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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 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.

Clinical Policies
A - H I - Q R - Z
25-hydroxyvitamin D testing in children and adolescents  CP.MP.157 (PDF) Implantable Wireless Pulmonary Artery Pressure Monitoring  CP.MP.160 (PDF) Radial Head Implant  CP.MP.148 (PDF)
Acupuncture  CP.MP.92 (PDF)
Implantable Intrathecal Pain Pump CP.MP.173 (PDF)
Reduction mammoplasty and gynecomastia surgery  CP.MP.51 (PDF)
ADHD Assessment and Treatment  CP.MP.124 (PDF) Inhaled nitric oxide  CP.MP.87 (PDF) Sacroiliac joint fusion  CP.MP.126 (PDF)
Allergy Testing and Therapy  CP.MP.100 (PDF) Intensity-Modulated Radiotherapy  CP.MP.69 (PDF) Sacroiliac Joint Interventions  CP.MP.166 (PDF)
Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia  CP.MP.108 (PDF) Intestinal and multivisceral transplant  CP.MP.58 (PDF) Sacroiliac Joint Interventions for Pain Management  CP.MP.166 (PDF)
Ambulatory EEG  CP.MP.96 (PDF) Intradiscal Steroid Injections  CP.MP.167 (PDF) Sclerotherapy for Vericose Veins  CP.MP.146 (PDF)
Ambulatory Surgery Center Optimization  CP.MP.158 (PDF) Intradiscal Steroid Injections for Pain Management  CP.MP.167 (PDF) Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management  CP.MP.165 (PDF)
Applied Behavioral Analysis for Autism  CP.MP.104 (PDF) Laser therapy for skin conditions  CP.MP.123 (PDF) Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections  CP.MP.165 (PDF)
Articular Cartilage Defect Repairs  CP.MP.26 (PDF) Long Term Care Placement Criteria  CP.MP.71 (PDF) Sickle cell disease observation  CP.MP.88 (PDF)
Assisted Reproductive Technology  CP.MP.55 (PDF) Low-frequency ultrasound therapy for wound management  CP.MP.139 (PDF) Spinal Cord Stimulation  CP.MP.117 (PDF)
Balloon sinus ostial dilation  CP.MP.119 (PDF) Lung Transplantation  CP.MP.57 (PDF) Stereotactic Body Radiation Therapy  CP.MP.22 (PDF)
Bariatric Surgery  CP.MP.37 (PDF) Lysis of Epidural Lesions  CP.MP.116 (PDF) Tandem Transplant  CP.MP.162 (PDF)
Biofeedback  CP.MP.168 (PDF) Measurement of serum 1, 25-dihydroxyvitamin D  CP.MP.152 (PDF) Testing for rupture of fetal membranes  CP.MP.149 (PDF)
Bone-anchored hearing aid  CP.MP.93 (PDF) Mechanical Stretching Devices for Joint Stiffness and Contracture  CP.MP.144 (PDF) Testing for select genitourinary conditions  CP.MP.97 (PDF)
Bronchial Thermoplasty  CP.MP.110 (PDF) Medical Necessity Criteria  CP.MP.68 (PDF) Therapy Services (PT/OT/ST)  CP.MP.49 (PDF)
Cardiac biomarker testing  CP.MP.156 (PDF) Monitored Anesthesia Care for Gastrointestinal Endoscopy  CP.MP.161 (PDF) Thyroid hormones and insulin testing in pediatrics  CP.MP.154 (PDF)
Carrier Screening in Pregnancy  CP.MP.83 (PDF) Multiple Sleep Latency Testing  CP.MP.24 (PDF) Total artificial heart  CP.MP.127 (PDF)
Caudal or Interlaminar Epidural Steroid Injections  CP.MP.164 (PDF) Neonatal abstinence syndrome guidelines  CP.MP.86 (PDF) Total Parenteral Nutrition and Intradialytic Parenteral Nutrition  CP.MP.163 (PDF)
Caudal or Interlaminar Epidural Steroid Injections for Pain Management  CP.MP.164 (PDF) Neonatal sepsis management  CP.MP.85 (PDF) Transcatheter closure of patent foramen ovale  CP.MP.151 (PDF)
