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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.
- Air Ambulance (PDF)
- Applied Behavioral Analysis (PDF)
- ADHD Assessment and Treatment (PDF)
- Allergy Testing (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF)
- Ambulatory Surgery Center Optimization (PDF)
- Articular Cartilage Defect Repairs (PDF)
- Assisted Reproductive Technology (PDF)
- Bariatric Surgery (PDF)
- Biofeedback (PDF)
- Bone-Anchored Hearing Aid (PDF)
- Bronchial Thermoplasty (PDF)
- Burn Surgery (PDF)
- Cardiac Biomarker Testing for Acute MI (PDF)
- Caudal or Interlaminar Epidural Steroid Injections (PDF)
- Clinical Trials (PDF)
- Cochlear Implant Replacements (PDF)
- Cosmetic and Reconstructive Surgery (PDF)
- Dental Anesthesia (PDF)
- Diagnosis of Vaginitis (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF)
- Digital Analysis of EEGs (PDF)
- Disc Decompression Procedures (PDF)
- Discography (PDF)
- Donor Lymphocyte Infusion (PDF)
- Durable Medical Equipment (DME) (PDF)
- EEG in Evaluation of Headache (PDF)
- Electric Tumor Treating Fields (PDF)
- Endometrial Ablation (PDF)
- Enteral Nutrition Policy (PDF)
- Evoked Potential Testing (PDF)
- Experimental Technologies (PDF)
- Facet Joint Interventions (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)
- 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)
- Hyperemesis Gravidarum Treatment (PDF)
- Hyperhidrosis Treatments (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)
- Implantable Intrathecal Pain Pump (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)
- Laser Skin Treatment (PDF)
- Long Term Care Placement Criteria (PDF)
- Low-Frequency Ultrasound Wound Therapy (PDF)
- Lung Transplantation (PDF)
- Lysis of Epidural Lesions (PDF)
- Measure Serum 1, 25 Vitamin D (PDF)
- Mechanical Stretch Devices (PDF)
- Multiple Sleep Latency Testing (PDF)
- Neonatal Abstinence Syndrome Guidelines (PDF)
- Neonatal Sepsis Management (PDF)
- Nerve Blocks fo Pain Management (PDF)
- Neuromuscular Electrical Stimulation (NMES) (PDF)
- NICU Apnea Bradycardia Guidelines (PDF)
- NICU Discharge Guidelines (PDF)
- Non-Invasive Home Ventilators (PDF)
- Non-Myeloablative Allogeneic Stem Cell Transplants (PDF)
- Obstetrical Home Health Care Programs (PDF)
- Optic Nerve Decompression Surgery (PDF)
- Outpatient Cardiac Rehabilitation (PDF)
- Outpatient Testing for Drugs of Abuse (PDF)
- Oxygen Use and Concentrators (PDF)
- Pancreas Transplant (PDF)
- Panniculectomy (PDF)
- Pediatric Heart Transplant (PDF)
- Pediatric Liver Transplant (PDF)
- Pediatric Oral Function Therapy (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
- Physical, Occupational, and Speech Therapy Services (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
- Proton and Neutron Beam Testing (PDF)
- Pulmonary Function Testing (PDF)
- Radial Head Implant (PDF)
- Radiofrequency Ablation of Uterine Fibroids (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF)
- Repair of Nasal Valve Compromise (PDF)
- Respiratory Viral Panel Testing (PDF)
- Sacroiliac Joint Fusion (PDF)
- Sacroiliac Joint Interventions for Pain Management (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF)
- Selective Dorsal Rhizotomy (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
- Short Inpatient Hospital Stay (PDF)
- Skilled Nursing Facility Leveling (PDF)
- Skin Substitutes for Chronic Wounds (PDF)
- Spinal Cord Stimulation (PDF)
- Stereotactic Body Radiation Therapy (PDF)
- Tandem Transplant (PDF)
- Thyroid Testing in Pediatrics (PDF)
- Thymus Transplantation (PDF)
- Total Artificial Heart (PDF)
- Transcatheter Closure of Patent Foramen Ovale (PDF)
- Trigger Point Injections for Pain Management (PDF)
- Ultrasound in Pregnancy (PDF)
- Urinary Incontinence Devices and Treatments (PDF)
- Urodynamic Testing (PDF)
- Vagus Nerve Stimulation (PDF)
- Ventricular Assist Devices (PDF)
- Video Electroencephalographic Monitoring (PDF)
- Vitamin D Testing in Children (PDF)
- Wheelchair Seating (PDF)
- Wireless Motility Capsule (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 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 - Clean Claim Reviews (PDF)
Effective Date: 11/1/2022 - CLIA Number (PDF)
Effective Date: 1/1/2013 - Coding Overview (PDF)
Effective Date: 1/1/2013 - Cosmetic Procedures (PDF)
Effective Date: 1/1/2014 - Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: 9/1/2022 - 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: 6/1/2022 - 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 - Office Visits Billed with Treatment Rooms (PDF)
Effective Date: 5/1/2022 - Optum Comprehensive Payment Integrity (CPI) (PDF)
Effective Date: 4/1/2023 - 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 - Sepsis Diagnosis (PDF)
Effective Date: 3/1/2022 - 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 - Unbundling Adjustments on Clean Claim Reviews (PDF)
Effective Date: 9/1/2022 - Unlisted Procedure Codes (PDF)
Effective Date: 1/1/2013 - Wheelchair Accessories (PDF)
Effective Date: 10/1/2015