Date: 1/1/2023
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF) Effective Date: 1/1/2023
- Laser Therapy for Skin Conditions (PDF) Effective Date: 1/1/2023
- Liposuction for Lipedema (PDF) Effective Date: 1/1/2023
- Long Term Care Placement Criteria (PDF) Effective Date: 1/1/2023
- Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) Effective Date: 1/1/2023
- Lung Transplantation (PDF) Effective Date: 1/1/2023
- Lysis of Epidural Lesions (PDF) Effective Date: 1/1/2023
- Measurement of Serum 1,25-dihydroxyvitamin D (PDF) Effective Date: 1/1/2023
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) Effective Date: 1/1/2023
- Multiple Sleep Latency Testing (PDF) Effective Date: 1/1/2023
- Neonatal Abstinence Syndrome Guidelines (PDF) Effective Date: 1/1/2023
- Neonatal Sepsis Management (PDF) Effective Date: 1/1/2023
- Nerve Blocks for Pain Management (PDF) Effective Date: 1/1/2023
- Neuromuscular Electric al Stimulation (NMES) (PDF) Effective Date: 1/1/2023
- NICU Apnea Bradycardia Guidelines (PDF) Effective Date: 1/1/2023
- NICU Discharge Guidelines (PDF) Effective Date: 1/1/2023
- Non-Myeloablative Allogeneic Stem Cell Transplants (PDF) Effective Date: 1/1/2023
- Obstetrical Home Health Care Programs (PDF) Effective Date: 1/1/2023
- Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF) Effective Date: 1/1/2023
- Optic Nerve Decompression Surgery (PDF) Effective Date: 1/1/2023
- Orthognathic Surgery (PDF) Effective Date: 1/1/2023
- Osteogenic Stimulation (PDF) Effective Date: 1/1/2023
- Outpatient Cardiac Rehabilitation (PDF) Effective Date: 1/1/2023
- Oxygen Use and Concentrators (PDF) Effective Date: 1/1/2023
- Pancreas Transplant (PDF) Effective Date: 1/1/2023
- Panniculectomy (PDF) Effective Date: 1/1/2023
- Pediatric Heart Transplant (PDF) Effective Date: 1/1/2023
- Pediatric Liver Transplant (PDF) Effective Date: 1/1/2023
- Pediatric Oral Function Therapy (PDF) Effective Date: 1/1/2023
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) Effective Date: 1/1/2023
- Phototherapy for Neonatal Hyperbilirubinemia (PDF) Effective Date: 1/1/2023
- Physical, Occupational, and Speech Therapy Services (PDF) Effective Date: 1/1/2023
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) Effective Date: 1/1/2023
- Post-Acute Care (PDF) Effective Date: 1/1/2023
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) Effective Date: 1/1/2023
- Proton and Neutron Beam Therapies (PDF) Effective Date: 1/1/2023
- Pulmonary Function Testing (PDF) Effective Date: 1/1/2023
- Radial Head Implant (PDF) Effective Date: 1/1/2023
- Radiofrequency Ablation of Uterine Fibroids (PDF) Effective Date: 1/1/2023
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) Effective Date: 1/1/2023
- Repair of Nasal Valve Compromise (PDF) Effective Date: 1/1/2023
- Sacroiliac Joint Fusion (PDF) Effective Date: 1/1/2023
- Sacroiliac Joint Interventions for Pain Management (PDF) Effective Date: 1/1/2023
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF) Effective Date: 1/1/2023
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) Effective Date: 1/1/2023
- Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF) Effective Date: 1/1/2023
- Short Inpatient Hospital Stay (PDF) Effective Date: 1/1/2023
- Skilled Nursing Facility Leveling (PDF) Effective Date: 1/1/2023
- Skin Substitutes for Chronic Wounds (PDF) Effective Date: 1/1/2023
- Spinal Cord Stimulation (PDF) Effective Date: 1/1/2023
- Stereotactic Body Radiation Therapy (PDF) Effective Date: 1/1/2023
- Substance Use Disorders Treatment and Services (PDF) Effective Date: 1/1/2023
- Tandem Transplant (PDF) Effective Date: 1/1/2023
- Testing for Select Genitourinary Conditions (PDF) Effective Date: 1/1/2023
- Thyroid Hormones and Insulin Testing in Pediatrics (PDF) Effective Date: 1/1/2023
- Total Artificial Heart (PDF) Effective Date: 1/1/2023
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) Effective Date: 1/1/2023
- Transcatheter Closure of Patent Foramen Ovale (PDF) Effective Date: 1/1/2023
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF) Effective Date: 1/1/2023
- Trigger Point Injections for Pain Management (PDF) Effective Date: 1/1/2023
- Ultrasound in Pregnancy (PDF) Effective Date: 1/1/2023
- Urinary Incontinence Devices and Treatments (PDF) Effective Date: 1/1/2023
- Urodynamic Testing (PDF) Effective Date: 1/1/2023
- Vagus Nerve Stimulation (PDF) Effective Date: 1/1/2023
- Ventricular Assist Devices (PDF) Effective Date: 1/1/2023
- Wheelchair Seating (PDF) Effective Date: 1/1/2023
- Wireless Motility Capsule (PDF) Effective Date: 1/1/2023
- 25-hydroxyvitamin D Testing in Children and Adolescents (PDF) Effective Date: 1/1/2023
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 Alabama Payment Policy Manual apply with respect to Ambetter of Alabama members. Policies in the Ambetter of Alabama Payment Policy Manual may have either a Ambetter of Alabama or a “Centene” heading. In addition, Ambetter of Alabama 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 Alabama.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.