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 Nebraska Total Care Clinical Policy Manual apply to Ambetter from Nebraska Total Care members. Policies in the Ambetter from Nebraska Total Care Clinical Policy Manual may have either a Ambetter from Nebraska Total Care or a “Centene” heading. Ambetter from Nebraska Total Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter from Nebraska 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 into the secure provider portal or by calling Ambetter from Nebraska Total Care. In addition, Ambetter from Nebraska 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 Ambetter from Nebraska Total Care.   

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
Acupuncture (PDF)
Effective Date: 1/1/2022		Heart-Lung Transplant (PDF)
Effective Date: 1/1/2022		Pancreas transplant (PDF)
Effective Date: 1/1/2022
Air Ambulance (PDF)
Effective Date: 1/1/2022		Home Birth (PDF)
Effective Date: 1/1/2022		Panniculectomy (PDF)
Effective Date: 1/1/2022
Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF)
Effective Date: 1/1/2022		Home phototherapy for neonatal hyperbilirubinemia (PDF)
Effective Date: 1/1/2022		Pediatric heart transplant (PDF)
Effective Date: 1/1/2022
Ambulatory Surgery Center Optimization (PDF)
Effective Date: 1/1/2022		Hospice Services (PDF)
Effective Date: 1/1/2022		Pediatric Liver Transplant (PDF)
Effective Date: 1/1/2022
Antithrombin III (Thrombate III, Atryn) (PDF)
Effective Date: 1/1/2022		Hyperemesis gravidarum treatment (PDF)
Effective Date: 1/1/2022		Pediatric Oral Function Therapy (PDF)
Effective Date: 1/1/2022
Articular Cartilage Defect Repairs (PDF)
Effective Date: 1/1/2022		Hyperhidrosis treatments (PDF)
Effective Date: 1/1/2022		Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
Effective Date: 1/1/2022
Assisted Reproductive Technology (PDF)
Effective Date: 1/1/2022		Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)
Effective Date: 1/1/2022		Physical, Occupational, and Speech Therapy Services (PDF)
Effective Date: 1/1/2022
Bariatric Surgery (PDF)
Effective Date: 1/1/2022		Implantable Intrathecal Pain Pump (PDF)
Effective Date: 1/1/2022		Post-Acute Care (PDF)
Effective Date: 1/1/2022
Biofeedback (PDF)
Effective Date: 1/1/2022		Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
Effective Date: 1/1/2022		Posterior tibial nerve stimulation for voiding dysfunction (PDF)
Effective Date: 1/1/2022
Bone-anchored hearing aid (PDF)
Effective Date: 1/1/2022		Inhaled nitric oxide (PDF)
Effective Date: 1/1/2022		Proton and neutron beam therapies (PDF)
Effective Date: 1/1/2022
Burn Surgery (PDF)
Effective Date: 1/1/2022		Intensity-Modulated Radiotherapy (PDF)
Effective Date: 1/1/2022		Radial Head Implant (PDF)
Effective Date: 1/1/2022
Caudal or Interlaminar Epidural Steroid Injections (PDF)
Effective Date: 1/1/2022		Intestinal and multivisceral transplant (PDF)
Effective Date: 1/1/2022		Radiofrequency Ablation of Uterine Fibroids (PDF)
Effective Date: 1/1/2022
Cell-free Fetal DNA Testing (PDF)
Effective Date: 1/1/2022		Intradiscal Steroid Injections for Pain Management (PDF)
Effective Date: 1/1/2022		Reduction mammoplasty and gynecomastia surgery (PDF)
Effective Date: 1/1/2022
Clinical Trials (PDF)
Effective Date: 1/1/2022		Long Term Care Placement Criteria (PDF)
Effective Date: 1/1/2022		Repair of Nasal Valve Compromise (PDF)
Effective Date: 1/1/2022
Cochlear Implant Replacements (PDF)
Effective Date: 1/1/2022		Lung Transplantation (PDF)
Effective Date: 1/1/2022		Sacroiliac joint fusion (PDF)
Effective Date: 1/1/2022
Cosmetic and Reconstructive Surgery (PDF)
