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 Absolute Total Care Clinical Policy Manual apply to Absolute Total Care members. Policies in the Absolute Total Care Clinical Policy Manual may have either an Absolute Total Care or a “Centene” heading. Absolute Total Care utilizes InterQual® criteria for those medical technologies, procedures, or pharmaceutical treatments for which an Absolute Total Care 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 in to the Secure Provider Portal or by calling Absolute Total Care.

In addition, Absolute Total Care 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 Absolute Total Care.   

If you have any questions regarding these policies, please contact Provider Services at 1-866-433-6041 and ask to be directed to the Medical Management Department.

A-H I-Q R-Z
25-Hydroxyvitamin D Testing (PDF) Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) Radial Head Implant (PDF)
Acupuncture (PDF)
Inhaled Nitric Oxide (PDF)
Reduction Mammoplasty and Gynecomastia Surgery (PDF)
ADHD Assessment and Treatment (PDF)

Intensity-Modulated Radiotherapy (PDF)

Sacroiliac Joint Fusion (PDF)
Allergy Testing and Therapy (PDF) Intestinal and multivisceral transplant (PDF)
Sacroiliac Joint Interventions for Pain Management (PDF)
Allogeneic Hematopoietic Cell Transplants (PDF)
Intradiscal Steroid Injections for Pain Management (PDF)
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF)
Ambulatory EEG (PDF)
Laser Skin Treatment (PDF)
Sclerotherapy for Varicose Veins (PDF)
Ambulatory Surgery Center Optimization (PDF)
Long-Term Care Placement Criteria (PDF)
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Applied Behavioral Analysis for Autism (PDF)
Low-Frequency Ultrasound Wound Therapy (PDF)
Short Inpatient Hospital Stay (PDF)
Articular Cartilage Defect Repairs (PDF)
Lung Transplantation (PDF)
Sickle Cell Disease Observation (PDF)
Assisted Reproductive Technology (PDF)
Lysis of Epidural Lesions (PDF)
Spinal Cord Stimulation (PDF)
Balloon Sinus Ostial Dilation (PDF)
Measure Serum 1,25 Vitamin D (PDF)
Stereotactic Body Radiation Therapy (PDF)
Bariatric Surgery (PDF)
Mechanical Stretch Devices (PDF)

Tandem Transplant (PDF)
Biofeedback (PDF)
Medical Necessity Criteria (PDF)
Testing for Rupture of Fetal Membranes (PDF)
Bone-anchored Hearing Aid (PDF)
Multiple Sleep Latency Testing (PDF) Testing for Select Genitourinary Conditions (PDF)
Bronchial Thermoplasty (PDF)
Neonatal Abstinence Syndrome Guidelines (PDF) Therapy Services (PTOTST) (PDF)
Cardiac Biomarker Testing for Acute MI (PDF)
Neonatal Sepsis Management Guidelines (PDF) Thyroid Testing in Pediatrics (PDF)
Carrier Screening in Pregnancy (PDF)
Nerve Blocks for Pain Management (PDF) Total Artificial Heart (PDF)
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)
NICU Apnea Bradycardia Guidelines (PDF) Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Cell-free Fetal DNA Testing (PDF)
NICU Discharge Guidelines (PDF) Transcatheter Closure of Patent Foramen Ovale (PFO) (PDF)
Clinical Trials (PDF)
Nonmyeloablative allogeneic stem cell transplant (PDF) Transcranial Magnetic Stimulation (PDF)
Cochlear Implant Replacements (PDF)
OB Home Health Programs (PDF) Trigger Point Ingections for Pain Management (PDF)
Cosmetic and Reconstructive Surgery (PDF)
Optic Nerve Decompression Surgery (PDF) Ultrasound in Pregnancy (PDF)
Dental Anesthesia (PDF)
Outpatient Testing for Drugs of Abuse (PDF) Urinary Incontinence Devices and Treatments (PDF)
Diagnosis of Vaginitis (PDF)
Paclitaxel, Protein-Bound (Abraxane) (PDF) Urodynamic Testing (PDF)
Digital Analysis of EEGs (PDF)
Pancreas Transplantation (PDF) Vagus Nerve Stimulation (PDF)
Disc Decompression Procedures (PDF)
Panniculectomy (PDF) Ventricular Assist Devices (PDF)
Discography (PDF)
Pediatric Heart Transplant (PDF) Ventriculectomy and Cardiomyoplasty (PDF)
DNA Analysis of Stool (PDF)
Pediatric Liver Transplant (PDF) Visual Field Testing (PDF)
Donor Lymphocyte Infusion (PDF)
Percutaneous LAAD Stroke Prevention (PDF) Vitamin D Testing in Children (PDF)
Durable Medical Equipment (DME) (PDF)
Posterior Nerve Stimulation for Voiding Dysfunction (PDF) Wheelchair Seating (PDF)
EEG in Evaluation of Headache (PDF)
Preventive Health and Clinical Practice Guideline Policy (PDF) Wireless Motility Capsule (PDF)
Electric Tumor Treating Fields (PDF)
PROM Testing (PDF) Zika Virus Testing (PDF)
Endometrial Ablation (EA) (PDF)
Proton and Neutron Beam Therapy (PDF)  
EpiFix Wound Treatment (PDF)
   
