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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.

A-H I-Z                             
ADHD Assessment and Treatment (PDF)
Effective 01/01/2018
Lipid management, low back pain, and respiratory illness (PDF)
ADHD Assessment and Treatment (PDF)
Effective 01/01/2018
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
Effective 01/01/2018
Allergy Testing and Therapy (PDF)
Effective 03/15/2018     
PROM Testing (PDF)
Effective 01/01/2018
Bronchial Thermoplasty (PDF)
Effective 01/01/2018   
Proton and Neutron Beam Therapy (PDF)
Effective 03/15/2018                                   
Cardiac Biomarker Testing for Acute MI (PDF)
Effective 06/01/2018 
Testing for Select Genitourinary Conditions (PDF)
Effective 03/15/2018
Digital Analysis of EEGs (PDF)
Effective Date: 6/1/2018  
Ultrasound in Pregnancy (PDF)
Effective 03/15/2018
Digital Breast Tomosynthesis (PDF)
Effective 03/15/2018
Urodynamic Testing (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.

Clinical Policies
Ferriscan R2 MRI Cell-free Fetal DNA Testing Allergy Testing and Therapy
Clinical Trials Medical Necessity Criteria Digital electroencephalography spike analysis
Gender Affirming Procedures Bariatric Surgery Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia
Donor Lymphocyte Infusion Gastric Electrical Stimulation Pediatric Heart Transplant
Essure Removal Functional MRI Low-frequency ultrasound therapy for wound management
Evoked Potentials Lung Transplantation Ambulatory Surgery Center Optimization
Urinary Incontinence Devices Neonatal Abstinene Syndrome Guidelines Stereotactic Body Radiation Therapy
Sclerotherapy Acupuncture Hyperbaric Oxygen Therapy
Home Phototherapy for Neonatal Hyperbilirubinemia Bone-Anchored Hearing Aid Therapy Services PT/OT/ST
Infusion SOC Optimization Urodynamic Testing Proton and Neutron Beam Therapy
Nerve Blocks Wheelchair Seating NICU Apnea Bradycardia Guidelines
Video Electroencephalographic (VEEG) Monitoring Balloon Sinus Ostial Dilation Obstetrical Home Health Care Programs
Antithrombin III Fertility Preservation Proton and Neutron Beam Therapy
Urodynamic Testing Home Births Vagus Nerve Stimulation
Neonatal Sepsis Management Sclerotherapy for Varicose Veins Transcranial magnetic stimulation
Genetic Testing Nerve Blocks Hyperemesis gravidarum treatment
Vagus Nerve Stimulation Sacroiliac Joint Interventions Ventriculectomy and cardiomyoplasty
Caudal or Interlaminar Epidural Steroid Injections Testing for Select Genitourinary Conditions Hyperhidrosis treatments
Fetal Surgery in Utero Optic Nerve Decompression Surgery Intensity-Modulated Radiotherapy
Bariatric Surgery Trigger Point Injections Pancreas transplant

SNRBs and Transforaminal epidural steroid injections
Posterior Tibial Nerve Stimulation for Voiding Dysfunction Applied Behavioral Analysis for Autism



Cardiac biomarker testing


 

Assisted Reproductive Technology
Non-myeloablative allogeneic stem cell transplants
Pediatric Liver Transplant Articular Cartilage Defect Repairs Bronchial Thermoplasty
Wireless Motility Capsule Electric Tumor Treatment Fields Selective Dorsal Rhizotomy for Spasticity in CP
Cosmetic and Reconstructive Surgery Cell-Free Fetal DNA Testing Panniculectomy
Epifix Wound Treatment Urinary Incontinence Devices and Treatments Transcranial Magnetic Stimulation
Applied Behavioral Analysis Outpatient Testing for Drugs of Abuse  
Ferriscan R2 MRI
Clinical Trials
Gender Affirming Procedures
Donor Lymphocyte Infusion
Essure Removal
Evoked Potentials
Urinary Incontinence Devices
Sclerotherapy
Home Phototherapy for Neonatal Hyperbilirubinemia
Infusion SOC Optimization
Nerve Blocks
Video Electroencephalographic (VEEG) Monitoring
Antithrombin III
Urodynamic Testing
Neonatal Sepsis Management
Medical Necessity Criteria
A-H I-O P-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: 1/1/17 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