Cell-free Fetal DNA Testing  CP.MP.84 (PDF) Nerve Blocks  CP.MP.170 (PDF) Trigger Point Injections  CP.MP.169 (PDF)
Clinical Trials  CP.MP.94 (PDF) Nerve Blocks for Pain Management  CP.MP.170 (PDF) Trigger Point Injections for Pain Management  CP.MP.169 (PDF)
Cochlear Implant Replacements  CP.MP.14 (PDF) NICU Apnea Bradycardia Guidelines  CP.MP.82 (PDF) Ultrasound in Pregnancy  CP.MP.38 (PDF)
Cosmetic and Reconstructive Surgery  CP.MP.31 (PDF) NICU discharge guidelines  CP.MP.81 (PDF) Urinary Incontinence Devices and Treatments  CP.MP.142 (PDF)
Dental Anesthesia  CP.MP.61 (PDF) Non-myeloablative allogeneic stem cell transplants  CP.MP.141 (PDF) Urodynamic testing  CP.MP.98 (PDF)
Digital electroencephalography spike analysis  CP.MP.105 (PDF) Obstetrical Home Health Care Programs  CP.MP.91 (PDF) Vagus Nerve Stimulation  CP.MP.12 (PDF)
Disc Decompression Procedures  CP.MP.114 (PDF) Optic nerve decompression surgery  CP.MP.128 (PDF) Ventricular Assist Devices  CP.MP.46 (PDF)
Discography  CP.MP.115 (PDF) Outpatient testing for drugs of abuse  CP.MP.50 (PDF) Ventriculectomy and cardiomyoplasty  CP.MP.56 (PDF)
DNA analysis of stool to screen for colorectal cancer  CP.MP.125 (PDF) Pancreas transplant  CP.MP.102 (PDF) Wheelchair seating  CP.MP.99 (PDF)
Donor lymphocyte infusion  CP.MP.101 (PDF) Panniculectomy  CP.MP.109 (PDF) Wireless Motility Capsule  CP.MP.143 (PDF)
Durable Medical Equipment (DME)  CP.MP.107 (PDF) Pediatric heart transplant  CP.MP.138 (PDF) Zika Virus Testing  CP.MP.111 (PDF)
Electric Tumor Treating Fields  CP.MP.145 (PDF) Pediatric Liver Transplant  CP.MP.120 (PDF)  
Electroencephalography in the evaluation of headache  CP.MP.155 (PDF) Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention  CP.MP.147 (PDF)  
Endometrial ablation  CP.MP.106 (PDF) Posterior tibial nerve stimulation for voiding dysfunction  CP.MP.133 (PDF)  
EpiFix Wound Treatment  CP.MP.140 (PDF) Proton and neutron beam therapy  CP.MP.70 (PDF)  
Essure Removal  CP.MP.131 (PDF)    
Evoked Potential Testing  CP.MP.134 (PDF)    
Experimental Technologies  CP.MP.36 (PDF)    
Facet Joint Interventions  CP.MP.171 (PDF)    
Facet Joint Interventions for Pain Management  CP.MP.171 (PDF)    
Fecal incontinence treatments  CP.MP.137 (PDF)    
Ferriscan R2-MR  CP.MP.53 (PDF)    
Fertility preservation  CP.MP.130 (PDF)

Fetal surgery in utero for prenatally diagnosed malformations  CP.MP.129 (PDF)    
Fractional exhaled nitric oxide  CP.MP.103 (PDF)    
Functional MRI  CP.MP.43 (PFD)    
Gastric electrical stimulation  CP.MP.40 (PDF)    
Genetic Testing  CP.MP.89 (PDF)    
H. Pylori serology testing  CP.MP.153 (PDF)    
Heart-Lung Transplant  CP.MP.132 (PDF)    
Holter Monitors  CP.MP.113 (PDF)    
Home Birth  CP.MP.136 (PDF)    
Home phototherapy for neonatal hyperbilirubinemia  CP.MP.150 (PDF)    
Homocysteine testing  CP.MP.121 (PDF)    
Hospice Services  CP.MP.54 (PDF)    
Hyperbaric Oxygen Therapy  CP.MP.27 (PDF)    
Hyperemesis gravidarum treatment  CP.MP.34 (PDF)    
Hyperhidrosis treatments  CP.MP.62 (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.

Payment Policies
A - H I - Q R - Z
30-Day Readmission  CC.PP.501 (PDF) