Clinical Payment Policies | Ambetter from Meridian


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 from Meridian Clinical Policy Manual apply to Ambetter from Meridian members. Policies in the Ambetter from Meridian Clinical Policy Manual may have either a Ambetter from Meridian or a “Centene” heading. Ambetter from Meridian utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter from Meridian 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 from Meridian. In addition, Ambetter from Meridian 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 from Meridian.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Clinical Policy List

3-Day Payment Window (PDF)
Effective Date: 7/01/2014
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: 10/1/2021
Paclitaxel, Protein-Bound (Abraxane) (PDF)
Effective Date: 5/1/2021
30 Day Readmission (PDF)
Effective Date: 1/01/2015
Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
Last Review Date: 8/23/2020
Physician’s Office Lab Testing (PDF)
Effective Date: 8/1/2021
Allergy Testing and Therapy (PDF)
Effective Date: 9/21/2021
Non-obstetrical and Obstetrical Transabdominal
and Transvaginal Ultrasounds  (PDF)

Effective Date: 4/1/2022
Renal Hemodialysis (PDF)
Effective Date: 4/1/2022
ADHD Assessment and Treatment (PDF)
Last Review Date: 5/21/2021
Outpatient Testing for Drugs of Abuse (PDF)
Effective Date: 4/1/2022
Scanning Computerized Opthalmic Diagnostic Imaging (PDF)
Effective Date: 4/2/2022
Ambulatory EEG (PDF)
Last Review Date: 8/2019
  Sleep Studies Place of Service (PDF)
Effective Date: 4/1/2022
Cardiac Biomarker Testing (PDF)
Effective Date: 1/1/2021
  Testing for Rupture of Fetal Membranes (PDF)
Effective Date: 4/1/2022
EEG in the Evaluation of Headache (PDF)
Effective Date: 6/21/2021
  Testing for Select Genitourinary Conditions (PDF)
Effective Date: 7/1/2021
Endometrial Ablation (PDF)
Effective Date: 4/1/2022
  Ultrasound in Pregnancy (PDF)
Effective Date: 6/1/2021
Evoked Potential Testing (PDF)
Effective Date: 8/21/2021
  Urine Specimen Validity Testing (PDF)
Effective Date: 4/1/2022
Extended Ophthalmoscopy (PDF)
Effective Date: 4/1/2022
  Visual Field Testing (PDF)
Effective Date: 4/1/2022
External Ocular
Photography (PDF)

Effective Date: 4/1/2022
Fluorescein Angiography (PDF)
Effective Date: 4/1/2022
Fractional Exhaled Nitric Oxide (PDF)
Effective Date: 11/1/2020
Fundus Photography (PDF)
Effective Date: 4/1/2022
Gonioscopy (PDF)
Effective Date: 4/1/2022