Effective Date: 1/1/2022		Lysis of Epidural Lesions (PDF)
Effective Date: 1/1/2022		Sacroiliac Joint Interventions for Pain Management (PDF)
Effective Date: 1/1/2022
Dental Anesthesia (PDF)
Effective Date: 1/1/2022		Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
Effective Date: 1/1/2022		Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF)
Effective Date: 1/1/2022
Diaphragmatic/Phrenic Nerve Stimulation (PDF)
Effective Date: 1/1/2022		Multiple Sleep Latency Testing (PDF)
Effective Date: 1/1/2022		Selective Dorsal Rhizotomy (PDF)
Effective Date: 1/1/2022
Disc Decompression Procedures (PDF)
Effective Date: 1/1/2022		Neonatal abstinence syndrome guidelines (PDF)
Effective Date: 1/1/2022		Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF)
Effective Date: 1/1/2022
Discography (PDF)
Effective Date: 1/1/2022		Neonatal sepsis management (PDF)
Effective Date: 1/1/2022		Short Inpatient Hospital Stay (PDF)
Effective Date: 1/1/2022
Donor lymphocyte infusion (PDF)
Effective Date: 1/1/2022		Nerve Blocks for Pain Management (PDF)
Effective Date: 1/1/2022		Skilled Nursing Facility Leveling (PDF)
Effective Date: 1/1/2022
Durable Medical Equipment (DME) (PDF)
Effective Date: 1/1/2024		Neuromuscular Electrical Stimulation (NMES) (PDF)
Effective Date: 1/1/2022		Skin Substitutes for Chronic Wounds (PDF)
Effective Date: 1/1/2022
Electric Tumor Treating Fields (PDF)
Effective Date: 1/1/2022		NICU Apnea Bradycardia Guidelines (PDF)
Effective Date: 1/1/2022		Spinal Cord Stimulation (PDF)
Effective Date: 1/1/2022
Electromyography and Nerve Conduction Studies (PDF)
Effective Date: 1/1/2022		NICU discharge guidelines (PDF)
Effective Date: 1/1/2022		Stereotactic Body Radiation Therapy (PDF)
Effective Date: 1/1/2022
Essure Removal (PDF)
Effective Date: 1/1/2022		Non-Invasive Home Ventilators (PDF)
Effective Date: 1/1/2022		Tandem Transplant (PDF)
Effective Date: 1/1/2022
Experimental Technologies (PDF)
Effective Date: 1/1/2022		Non-myeloablative allogeneic stem cell transplants (PDF)
Effective Date: 1/1/2022		Thymus Transplantation (PDF)
Effective Date: 1/1/2022
Facet Joint Interventions (PDF)
Effective Date: 1/1/2022		Obstetrical Home Health Care Programs (PDF)
Effective Date: 1/1/2022		Total artificial heart (PDF)
Effective Date: 1/1/2022
Fecal incontinence treatments (PDF)
Effective Date: 1/1/2022		Optic nerve decompression surgery (PDF)
Effective Date: 1/1/2022		Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Effective Date: 1/1/2022
Ferriscan R2-MRI (PDF)
Effective Date: 1/1/2022		Osteogenic Stimulation (PDF)
Effective Date: 1/1/2022		Transcatheter closure of patent foramen ovale (PDF)
Effective Date: 1/1/2022
Fertility preservation (PDF)
Effective Date: 1/1/2022		Outpatient Cardiac Rehabilitation (PDF)
Effective Date: 1/1/2022		Trigger Point Injections for Pain Management (PDF)
Effective Date: 1/1/2022
Fetal surgery in utero for prenatally diagnosed malformations (PDF)
Effective Date: 1/1/2022		Oxygen Use and Concentrators (PDF)
Effective Date: 1/1/2022		Urinary Incontinence Devices and Treatments (PDF)
Effective Date: 1/1/2022
Functional MRI (PDF)
Effective Date: 1/1/2022		 Vagus Nerve Stimulation (PDF)
Effective Date: 1/1/2022
Fundus Photography (PDF)
Effective Date: 1/1/2022		 Ventricular Assist Devices (PDF)
Effective Date: 1/1/2022
Gastric Electrical Stimulation (PDF)
Effective Date: 1/1/2022		 Video Electroencephalographic Monitoring (PDF)
Effective Date: 1/1/2022
Gender Affirming Procedures (PDF)
Effective Date: 1/1/2022		  
Genetic and Pharmacogenetic Testing (PDF)
Effective Date: 1/1/2022		  

