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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

Policy NamePolicy Number
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157
Acupuncture (PDF)CP.MP.92
Air Ambulance (PDF)CP.MP.175
Allergy Testing and Therapy (PDF)CP.MP.100
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108
Applied Behavior Analysis (PDF)CP.BH.104
Articular Cartilage Defect Repairs (PDF)CP.MP.26
Assisted Reproductive Technology (PDF)CP.MP.55
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.MP.124
Bariatric Surgery (PDF)CP.MP.37
Behavioral Health Treatment Document Requirements (PDF)CP.BH.500
Biofeedback (PDF)CP.MP.168
Biofeedback for Behavioral Health Disorders (PDF)CP.BH.300
Bone-Anchored Hearing Aid (PDF)CP.MP.93
Bronchial Thermoplasty (PDF)CP.MP.110
Burn Surgery (PDF)CP.MP.186
Cardiac Biomarker Testing (PDF)CP.MP.156
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164
Clinical Trials (PDF)CP.MP.94
Cochlear Implant Replacements (PDF)CP.MP.14
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203
Digital EEG Spike Analysis (PDF)CP.MP.105
Disc Decompression Procedures (PDF)CP.MP.114
Discography (PDF)CP.MP.115
Donor Lymphocyte Infusion (PDF)CP.MP.101
Drugs of Abuse: Definitive Testing (PDF)CP.MP.50
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)CP.MP.107
EEG in the Evaluation of Headache (PDF)CP.MP.155
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.145
Endometrial Ablation (PDF)CP.MP.106
Evoked Potential Testing (PDF)CP.MP.134
Experimental Technologies (PDF)CP.MP.36
Facet Joint Interventions (PDF)CP.MP.171
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248
Fecal Incontinence Treatments (PDF)CP.MP.137
Ferriscan R2-MRI (PDF)CP.MP.53
Fertility Preservation (PDF)CP.MP.130
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129
Functional MRI (PDF)CP.MP.43
Gastric Electrical Stimulation (PDF)CP.MP.40
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)CP.MP.209
Gender-Affirming Procedures (PDF)CP.MP.95
Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)CP.MP.215
Genetic Testing: Cardiac Disorders (PDF)CP.MP.216
Genetic Testing: Dermatologic Conditions (PDF)CP.MP.217
Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders (PDF)CP.MP.218
Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)CP.MP.219
Genetic Testing: Eye Disorders (PDF)CP.MP.220
Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)CP.MP.221
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: Non-Invasive Prenatal Screening (NIPS) (PDF)CP.MP.231
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 (Via Amniocentises, CVS, or PUBS) and Pregnancy Loss (PDF)CP.MP.235
Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)CP.MP.236
Helicobacter Pylori Serology Testing (PDF)CP.MP.153
Holter Monitors (PDF)CP.MP.113
Home Births (PDF)CP.MP.136
Home Ventilators (PDF)CP.MP.184
Homocysteine Testing (PDF)CP.MP.121
Hospice Services (PDF)CP.MP.54
Hyperhidrosis Treatments (PDF)CP.MP.62
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173
Implantable Loop Recorder (PDF)CP.MP.243
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.160
Intensity-Modulated Radiotherapy (PDF)CP.MP.69
Intestinal and Multivisceral Transplant (PDF)CP.MP.58
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.167
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61
Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)CP.MP.250
Laser Therapy for Skin Conditions (PDF)CP.MP.123
Liposuction for Lipedema (PDF)CP.MP.244
Long Term Care Placement (PDF)CP.MP.71
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.139
Lung Transplantation (PDF)CP.MP.57
Lysis of Epidural Lesions (PDF)CP.MP.116
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.144
Multiple Sleep Latency Testing (PDF)CP.MP.24
Neonatal Abstinence Syndrome Guidelines (PDF)CP.MP.86
Neonatal Sepsis Management (PDF)CP.MP.85
