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

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

Medicaid Clinical and Behavioral Health Policies


25-hydroxyvitamin D Testing in Children and Adolescents (PDF) (CP.MP.157)

Holter Monitors (PDF) (CP.MP.113)

Radial Head Implant (PDF)(CP.MP.148)

Acupuncture (PDF) (CP.MP.92)

Home Birth (PDF)(CP.MP.136)

Reduction Mammoplasty and Gynecomastia Surgery (PDF)(CP.MP.51)

ADHD Assessment and Treatment (PDF) (CP.MP.124)

Home Ventilators (PDF)(CP.MP.184)

Repair of Nasal Valve Compromise (PDF)(CP.MP.210)

Air Ambulance (PDF)(CP.MP.175)

Homocysteine Testing (PDF) (CP.MP.121)

Sacroiliac Joint Fusion (PDF)(CP.MP.126)

Allergy Testing and Therapy (PDF) (CP.MP.100)

Hospice Services (PDF)(CP.MP.54)

Sacroiliac Joint Interventions for Pain Management (PDF)(CP.MP.166)

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia(PDF) (CP.MP.108)

Hyperhidrosis Treatments (PDF)(CP.MP.62)


Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF)(CP.MP.146)

Ambulatory Surgery Center Optimization (PDF) (CP.MP.158)

Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea(PDF)(CP.MP.180)

Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)(CP.MP.174)

Applied Behavior Analysis (PDF) (CP.BH.104)

Implantable Intrathecal Pain Pump (PDF)(CP.MP.173)

Selective Nerve Root Blocks and Transforaminal Epidural Injections(PDF)(CP.MP.165)

Assisted Reproductive Technology (PDF)(CP.MP.55)

Implantable Loop Recorder (PDF)(CP.MP.243)

Short Inpatient Hospital Stay (PDF)(CP.MP.182)

Articular Cartilage Defect Repairs (PDF)(CP.MP.26)

Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)(CP.MP.160)

Skilled Nursing Facility Leveling (PDF)(CP.MP.206)

Bariatric Surgery (PDF)(CP.MP.37)

Inhaled Nitric Oxide (PDF)(CP.MP.87)

Skin Substitutes for Chronic Wounds (PDF)(CP.MP.185)

Behavioral Health Treatment Document Requirement (PDF)(CP.BH.500)

Intensity-Modulated Radiotherapy (PDF)(CP.MP.69)

Spinal Cord Stimulation (PDF)(CP.MP.117)


Intestinal and Multivisceral Transplant (PDF)(CP.MP.58)

Stereotactic Body Radiation Therapy (PDF)(CP.MP.22)

Biofeedback for Behavioral Health Disorders(PDF)(CP.BH.300)

Intradiscal Steroid Injections for Pain Management (PDF)(CP.MP.167)

Substance Use Treatment and Services (PDF) (CP.BH.100)

Bone-Anchored Hearing Aid (PDF)(CP.MP.93)

IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)(CP.MP.61)

Tandem Transplant (PDF)(CP.MP.162)

Bronchial Thermoplasty (PDF)(CP.MP.110)

Laser Therapy for Skin Conditions (PDF)(CP.MP.123)

Testing for Select Genitourinary Conditions (PDF)(CP.MP.97) (Revision in Process)

Burn Surgery (PDF) (CP.MP.186)

Liposuction for Lipedema (PDF)(CP.MP.244)

Therapeutic Utilization of Inhaled Nitric Oxide (PDF)(CP.MP.87)

Cardiac Biomarker Testing (PDF) (CP.MP.156)

Long Term Care Placement Criteria (PDF)(CP.MP.71)

Thyroid Hormones and Insulin Testing in Pediatrics (PDF)(CP.MP.154)

Caudal or Interlaminar Epidural Steroid Injections (PDF) (CP.MP.164)

Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)(CP.MP.139)

TMS for Major Depressive Disorder (PDF) (CP.BH.200)

Clinical Trials (PDF) (CP.MP.94)

Lung Transplantation (PDF)(CP.MP.57)

Total Artificial Heart (PDF)(CP.MP.127)

Cochlear Implant Replacements (PDF)(CP.MP.14)

Lysis of Epidural Lesions (PDF)(CP.MP.116)

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)(CP.MP.163)

Cosmetic and Reconstructive Surgery (PDF)(CP.MP.31)

Measurement of Serum 1,25-dihydroxyvitamin D (PDF)(CP.MP.152)

Transcatheter Closure of Patent Foramen Ovale (PDF)(CP.MP.151)

Diaphragmatic/Phrenic Nerve Stimulation (PDF)(CP.MP.203)

Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)(CP.MP.144)

Trigger Point Injections for Pain Management (PDF)(CP.MP.169)

Digital Electroencephalography Spike Analysis (PDF) (CP.MP.105)

Multiple Sleep Latency Testing (PDF)(CP.MP.24)

Ultrasound in Pregnancy (PDF) (CP.MP.38)

Disc Decompression Procedures (PDF)(CP.MP.114)

Neonatal Abstinence Syndrome Guidelines (PDF)(CP.MP.86)

Urinary Incontinence Devices and Treatments (PDF)(CP.MP.142)

Discography (PDF)(CP.MP.115)

Neonatal Sepsis Management (PDF)(CP.MP.85)

Urodynamic Testing (PDF) (CP.MP.98)

Donor Lymphocyte Infusion (PDF)(CP.MP.101)

Nerve Blocks for Pain Management (PDF)(CP.MP.170)

Vagus Nerve Stimulation (PDF)(CP.MP.12)

Drugs of Abuse, Definitive Testing (PDF)(CP.MP.50)

Neuromuscular Electrical Stimulation (NMES)(PDF)(CP.MP.48)

Ventricular Assist Devices (PDF)(CP.MP.46)

Durable Medical Equipment (DME) (PDF)(CP.MP.107)

NICU Apnea Bradycardia Guidelines (PDF)(CP.MP.82)

Wheelchair Seating (PDF)(CP.MP.99)

Electric Tumor Treating Fields (PDF)(CP.MP.145)

NICU Discharge Guidelines (PDF)(CP.MP.81)

Wireless Motility Capsule (PDF)(CP.MP.143)

Electroencephalography in the Evaluation of Headache (PDF) (CP.MP.155)

Non-Myeloablative Allogeneic Stem Cell Transplants (PDF)(CP.MP.141)


Endometrial Ablation (PDF) (CP.MP.106)

Obstetrical Home Health Care Programs (PDF)(CP.MP.91)


Endometrial Ablation (PDF)(CP.MP.106)

Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)(PDF)(CP.MP.239)


Evoked Potential Testing (PDF) (CP.MP.134)

Optic Nerve Decompression Surgery (PDF)(CP.MP.128)


Experimental Technologies (PDF) (CP.MP.36)

Orthognathic Surgery (PDF)(CP.MP.202)


Facet Joint Interventions (PDF) (CP.MP.171)

Osteogenic Stimulation (PDF)(CP.MP.194)


Fecal Incontinence Treatments (PDF)(CP.MP.137)

Outpatient Cardiac Rehabilitation (PDF)(CP.MP.176)


Ferriscan R2-MRI (PDF)(CP.MP.53)

Oxygen Use and Concentrators (PDF)(CP.MP.190)


Fertility Preservation (PDF)(CP.MP.130)

Pancreas Transplant (PDF)(CP.MP.102)


Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)(CP.MP.129)

Panniculectomy (PDF)(CP.MP.109)


Functional MRI (PDF)(CP.MP.43)

Pediatric Heart Transplant (PDF)(CP.MP.138)


Gastric Electrical Stimulation (PDF)(CP.MP.40)

Pediatric Kidney Transplant (PDF)(CP.MP.246)


Gender Affirming Procedures (PDF)(CP.MP.95)

Pediatric Liver Transplant (PDF)(CP.MP.120)


Genetic Testing Aortopathies and Connective Tissue Disorders (PDF)(CP.MP.215)

Pediatric Oral Function Therapy (PDF)(CP.MP.188)


Genetic Testing Cardiac Disorders (PDF)(CP.MP.216)

Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)(CP.MP.147)


Genetic Testing Dermatologic Conditions (PDF)(CP.MP.217)

Phototherapy for Neonatal Hyperbilirubinemia (PDF)(CP.MP.150)


Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Disorders (PDF)(CP.MP.218)

Physical, Occupational, and Speech Therapy Services (PDF)(CP.MP.49)


Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)(CP.MP.219)

Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)(CP.MP.181)


Genetic Testing Eye Disorders (PDF)(CP.MP.220)

Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)(CP.MP.133)


Genetic Testing for Non-Invasive Prenatal Screening (NIPS) (PDF)(CP.MP.231)

Proton and Neutron Beam Therapies (PDF) (CP.MP.70)


