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)
- Air Ambulance (PDF)
- Allergy Testing and Therapy (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)
- Applied Behavior Analysis (PDF)
- Articular Cartilage Defect Repairs (PDF)
- Assisted Reproductive Technology (PDF)
- Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)
- Bariatric Surgery (PDF)
- Behavioral Health Treatment Documentation Requirements (PDF)
- Biofeedback (PDF)
- Biofeedback for Behavioral Health Disorders (PDF)
- Bone-Anchored Hearing Aid (PDF)
- Bronchial Thermoplasty (PDF)
- Burn Surgery (PDF)
- Cardiac Biomarker Testing (PDF)
- Caudal or Interlaminar Epidural Steroid Injections (PDF)
- Clinical Practice and Preventive Health Guidelines (CPG Grid) (PDF)
- Clinical Trials (PDF)
- Cochlear Implant Replacements (PDF)
- Concert Genetics Oncology: Algorithmic Testing (PDF)
- Concert Genetics Oncology: Cancer Screening (PDF)
- Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)
- Concert Genetics Oncology: Cytogenetic Testing (PDF)
- Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)
- Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)
- Concert Genetic Testing: Cardiac Disorders (PDF)
- Concert Genetic Testing: Dermatologic Conditions (PDF)
- Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)
- Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)
- Concert Genetic Testing: Eye Disorders (PDF)
- Concert Genetic Testing: Gastroenterologic Disorders (non cancerous) (PDF)
- Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)
- Concert Genetic Testing: Hearing Loss (PDF)
- Concert Genetic Testing: Hematologic Conditions (non cancerous) (PDF)
- Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)
- Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)
- Concert Genetic Testing: Kidney Disorders (PDF)
- Concert Genetic Testing: Lung Disorders (PDF)
- Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)
- Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)
- Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS) (PDF)
- Concert Genetic Testing: Pharmacogenetics (PDF)
- Concert Genetic Testing: Preimplantation Genetic Testing (PDF)
- Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)
- Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)
- Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)
- Cosmetic and Reconstructive Procedures (PDF)
- Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF)
- Digital Electroencephalography Spike Analysis (PDF)
- Disc Decompression Procedures (PDF)
- Discography (PDF)
- Donor Lymphocyte Infusion (PDF)
- Drugs of Abuse, Definitive Testing (PDF)
- Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)
- Electroencephalography in the Evaluation of Headache (PDF)
- Electric Tumor Treating Fields (Optune) (PDF)
- Endometrial Ablation (PDF)
- Evoked Potential Testing (PDF)
- Experimental Technologies (PDF)
- Facet Joint Interventions (PDF)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)
- Fecal Incontinence Treatments (PDF)
- Ferriscan R2-MRI (PDF)
- Fertility Preservation (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)
- Functional MRI (PDF)
- Gastric Electrical Stimulation (PDF)
- Gender-Affirming Procedures (PDF)
- GI Pathogen Nucleic Acid Detection Panel Testing (PDF)
- Heart-Lung Transplant (PDF)
- Home Birth (PDF)
- Home Ventilators (PDF)
- H. Pylori Serology Testing (PDF)
- Holter Monitors (PDF)
- Homocysteine Testing (PDF)
- Hospice Services (PDF)
- Hyperhidrosis Treatments (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)
- Implantable Intrathecal Pain Pump (PDF)
- Implantable Loop Recorder (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
- Inhaled Nitric Oxide (PDF)
- Intensity-Modulated Radiotherapy (PDF)
- Intestinal and Multivisceral Transplant (PDF)
- Intradiscal Steroid Injections for Pain Management (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)
- Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy (PDF)
- Laser Therapy for Skin Conditions (PDF)
- Liposuction for Lipedema (PDF)
- Long Term Care Placement Criteria (PDF)
- Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)
- Lung Transplantation (PDF)
- Lysis of Epidural Lesions (PDF)
- Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
- Multiple Sleep Latency Testing (PDF)
- Neonatal Abstinence Syndrome Guidelines (PDF)
- Neonatal Sepsis Management (PDF)
- Nerve Blocks and Neurolysis for Pain Management (PDF)
- Neuromuscular and Peroneal Never Electrical Stimulation (NMES) (PDF)
- NICU Apnea Bradycardia Guidelines (PDF)
- NICU Discharge Guidelines (PDF)
- Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)
- Obstetrical Home Care Programs (PDF)
- Omisirge (omidubicel): Nicotinamide-modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)
- Orthognathic Surgery (PDF)
- Osteogenic Stimulation (PDF)
- Outpatient Cardiac Rehabilitation (PDF)
- Outpatient Oxygen Use (PDF)
- Pancreas Transplantation (PDF)
- Panniculectomy (PDF)
- Pediatric Heart Transplant (PDF)
- Pediatric Kidney Transplant (PDF)
- Pediatric Liver Transplant (PDF)
- Pediatric Oral Function Therapy (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF
- Phototherapy for Neonatal Hyperbilirubinemia (PDF)
- Physical, Occupational, and Speech Therapy Services (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
- Proton and Neutron Beam Therapies (PDF)
- Pulmonary Function Testing (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF)
- Repair of Nasal Valve Compromise (PDF)
- Sacroiliac Joint Fusion (PDF)
- Sacroiliac Joint Interventions for Pain Management (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
- Short Inpatient Hospital Stay (PDF)
- Skin Substitutes for Chronic Wounds (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)
- Stereotactic Body Radiation Therapy (PDF)
- Tandem Transplant (PDF)
- Testing for Select Genitourinary Conditions (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
- Total Artificial Heart (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
- Transcatheter Closure of Patent Foramen Ovale (PDF)
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)
- Transplant Service Documentation Requirements (PDF)
- Trigger Point Injections for Pain Management (PDF)
- Urinary Incontinence Devices and Treatments (PDF)
- Urodynamic Testing (PDF)
- Vagus Nerve Stimulation (PDF)
- Ventricular Assist Devices (PDF)
- Wheelchair Seating (PDF)
- Wireless Motility Capsule (PDF)
- 25-hydroxyvitamin D Testing in Children and Adolescents (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 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.
