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Clinical & Payment Policies

Clinical Policies (CP.MP.XX)

Clinical policies are 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 for plans that cover outpatient medications.

Clinical policies 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 this Clinical Policy site are listed by Line of Business – Medicaid, Marketplace (Ambetter) and Medicare (Wellcare and WellCare by Allwell).  

 

 

We are committed to providing appropriate, high-quality, and cost-effective drug therapy to all Ambetter Health members.

Use our Preferred Drug List to find more information on the drugs that Ambetter Health covers.

Pharmacy Resources for Providers | Ambetter from Home State Health

For Medicare information, please visit our Medicare Prior Authorization website.

Payment Policies (CC.PP.XX)

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).

Policies in this site may have either a Home State Health or a “Centene” heading.  In addition, Home State Health 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 guidance (e.g., MO HealthNet’s managed care policy statements) or provider contract terms may further determine whether a technology, procedure or treatment not addressed in a policy, one of our Provider Manuals or other posted information is payable.