Genetic Testing Gastroenterologic Disorders (non-cancerous) (PDF)(CP.MP.221)

Pulmonary Function Testing (PDF) (CP.MP.242)


Genetic Testing General Approach to Genetic Testing (PDF)(CP.MP.222)


Genetic Testing Hearing Loss (PDF)(CP.MP.223)


Genetic Testing Hematologic Condition (non-cancerous) (PDF)(CP.MP.224)


Genetic Testing Hereditary Cancer Susceptibility (PDF)(CP.MP.225)


Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders (PDF)(CP.MP.226)


Genetic Testing Kidney Disorders (PDF)(CP.MP.227)


Genetic Testing Lung Disorders (PDF)(CP.MP.228)


Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (PDF)(CP.MP.229)


Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)(CP.MP.230)


Genetic Testing Oncology Algorithmic Testing (PDF)(CP.MP.237)


Genetic Testing Oncology Cancer Screening (PDF)(CP.MP.238)


Genetic Testing Oncology Cytogenetic Testing (PDF)(CP.MP.240)


Genetic Testing Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) (CP.MP.241)


Genetic Testing Pharmacogenetics (PDF)(CP.MP.232)


Genetic Testing Preimplantation Genetic Testing (PDF)(CP.MP.233)


Genetic Testing Prenatal and Preconception Carrier Screening (PDF)(CP.MP.234)


Genetic Testing Prenatal Diagnosis (PDF)(CP.MP.235)


Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (PDF)(CP.MP.236)


GI Pathogen Nucleic Acid Detection Panel Testing (PDF)(CP.MP.209)


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

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)
Effective Date: 07/1/14
Inpatient Consultation (PDF)
Effective Date: 1/1/14
Place of Service Mismatch (PDF)
Effective Date: 9/1/2018
Add on Code Billed Without Primary Code (PDF)
Effective Date: 1/1/13
Inpatient Only Procedures (PDF)
Effective Date: 1/1/13
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/13
Assistant Surgeon (PDF)
Effective Date: 1/1/14
IV Hydration (PDF)
Effective Date: 1/1/13
Physician's Consultation Services (PDF)
Effective Date: 11/1/17
Bilateral Procedures (PDF) Effective Date: 1/1/14   Leveling of ER Services (PDF) Effective Date: 1/1/17 Physician's Office Lab Testing (PDF)
Effective Date: 11/01/17
Cerumen Removal (PDF) Effective Date: 1/1/1 Maximum Units (PDF)
Effective Date: 1/1/13
Post-Operative Visits (PDF) Effective Date: 1/1/14
CLIA Number 
Effective Date: 1/1/13  
Moderate Conscious Sedation (PDF)
Effective Date: 1/1/13  
Pre-Operative Visits (PDF)
Effective Date: 1/1/14
Coding Overview (PDF)
Effective Date: 1/1/13
Modifier -25 clinical validation (PDF)
Effective Date: 1/1/13
Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: 1/1/18
Cosmetic Procedures (PDF)
Effective Date: 1/1/14
Modifier -59 clinical validation (PDF)
Effective Date: 1/1/14
Professional Component (PDF)
Effective Date: 1/1/18
Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/13
Modifier DOS Validation (PDF)
Effective Date: 1/1/13
Pulse Oximetry (PDF)
Effective Date: 1/1/14
Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/14
Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/13
Same Day Visits (PDF)
Effective Date: 3/1/18
E&M Medical Decision-Making (PDF)
Effective Date: 6/1/17
Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/14
Status "B" Bundled Services (PDF)
Effective Date: 1/1/14
EM Bundling Edits (PDF)
Effective Date: 1/1/13
NCCI Unbundling (PDF)
Effective Date: 1/1/13
Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/13
Global Maternity Billing (PDF)
Effective Date: 1/1/13
Never Paid Events (PDF)
Effective Date: 1/1/13
Transgender Related Services (PDF)
Effective Date: 1/1/17
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18  
New Patient (PDF)
Effective Date: 1/1/14
Unbundled Professional Services (PDF)
Effective Date: 1/1/14
  Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 6/1/18
Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/2014
  Outpatient Consultation (PDF)
Effective Date: 1/1/14
Unlisted Procedure Codes (PDF)
Effective Date: 1/1/2014

Optum Comprehensive Payment Integrity (PDF)

Effective Date: 6/1/23

Urine Specimen Validity Testing (PDF)
Effective 01/01/2018