Neurofeedback for Behavioral Health Disorders (PDF)NV.CP.BH.300
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.170
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.48
NICU Apnea Bradycardia Guidelines (PDF)CP.MP.82
NICU Discharge Guidelines (PDF)CP.MP.81
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.141
Obstetrical Home Care Programs (PDF)CP.MP.91
Oncology Algorithmic Testing (PDF)CP.MP.237
Oncology Cancer Screening (PDF)CP.MP.238
Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)CP.MP.239
Oncology Cytogenetic Testing (PDF)CP.MP.240
Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)CP.MP.241
Orthognathic Surgery (PDF)CP.MP.202
Osteogenic Stimulation (PDF)CP.MP.194
Outpatient Cardiac Rehabilitation (PDF)CP.MP.176
Outpatient Oxygen Use (PDF)CP.MP.190
Pancreas Transplantation (PDF)CP.MP.102
Panniculectomy (PDF)CP.MP.109
Pediatric Heart Transplant (PDF)CP.MP.138
Pediatric Kidney Transplant (PDF)CP.MP.246
Pediatric Liver Transplant (PDF)CP.MP.120
Pediatric Oral Function Therapy (PDF)CP.MP.188
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.147
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.150
Physical, Occupational, and Speech Therapy Services (PDF)CP.MP.49
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)CP.MP.181
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133
Proton and Neutron Beam Therapies (PDF)CP.MP.70
Pulmonary Function Testing (PDF)CP.MP.242
Reduction Mammoplasty and Gynecomastia Surgery (PDF)CP.MP.51
Repair of Nasal Valve Compromise (PDF)CP.MP.210
Sacroiliac Joint Fusion (PDF)CP.MP.126
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)CP.MP.165
Short Inpatient Hospital Stay (PDF)CP.MP.182
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117
Stereotactic Body Radiation Therapy (PDF)CP.MP.22
Substance Use Disorders Treatment and Services (PDF)CP.BH.100
Tandem Transplant (PDF)CP.MP.162
Testing for Select Genitourinary Conditions (PDF)CP.MP.97
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)CP.MP.154
Total Artificial Heart (PDF)CP.MP.127
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163
Transcatheter Closure of Patent Foramen Ovale (PDF)CP.MP.151
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)CP.BH.200
Transplant Service Documentation Requirements (PDF)CP.MP.247
Trigger Point Injections for Pain Management (PDF)CP.MP.169
Ultrasound in Pregnancy (PDF)CP.MP.38
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142
Urodynamic Testing (PDF)CP.MP.98
Vagus Nerve Stimulation (PDF)CP.MP.12
Ventricular Assist Devices (PDF)CP.MP.46
Wheelchair Seating (PDF)(CP.MP.99)CP.MP.99
Wireless Motility Capsule (PDF)(CP.MP.143)CP.MP.143

 

 

 

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.

A-HI-OP-Z
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: 1/1/17Physician's Office Lab Testing (PDF)
Effective Date: 11/01/17
Cerumen Removal (PDF) Effective Date: 1/1/1Maximum 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
Skilled Nursing Facility Leveling (CC.PP.206) (PDF)
EM Bundling Edits (PDF)
Effective Date: 1/1/13
NCCI Unbundling (PDF)
Effective Date: 1/1/13
Status "B" Bundled Services (PDF)
Effective Date: 1/1/14
Global Maternity Billing (PDF)
Effective Date: 1/1/13
Never Paid Events (PDF)
Effective Date: 1/1/13
Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/13
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18  
New Patient (PDF)
Effective Date: 1/1/14
Transgender Related Services (PDF)
Effective Date: 1/1/17
 Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 6/1/18
Unbundled Professional Services (PDF)
Effective Date: 1/1/14
 Outpatient Consultation (PDF)
Effective Date: 1/1/14
Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/2014
 

Optum Comprehensive Payment Integrity (PDF)

Effective Date: 6/1/23

Unlisted Procedure Codes (PDF)
Effective Date: 1/1/2014
  Urine Specimen Validity Testing (PDF)
Effective 01/01/2018