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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 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.

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ADHD Assessment and Treatment (PDF) Effective 01/01/201 Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective 01/01/2018
ADHD Assessment and Treatment (PDF)
Effective 01/01/201
PROM Testing (PDF)
Effective 01/01/2018
Allergy Testing and Therapy (PDF)
Effective 03/15/2018             
Proton and Neutron Beam Therapy (PDF)
Effective 03/15/2018                                   
Bronchial Thermoplasty (PDF) 
Effective 01/01/2018
Testing for Select Genitourinary Conditions (PDF)
Effective 03/15/2018
Cardiac Biomarker Testing for Acute MI (PDF)
Effective 06/01/2018 
Ultrasound in Pregnancy (PDF)
Effective 03/15/2018
Digital Analysis of EEGs (PDF)
Effective Date: 6/1/2018  
Urodynamic Testing (PDF)
Effective 03/15/2018
Digital Breast Tomosynthesis (PDF)
Effective 03/15/2018
 
Endometrial Ablation (PDF)
Effective 03/15/2018
 
FeNo Testing (PDF)
Effective 01/01/2018
 
Holter Monitors (PDF)
Effective 01/01/2018 
 
Homocysteine Testing (PDF)
Effective 01/01/2018
 

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.

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