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Clinical Payment Policies | Ambetter from Arizona Complete Health
Clinical & Payment Policies
Clinical Policies
Important Notice
The Clinical Policies do not constitute medical advice. 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 Clinical Policy Manual apply to health plan members. The health plan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which health plan clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. In addition, the health plan 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 the health plan.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine. The health plan reserves the right to amend the Policies without notice to providers or Members.
Policies specifically developed to assist the health plan in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other health plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.
The Clinical Policy Manuals may be accessed through the links below.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
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 Arizona Complete Health Payment Policy Manual apply with respect to Arizona Complete Health members. Policies in the Arizona Complete Health Payment Policy Manual may have either a Arizona Complete Health or a “Centene” heading. In addition, Arizona Complete Health 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 Arizona Complete Health.
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) - (Medicaid, Medicare)
- 30 Day Readmission (PDF) - (Medicare, Marketplace)
- 340B Drug Payment Reduction (PDF) - (Medicare, Marketplace)
- Add on Code Billed Without Primary Code (PDF) - (Medicaid, Medicare, Marketplace)
- Assistant Surgeon (PDF) (PDF) - (Medicaid, Medicare, Marketplace)
- Bevacizumab (PDF) - (Medicaid, Medicare)
- Bilateral Procedured (PDF) - (Medicaid, Medicare, Marketplace)
- Cerumen Removal (PDF) - (Medicaid, Medicare, Marketplace)
- Coding Overview (PDF) - (Medicaid, Medicare, Marketplace)
- Distinct Procedural Modifiers (PDF) - (Medicaid, Medicare, Marketplace)
- Duplicate Primary Code Billing (PDF) - (Medicaid, Medicare, Marketplace)
- E&M Medical Decision-Making (PDF) - (Medicaid)
- E&M Services Billed with Treatment Room Revenue Codes (PDF) - (Marketplace)
- EEG in the Evaluation of Headache (PDF)
- Emergency Department (ED) Evaluation and Management (E&M) Coding for Facility Claims (PDF) - (Medicaid, Medicare, Marketplace)
- Flexible Provider Matching (PDF) - (Medicare)
- Fundus Photography (PDF) - (Medicaid, Marketplace)
- Global Maternity Billing (PDF) - (Medicaid, Medicare, Marketplace)
- Inpatient Consultation (PDF)- (Medicaid, Medicare, Marketplace)
- Inpatient Only Procedures (PDF) - (Medicaid, Medicare, Marketplace)
- IV Hydration (PDF) - (Medicaid, Medicare, Marketplace)
- Leveling of ER Services (PDF) - (Medicaid, Medicare, Marketplace)
- Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
- Moderate Conscious Sedation (PDF) - (Medicaid, Medicare)
- Modifier 25 clinical validation (PDF) - (Medicaid, Medicare, Marketplace)
- Modifier 59 clinical validation (PDF) - (Medicaid, Medicare, Marketplace)
- Modifier to Procedure Code Validation (PDF) - (Medicaid, Medicare, Marketplace)
- Multiple Procedure Reduction Ophthalology (PDF) - (Medicaid, Medicare, Marketplace)
- Multiple Procedure Payment Reduction for Therapeutic Services (PDF) - (Medicaid, Medicare, Marketplace)
- Never Paid Events (PDF) - (Medicaid, Medicare, Marketplace)
- New Patient (PDF) - (Medicaid, Medicare, Marketplace)
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF) - (Medicaid, Medicare, Marketplace)
- Not Medically Necessary Inpatient Services (PDF) - (Medicaid, Medicare, Marketplace)
- Outpatient Consultation (PDF) - (Medicaid, Medicare, Marketplace)
- Paclitaxel (PDF) - (Medicaid, Medicare)
- Physician Visit Codes Billed with Labs (PDF) - (Medicaid, Medicare, Marketplace)
- Physician's Consultation Services (PDF) - (Medicaid, Medicare, Marketplace)
- Physician's Office Lab Testing (PDF) - (Medicaid, Medicare, Marketplace)
- Place of Service Mismatch (PDF) - (Medicaid, Medicare, Marketplace)
- Post-Operative Visits (PDF) - (Medicaid, Medicare, Marketplace)
- Pre-Operative Visits (PDF) - (Medicaid, Medicare, Marketplace)
- Problem Oriented Visits with Preventative Visits (PDF) - (Medicaid, Medicare, Marketplace)
- Problem Oriented Visits with Surgical Procedures (PDF) - (Medicaid, Medicare, Marketplace)
- Professional Component (PDF) - (Medicaid, Medicare, Marketplace)
- Pulmonary Function Testing (PDF)
- Pulse Oximetry (PDF) - (Medicaid, Medicare, Marketplace)
- Rituximab (PDF) - (Medicaid, Medicare)
- Robotic Surgery (PDF) - (Medicaid)
- Same Day Visits (PDF) - (Medicaid, Medicare, Marketplace)
- Sepsis Diagnosis (PDF) - (Medicaid, Medicare, Marketplace)
- Skilled Nursing Facility Leveling (CC.PP.206) (PDF) - Effective Date 6/26/24
- Sleep Studies Place of Services (PDF) - (Medicaid, Medicare)
- Status "B" Bundled Services (PDF) - (Medicaid, Medicare, Marketplace)
- Status P Bundled Services (PDF) - (Medicaid, Medicare)
- Supplies Billed on Same Day As Surgery (PDF) - (Medicaid, Medicare, Marketplace)
- Ultrasound in Pregnancy (PDF)
- Unbundled Professional Services (PDF) - (Medicaid, Medicare, Marketplace)
- Unbundled Surgical Procedures (PDF) - (Medicaid, Medicare, Marketplace)
- Unlisted Procedure Codes (PDF) - (Medicaid, Medicare, Marketplace)
- Urine Specimen Validity Testing (PDF) - (Medicaid)