- 3 Day Payment Window (PDF) Effective Date: 6/1/2023
- 30 Day Readmission (PDF) Effective Date: 1/1/2024
- Add on Code Billed Without Primary Code (PDF) Effective Date: 1/1/2013
- Assistant Surgeon (PDF) Effective Date: 1/1/2014
- Bilateral Procedures (PDF) Effective Date: 1/1/2014
- Coding Overview (PDF) Effective Date: 1/1/2013
- Cosmetic Procedures (PDF) Effective Date: 1/1/2014
- Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF) Effective Date: 1/1/2013
- E/M Bundling with Labs and Radiology (PDF) Effective Date: 1/1/2013
- E&M Services Billed with Treatment Room Revenue Codes (PDF) Effective Date: 1/1/23
- Evaluation and Management Services Billed with Treatment Rooms (PDF) Effective Date: 6/1/2023
- Extended Ophthalmoscopy (PDF) Effective Date: 6/1/2023
- External Ocular Photography (PDF) Effective Date: 6/1/2023
- Fundus Photography (PDF) Effective Date: 6/1/2023
- Gonioscopy (PDF) Effective Date: 6/1/2023
- Inpatient Consultation (PDF) Effective Date: 1/1/2014
- Inpatient Only Procedures (PDF) Effective Date: 12/1/22
- Modifier DOS Validation (PDF) Effective Date: 1/1/2013
- Modifier to Procedure Code Validation (PDF) Effective Date: 1/1/2013
- Multiple CPT Codes Replacement (PDF) Effective Date: 1/1/2014
- Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) Effective Date: 6/1/2023
- Multiple Procedure Payment Reduction for Therapeutic Services (PDF) Effective Date: 6/1/2023
- Multiple Procedure Reduction: Ophthalmology (PDF) Effective Date: 6/1/2023
- NCCI Unbundling (PDF) Effective Date: 12/1/22
- New Patient (PDF) Effective Date: 1/1/2014
- Non-Obstetrical and OB Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: 6/1/2023
- Outpatient Consultations (PDF) Effective Date: 1/1/2014
- Paclitaxel Protein Bound (PDF) Effective Date: 6/1/2023
- Physician's Consultation Services (PDF) Effective Date: 1/1/2024
- Place of Service Mismatch (PDF) Effective Date: 9/1/2018
- Postoperative Visits (PDF) Effective Date: 1/1/2014
- Preoperative Visits (PDF) Effective Date: 1/1/2014
- Problem-Oriented Visits with Surgical Procedures (PDF) Effective Date: 1/1/2024
- Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF) Effective Date: 6/1/2023
- Skilled Nursing Facility Leveling (PDF)
- Sleep Studies Place of Service (PDF) Effective Date: 6/1/2023
- Status "B" Bundled Services (PDF) Effective Date: 1/1/2014
- Status "P" Bundled Services (PDF) Effective Date: 3/15/2017
- Supplies Billed on Same Day As Surgery (PDF) Effective Date: 1/1/2013
- Ultrasound in Pregnancy (PDF)
- Urine Specimen Validity Testing (PDF) Effective Date: 6/1/2023
- Visits on Same Day as Surgery (PDF) Effective Date: 12/1/2022
- Visual Field Testing (PDF) Effective Date: 6/1/2023
- Wheelchair Accessories (PDF) Effective Date: 6/1/2023
- Fluorescein Angiography (PDF) Effective Date: 6/1/2023