Essure Removal (PDF)
   
Evoked Potential Testing (PDF)
   
Experimental Technologies (PDF)
   
Extended Opthalmoscopy (PDF)    
External Ocular Photography (PDF)    
Facet Joint Interventions for Pain Management (PDF)
   
Fecal Calprotectin Assay (PDF)
   
Fecal Incontinence Treatments (PDF)
   
Ferriscan R2-MRI (PDF)
   
Fertility Preservation (PDF)
   
Fetal Surgery In Utero (PDF)
   
FeNo Testing (PDF)
   
Fluorescein Angiography (PDF)    
Functional MRI (PDF)    
Fundus Photography (PDF)    
Gastric Electrical Stimulation (PDF)
   
Gender Reassignment Surgery (PDF)
   
Genetic Testing (PDF)
   
Gonioscopy (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)
   
Hyperbaric Oxygen Therapy (PDF)
   
Hyperemesis Gravidarum Treatment (PDF)
   
Hyperhidrosis Treatments (PDF)
   

Payment Policies

Healthcare 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 healthcare 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 healthcare and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Absolute Total Care Payment Policy Manual apply with respect to Absolute Total Care members. Policies in the Absolute Total Care Payment Policy Manual may have either an Absolute Total Care or a “Centene” heading. In addition, Absolute Total Care 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 Absolute Total Care.     

If you have any questions regarding these policies, please contact Provider Services at 1-866-433-6041 and ask to be directed to the Medical Management Department.

A-H I-Q R-Z
30-Day Readmission (PDF) Inpatient Consultation (PDF) Robotic Surgery (PDF)
Add on Code Billed Without Primary Code (PDF)
Inpatient Only Procedures (PDF) Review of Acute Care Readmissions within 30 Calendar Days (PDF)
Assistant Surgeon (PDF) IV Hydration (PDF) Same Day Visits (PDF)
Bilateral Procedures (PDF) Lab Quantity Limits (PDF) Sleep Studies Place of Service (PDF)
Cerumen Removal (PDF) Maximum Units (PDF) Status "B" Bundled Services (PDF)
Code Editing Overview (PDF) Modifier -25 clinical validation Status "P" Bundled Services (PDF)
Cosmetic Procedures (PDF) Modifier -59 clinical validation (PDF) Supplies Billed on Same Day as Surgery (PDF)
Distinct Procedural Modifiers (PDF) Modifier DOS Validation (PDF) Transgender Related Services (PDF)
Duplicate Primary Code Billing (PDF) Modifier to Procedure Code Validation (PDF) Unbundled Professional Services (PDF)
EM Bundling Edits (PDF)

Multiple CPT Code Replacement (PDF)

Unbundled Surgical Procedures (PDF)
Global Maternity Billing (PDF) Multiple Procedure Payment Reduction for Diagnostic Cardiovascular Procedures (PDF) Unlisted Procedure Codes (PDF)
Hospital Visit Codes Billed with Labs (PDF) NCCI Unbundling (PDF) Urine Specimen Validity Testing (PDF)
  Never Paid Events (PDF) Wheelchair Accessories (PDF)
  New Patient (PDF)  
  Non-Emergent ER Services (PDF)  
  Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)  
  Outpatient Consultation (PDF)  
  Physician's Consultation Services (PDF)  
  Physician's Office Lab Testing (PDF)  
  Physician Visit Codes Billed with Labs (PDF)  
  Place of Service Mismatch (PDF)  
  Post-Operative Visits (PDF)  
  Pre-Operative Visits (PDF)  
  Professional Component (PDF)  
  Problem-Oriented Visits with Preventative Visits (PDF)  
  Problem-Oriented Visits with Surgical Procedures (PDF)  
  Pulse Oximetry (PDF)