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Clinical & Payment Policies | Ambetter de NH Healthy Families
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 NH Healthy Families Clinical Policy Manual apply to NH Healthy Families members. Policies in the NH Healthy Families Clinical Policy Manual may have either a NH Healthy Families or a “Centene” heading. NH Healthy Families utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a NH Healthy Families 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 NH Healthy Families. In addition, NH Healthy Families 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 NH Healthy Families.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- Applied Behavioral Analysis (PDF)
Effective Date: 1/1/2018 - ADHD Assessment and Treatment (PDF)
Effective Date: 1/1/2019 - Allergy Testing (PDF)
Effective Date: 1/1/2018 - Ambulatory EEG (PDF)
Effective Date: 9/1/2017 - Bariatric Surgery Policy (PDF)
Effective Date: 6/1/2009 - Biofeedback (PDF)
Effective Date: 5/1/2019 - Bronchial Thermoplasty (PDF)
Effective Date: 3/1/2018 - Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 3/1/2018 - Caudal or Interlaminar Epidural Steroid Injections (PDF)
Effective Date: 8/1/2019 - Dental Anesthesia & Facility Policy (PDF)
Effective Date: 9/1/2018 - Diagnosis of Vaginitis (PDF)
Effective Date: 9/1/2017 - Digital Analysis of EEGs (PDF)
Effective Date: 1/1/2018 - DNA Analysis of Stool (PDF)
Effective Date: 9/1/2017 - EEG in Evaluation of Headache (PDF)
Effective Date: 12/1/2017 - Endometrial Ablation (PDF)
Effective Date: 9/1/2017 - Enteral Nutrition Policy (PDF)
Effective Date: 6/1/2017 - EpiFix Wound Treatment (PDF)
Effective Date: 1/1/2018 - Evoked Potentials (PDF)
Effective Date: 11/1/2017 - Facet Joint Interventions (PDF)
Effective Date: 7/1/2019 - Fecal Calprotectin Assay (PDF) RETIRED 1/25/2019
Effective Date: 11/1/2017 - FeNo Testing (PDF)
Effective Date: 1/1/2018 - H Pylori Testing (PDF)
Effective Date: 12/1/2017 - Holter Monitors (PDF)
Effective Date: 6/1/2018 - Home Health Policy (PDF)
Effective Date: 9/15/2018 - Homocysteine Testing (PDF)
Effective Date: 8/1/2017
- Intradiscal Steroid Injections for Pain Management (PDF)
Effective Date: 8/1/2019 - Laser Skin Treatment (PDF)
Effective Date: 6/1/2009 - Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/2018 - Measure Serum 1, 25 Vitamin D (PDF)
Effective Date: 12/1/2017 - Mechanical Stretch Devices (PDF)
Effective Date: 1/1/2019 - Medical Policy Adoption Policy (PDF)
Effective Date: 3/15/2018 - Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
Effective Date: 5/1/2018
RETIRED: 9/1/2019 - Nerve Blocks fo Pain Management (PDF)
Effective Date: 8/1/2019 - Outpatient Testing for Drugs of Abuse (PDF)
Effective Date: 7/1/2018 - PROM Testing (PDF)
Effective Date: 8/1/2017 - PROM Testing (PDF)
Effective Date: 1/15/2020 - Proton and Neutron Beam Testing (PDF)
Effective Date: 2/1/2018
- Respiratory Viral Panel Testing (PDF)
Effective Date: 12/01/2020 - Sacroiliac Joint Interventions for Pain Management (PDF)
Effective Date: 8/1/2019 - Selective Dorsal Rhizotomy (PDF)
Effective Date: 3/1/2019 - Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
Effective Date: 8/1/2019 - Thyroid Testing in Pediatrics (PDF)
Effective Date: 12/1/2017 - Trigger Point Injections for Pain Management (PDF)
Effective Date: 8/1/2019 - Ultrasound in Pregnancy (PDF)
Effective Date: 8/1/2017 - Urodynamic Testing (PDF)
Effective Date: 10/1/2017 - Vitamin D Testing in Children (PDF)
