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

A-GH-OP-Z
Allergy Testing and Therapy (PDF)
Effective Date: 9/21/2021

 

Helicobacter Pylori (H.pylori) Serology Testing (PDF)
Effective Date: 9/1/2022

 

Paclitaxel, Protein-Bound (Abraxane) (PDF)
Effective Date: 5/1/2021
ADHD Assessment and Treatment (PDF)
Last Review Date: 5/21/2021

 

Holter Monitors (PDF)
Last Review Date: 4/1/2023

 

Scanning Computerized Opthalmic Diagnostic Imaging (PDF)
Effective Date: 4/2/2022
Ambulatory EEG (PDF)
Last Review Date: 8/2019

 

Homocysteine Testing (PDF)
Effective Date: 3/1/2023

 

Testing for Rupture of Fetal Membranes (PDF)
Effective Date: 4/1/2022
Bronchial Thermoplasty (PDF)
Effective Date: 4/7/2021
Laser Therapy for Skin Conditions (PDF)
Effective Date: 4/7/2021
Testing for Select Genitourinary Conditions (PDF)
Effective Date: 7/1/2021
Cardiac Biomarker Testing (PDF)
Effective Date: 1/1/2021
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: 10/1/2021
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: 4/7/2021
Clinical Trials (PDF)
Effective Date: 9/1/2022
Outpatient Testing for Drugs of Abuse (PDF)
Effective Date: 4/1/2022
Ultrasound in Pregnancy (PDF)
Effective Date: 6/1/2021
Digital EEG Spike Analysis (PDF)
Effective Date: 4/7/2021
 Urodynamic Testing (PDF)
Effective Date: 4/7/2021
EEG in the Evaluation of Headache (PDF)
Effective Date: 6/21/2021
 Visual Field Testing (PDF)
Effective Date: 4/1/2022
Endometrial Ablation (PDF)
Effective Date: 4/1/2022
 25-hydroxyvitamin D Testing in Children and Adolescents (PDF)
Effective Date: 4/7/2021
Evoked Potential Testing (PDF)
Effective Date: 8/21/2021
 Wheelchair Seating (PDF)
Effective Date: 4/7/2021
Extended Ophthalmoscopy (PDF)
Effective Date: 4/1/2022
 Wireless Motility Capsule (PDF)
Effective Date: 4/7/2021
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
  
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
Effective Date: 8/1/2022
  

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 Ambetter from Meridian Payment Policy Manual apply with respect to Ambetter from Meridian members. Policies in the Ambetter from Meridian Payment Policy Manual may have either a Ambetter from Meridian or a “Centene” heading.  In addition, Ambetter from Meridian 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 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.