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

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

CP.MP.12     Vagus Nerve Stimulation (PDF)
CP.MP.14     Cochlear Implant Replacements (PDF)
CP.MP.36     Experimental Technologies (PDF)
CP.MP.38     Ultrasound in Pregnancy (PDF)
CP.MP.40     Gastric electrical stimulation (PDF)
CP.MP.43     Functional MRI (PFD)
CP.MP.50     Outpatient testing for drugs of abuse (PDF)
CP.MP.51     Reduction mammoplasty and gynecomastia surgery (PDF)
CP.MP.58     Intestinal and multivisceral transplant (PDF)
CP.MP.68     Medical Necessity Criteria (PDF)
CP.MP.81     NICU discharge guidelines (PDF)
CP.MP.85     Neonatal sepsis management (PDF)
CP.MP.86     Neonatal abstinence syndrome guidelines (PDF)
CP.MP.87     Inhaled nitric oxide (PDF)
CP.MP.88     Sickle cell disease observation (PDF)
CP.MP.90     Digital breast tomosynthess (PDF)
CP.MP.96     Ambulatory EEG (PDF)
CP.MP.97     Testing for select genitourinary conditions (PDF)
CP.MP.98     Urodynamic testing (PDF)
CP.MP.99     Wheelchair seating (PDF)
CP.MP.106     Endometrial ablation (PDF)
CP.MP.113     Holter Monitors (PDF)
CP.MP.115     Discography (PDF)
CP.MP.121     Homocysteine testing (PDF)
CP.MP.123     Laser therapy for skin conditions (PDF)
CP.MP.125     DNA analysis of stool to screen for colorectal cancer (PDF)
CP.MP.126     Sacroiliac joint fusion (PDF)
CP.MP.128     Optic nerve decompression surgery (PDF)
CP.MP.129     Fetal surgery in utero for prenatally diagnosed malformations (PDF)
CP.MP.130     Fertility preservation (PDF)
CP.MP.133     Posterior tibial nerve stimulation for voiding dysfunction (PDF)
CP.MP.149     Testing for rupture of fetal membranes (PDF)
CP.MP.22     Stereotactic Body Radiation Therapy (PDF)
CP.MP.27     Hyperbaric Oxygen Therapy (PDF)
CP.MP.34     Hyperemesis gravidarum treatment(PDF)
CP.MP.37     Bariatric Surgery (PDF)
CP.MP.49     Therapy Services (PT/OT/ST) (PDF)
CP.MP.53     Ferriscan R2-MR( (PDF)
CP.MP.56     Ventriculectomy and cardiomyoplasty (PDF)
CP.MP.57     Lung Transplantation (PDF)
CP.MP.62     Hyperhidrosis treatments (PDF)
CP.MP.69     Intensity-Modulated Radiotherapy (PDF)
CP.MP.70     Proton and neutron beam therapy (PDF)
CP.MP.91     Obstetrical Home Health Care Programs (PDF)
CP.MP.92     Acupuncture (PDF)
CP.MP.93     Bone-anchored hearing aid (PDF)
CP.MP.94     Clinical Trials (PDF)
CP.MP.95     Gender reassignment surgery (PDF)
CP.MP.100     Allergy Testing and Therapy (PDF)
CP.MP.101     Donor lymphocyte infusion (PDF)
CP.MP.102     Pancreas transplant (PDF)
CP.MP.103     Fractional exhaled nitric oxide (PDF)
CP.MP.104     Applied Behavioral Analysis for Autism (PDF)
CP.MP.105     Digital electroencephalography spike analysis (PDF)
CP.MP.107     Durable Medical Equipment (DME) (PDF)
CP.MP.108     Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF)
CP.MP.119     Balloon sinus ostial dilation (PDF)
CP.MP.127     Total artificial heart (PDF)
CP.MP.131     Essure Removal (PDF)
CP.MP.134     Evoked Potential Testing (PDF)
CP.MP.135     Fecal calprotectin assay (PDF)
CP.MP.136     Home Birth (PDF)
CP.MP.137     Fecal incontinence treatments (PDF)
CP.MP.138     Pediatric heart transplant (PDF)
CP.MP.139     Low-frequency ultrasound therapy for wound management (PDF)
CP.MP.141     Non-myeloablative allogeneic stem cell transplants (PDF)
CP.MP.150     Home phototherapy for neonatal hyperbilirubinemia (PDF)
CP.MP.151     Transcatheter closure of patent foramen ovale (PDF)
CP.MP.152     Measurement of serum 1,25-dihydroxyvitamin D (PDF)
CP.MP.153     H. Pylori serology testing (PDF)
CP.MP.154     Thyroid hormones and insulin testing in pediatrics (PDF)
CP.MP.155     Electroencephalography in the evaluation of headache (PDF)
CP.MP.156     Cardiac biomarker testing (PDF)
CP.MP.157     25-hydroxyvitamin D testing in children and adolescents (PDF)
CP.MP.158     Ambulatory Surgery Center Optimization (PDF)
CP.MP.109     Panniculectomy (PDF)
CP.MP.110     Bronchial Thermoplasty (PDF)
CP.MP.111     Zika Virus Testing (PDF)
CP.MP.114     Disc Decompression Procedures (PDF)
CP.MP.116     Lysis of Epidural Lesions (PDF)
CP.MP.117     Spinal Cord Stimulation (PDF)
CP.MP.124     ADHD Assessment and Treatment (PDF)
CP.MP.132     Heart-Lung Transplant (PDF)
CP.MP.140     EpiFix Wound Treatment (PDF)
CP.MP.142     Urinary Incontinence Devices and Treatments (PDF)
CP.MP.143     Wireless Motility Capsule (PDF)
CP.MP.144     Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.145     Electric Tumor Treating Fields (PDF)
CP.MP.146     Sclerotherapy for Vericose Veins (PDF)
CP.MP.147     Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention(PDF)
CP.MP.148     Radial Head Implant (PDF)
CP.MP.168     Biofeedback (PDF)
CP.MP.24     Multiple Sleep Latency Testing (PDF)
CP.MP.26     Articular Cartilage Defect Repairs (PDF)
CP.MP.160     Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
CP.MP.161     Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
CP.MP.31     Cosmetic and Reconstructive Surgery (PDF)
CP.MP.54     Hospice Services (PDF)
CP.MP.55     Assisted Reproductive Technology (PDF)
CP.MP.61     Dental Anesthesia (PDF)
CP.MP.71     Long Term Care Placement Criteria (PDF)
CP.MP.82     NICU Apnea Bradycardia Guidelines (PDF)
CP.MP.83     Carrier Screening in Pregnancy (PDF)
CP.MP.84     Cell-free Fetal DNA Testing (PDF)
CP.MP.89     Genetic Testing (PDF)
CP.MP.163     Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
CP.MP.120     Pediatric Liver Transplant (PDF)
CP.MP.46     Ventricular Assist Devices (PDF)

CP.MP.164     Caudal or Interlaminar Epidural Steroid Injections (PDF)
CP.MP.165     Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
CP.MP.166     Sacroiliac Joint Interventions (PDF)
CP.MP.167     Intradiscal Steroid Injections (PDF)
CP.MP.169     Trigger Point Injections (PDF)
CP.MP.170     Nerve Blocks (PDF)
CP.MP.171     Facet Joint Interventions (PDF)
 

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

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

CC.PP.049     Status P Bundled Services (PDF)

CC.PP.047     Transgender Related Services (PDF)

CC.PP.046     Status "B" Bundled Services (PDF)

CC.PP.029     Assistant Surgeon (PDF)

CC.PP.037     Bilateral Procedures (PDF)

CC.PP.044     Duplicate Primary Code Billing (PDF)

CC.PP.038     Inpatient Consultation (PDF)

CC.PP.039     Outpatient Consultation (PDF)

CC.PP.042     Post-Operative Visits (PDF)

CC.PP.041     Pre-Operative Visits (PDF)

CC.PP.040     Same Day Visits (PDF)

CC.PP.036     New Patient (PDF)

CP.PHAR.176     Paclitaxel (PDF)

CP.MP.100     Allergy Testing (PDF)

CP.PHAR.93     Bevacizumab (PDF)

CP.PHAR.260     Rituximab (PDF)

CC.PP.502     Wheelchair Accessories (PDF)

CP.MP.98     Urodynamic Testing (PDF)

CP.MP.99     Wheelchair Seating (PDF)

CP.MP.38     Ultrasound in Pregnancy (PDF)

CP.MP.96     Ambulatory EEG (PDF)

CC.PP.008     Cerumen Removl (PDF)

CC.PP.007     Maximum Units (PDF)

CC.PP.009     Unlisted Procedure Codes (PDF)