Effective Date: 12/1/2017 - Wheelchair Seating (PDF)
Effective Date: 10/1/2017 - Wireless Motility Capsule (PDF)
Effective Date: 3/1/2018
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 NH Healthy Families Payment Policy Manual apply with respect to NH Healthy Families members. Policies in the NH Healthy Families Payment Policy Manual may have either a NH Healthy Families or a “Centene” heading. In addition, NH Healthy Families 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 NH Healthy Families.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- 30-Day Readmission (PDF)
Effective Date: 1/1/2015 - 3-Day Payment Window (PDF)
Effective Date: 3/1/2018 - 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 - Cerumen Removal (PDF)
Effective Date: 1/1/2014 - Clean Claims (PDF)
Effective Date: 1/1/2013 - CLIA Number (PDF)
Effective Date: 1/1/2013 - Coding Overview (PDF)
Effective Date: 1/1/2013 - Cosmetic Procedures (PDF)
Effective Date: 1/1/2014 - Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/2013 - Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/2014 - E&M Medical Decision-Making (PDF)
Effective Date: 1/1/2017 - EM Bundling Kits (PDF)
Effective Date: 1/1/2013 - Global Maternity Billing (PDF)
Effective Date: 1/1/2013 - Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013
- Inpatient Consultation (PDF)
Effective Date: 1/1/2014 - Inpatient Only Procedures (PDF)
Effective Date: 1/1/2013 - IV Hydration (PDF)
Effective Date: 1/1/2013 - Leveling of Care Policy (PDF)
Effective Date: 7/1/2019 - Maximum Units (PDF)
Effective Date: 1/1/2013 - Moderate Conscious Sedation (PDF)
Effective Date: 1/1/2013 - Modifier-25 Clinical Validation (PDF)
Effective Date: 1/1/2013 - Modifier-59 Clinical Validation (PDF)
Effective Date: 1/1/2013 - Modifier DOS Validation (PDF)
Effective Date: 1/1/2013 - Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/2013 - Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/2014 - Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)
Effective Date: 10/1/2020 - Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective Date: 2/15/2021 - NCCI Unbundling (PDF)
Effective Date: 1/1/2013 - Never Paid Events (PDF)
Effective Date: 1/1/2013 - New Patient (PDF)
Effective Date: 1/1/2014 - Outpatient Consultation (PDF)
Effective Date: 1/1/2014 - Outpatient Testing for Drugs of Abuse (PDF)
Effective Date: 5/1/2019 - Physician Consultation Services (PDF)
Effective Date: 9/1/2019 - Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013 - Post-Operative Visits (PDF)
Effective Date: 1/1/2014 - Pre-Operative Visits (PDF)
Effective Date: 1/1/2014 - Problem Oriented Visits Billed with Preventative Visits (PDF)
Effective Date: 1/15/2020 - Problem Oriented Visits Billed with Surgical Procedures (PDF)
Effective Date: 1/15/2020 - Professional Compenent (PDF)
Effective Date: 1/1/2013 - Pulse Oximetry (PDF)
Effective Date: 1/1/2014
- Robotic Surgery (PDF)
Effective Date: 8/1/2017 - Same Day Visits (PDF)
Effective Date: 3/1/2018 - Sleep Studies Place of Services (PDF)
Effective Date: 5/1/2017 - 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 - Telemedicine Services (PDF)
Effective Date: 9/18/2020 - Transgender Related Services (PDF)
Effective Date: 1/1/2017 - Unbundled Professional Services (PDF)
Effective Date: 1/1/2014 - Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/2014 - Unlisted Procedure Codes (PDF)
Effective Date: 1/1/2013 - Wheelchair Accessories (PDF)
Effective Date: 10/1/2015