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 Nebraska Total Care Payment Policy Manual apply with respect to Nebraska Total Care members. Policies in the Ambetter from Nebraska Total Care Payment Policy Manual may have either a Ambetter from Nebraska Total Care or a “Centene” heading.  In addition, Nebraska 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 Ambetter from Nebraska Total Care. If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Payment Policy List
A-GH-PQ-Z
3 Day Payment Window (PDF)
Effective Date: 1/1/2022		H Pylori Testing (PDF)
Effective Date: 1/1/2022		Robotic Surgery (PDF)
Effective Date: 1/1/2022
30 Day Readmission (PDF)
Effective Date: 1/1/2022		Holter Monitors (PDF)
Effective Date: 1/1/2022		Scanning computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF)
Effective Date: 1/1/2022
340B Drug Payment Reduction (PDF)
Effective Date: 1/1/2022		Homocysteine Testing (PDF)
Effective Date: 1/1/2022		Sleep Studies Place of Service (PDF)
Effective Date: 1/1/2022
ADHD Assessment and Treatment (PDF)
Effective Date: 1/1/2022		Laser Skin Treatment (PDF)
Effective Date: 1/1/2022		Testing for Select Genitourinary Conditions (previously Diagnosis of Vaginitis) (PDF)
Effective Date: 1/1/2022
Allergy Testing (PDF)
Effective Date: 1/1/2022		Leveling of Care: Evaluation and Management Overcoding (PDF)
Effective Date: 1/1/2022		Thyroid Testing in Pediatrics (PDF)
Effective Date: 1/1/2022
Assistant Surgeon (PDF) 
Effective Date: 1/1/2022		Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/2022		Ultrasound in Pregnancy (PDF)
Effective Date: 1/1/2022
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/2022
Measure Serum 1,25 Vitamin D (PDF)
Effective Date: 1/1/2022		Unbundling Adjustments on Clean Claim Reviews (PDF)
Effective Date: 9/1/2022
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 1/1/2022
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)
Effective Date: 1/1/2022
Urine Specimen Validity Testing (PDF)
Effective Date: 1/1/2022
Clean Claim Reviews (PDF)
Effectice Date: 11/1/2022
Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
Effective Date: 1/1/2022
Urodynamic Testing (PDF)
Effective Date: 1/1/2022
Clinical Validation of Modifier 25 (PDF)
Effective Date: 1/1/2022
Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: 1/1/2022		Visual Field Testing (PDF)
Effective Date: 1/1/2022
Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: 9/1/2022
Non-Emergent ER Services (fka Leveling of ER Services) (PDF)
Effective Date: 1/1/2022
Vitamin D Testing in Children (PDF)
Effective Date: 1/1/2022
Digital EEG Analysis (PDF)
Effective Date: 1/1/2022
Non-Obstetrical and OB Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 1/1/2022		Wheelchair Accessories (PDF)
Effective Date: 1/1/2022
Distinct Procedural Modifiers: XE, XS,
XP, & XU (PDF)
Effective Date: 1/1/2022
Physician's Consultation Services (PDF)
Effective Date: 1/1/2022
Wheelchair Seating (PDF)
Effective Date: 1/1/2022
Drugs of Abuse: Definitive Testing (previously Outpatient Testing for Drugs of Abuse) (PDF)
Effective Date: 1/1/2022
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
Effective Date: 1/1/2022
Wireless Motility Capsule (PDF)
Effective Date: 1/1/2022
EEG in Evaluation of Headache (PDF)
Effective Date: 1/1/2022
Problem-Oriented Visits with Preventative Visits (PDF)
Effective Date: 1/1/2022
 
Endometrial Ablation (PDF)
Effective Date: 1/1/2022
Problem-Oriented Visits with Surgical Procedures (PDF)
Effective Date: 1/1/2022
 
Evaluation and Management Services Billed with Treatment Rooms (PDF)
Effective Date: 1/1/2022
PROM Testing (PDF)
Effective Date: 1/1/2022
 
Evoked Potentials (PDF)
Effective Date: 1/1/2022		  
Extended Ophthalmoscopy (PDF)
Effective Date: 1/1/2022		  
External Ocular Photography (PDF)
Effective Date: 1/1/2022		  
Fluorescein Angiography (PDF)
Effective Date: 1/1/2022		  
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
Effective Date: 1/1/2022		  
Global Maternity Package (PDF)
Effective Date: 1/1/2022		  
Gonioscopy (PDF)
Effective Date: 1/1/2022		  

Pharmacy Policies