CC.PP.010     EM Bundling Edits (PDF)

CC.PP.021     Clean Claims (PDF)

CC.PP.011     Coding Overview (PDF)

CC.PP.020     Distinct Procedural Modifiers (PDF)

CC.PP.016     Global Maternity Billing (PDF)

CC.PP.018     Inpatient Only Procedures (PDF)

CC.PP.012     IV Hydration (PDF)

CC.PP.013     Modifier -25 clinical validation (PDF)

CC.PP.014     Modifier -59 clinical validation (PDF)

CC.PP.017     Never Paid Events (PDF)

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

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

CC.PP.022     CLIA Number (PDF)

CC.PP.023     Hospital Visit Codes Billed with Labs (PDF)

CC.PP.015     Moderate Conscious Sedation (PDF)

CC.PP.019     Physician Visit Codes Billed with Labs (PDF)

CC.PP.028     Modifier to Procedure Code Validation (PDF)

CC.PP.031     NCCI Unbundling (PDF)

CC.PP.033     Multiple CPT Code Replacement (PDF)

CC.PP.024     Cosmetic Procedures (PDF)

CC.PP.025     Pulse Oximetry (PDF)

CC.PP.027     Professional Component (PDF)

CC.PP.030     Add on Code Billed Without Primary Code (PDF)

CC.PP.032     Supplies Billed on Same Day As Surgery (PDF)

CC.PP.034     Modifier DOS Validation (PDF)

CP.MP.110    Bronchial Thermoplasty (PDF)

CP.MP.97     Diagnosis of Vaginitis (PDF)

CP.MP.113     Holter Monitor (PDF)

CP.MP.123     Laser Skin Treatment (PDF)

CP.MP.121     Homocysteine Testing (PDF)

CP.MP.103     FeNo Testing (PDF)

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

CC.PP.500     3-Day Payment Window (PDF)

CC.PP.501     30-Day Readmission (PDF)

CP.MP.90     Digital Breast Tomosynthesis (DBT) (PDF)

CP.MP.105     Digital Analysis of EEGs (PDF)

CP.MP.125     DNA Analysis of Stool (PDF)

CP.MP.134     Evoked Potentials (PDF)

CP.MP.135     Fecal Calprotectin Assay (PDF)

CC.PP.035     Sleep Studies Place of Services (PDF)

CC.PP.043     Unbundled Professional Services (PDF)

CC.PP.045     Unbundled Surgical Procedures (PDF)

CP.MP.140     EpiFix Wound Treatment (PDF)

CP.MP.139     Low-Frequency Ultrasound Wound Therapy (PDF)

CP.MP.143     Wireless Motility Capsule (PDF)

CP.MP.144     Mechanical Stretch Devices (PDF)

CC.PP.050     Robotic Surgery (PDF)

CC.PP.051     E&M Medical Decision-Making (PDF)

CC.PP.053     Leveling of ER Services (PDF)

CC.PP.054     Physician's Consultation Services (PDF)

CC.PP.057     Problem Oriented Visits with Preventative Visits (PDF)

CC.PP.052     Problem Oriented Visits with Surgical Procedures (PDF)

CP.MP.149     PROM Testing (PDF)

CC.PP.056     Urine Specimen Validity Testinp (PDF)

CP.MP.156     Cardiac Biomarker Testing for Acute MI (PDF)

CP.MP.155     EEG in Evaluation of Headache (PDF)

CP.MP.153     H Pylori Testing (PDF)

CP.MP.152     Measure Serum 1,25 Vitamin D (PDF)

CP.MP.154     Thyroid Testing in Pediatrics (PDF)

CP.MP.157     Vitamin D Testing in Children (PDF)

CC.PP.059     Clinic Facility Charge (PDF)

CC.PP.060     Not Medically Necessary IP Serv (PDF)

CP.MP.161     Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)

CC.PP.063     Place of Service Mismatch (PDF)

CC.PP.061     Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)

OC.UM.CP.0026      Extended Ophthalmoscopy (PDF)

OC.UM.CP.0043      External Ocular Photography (PDF)

OC.UM.CP.0028      Fluorescein Angiography(PDF)

OC.UM.CP.0029      Fundud Photography (PDF)

OC.UM.CP.0031      Gonioscopy (PDF)

OC.UM.CP.0014      Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)

OC.UM.CP.0063      Visual Field Test (PDF)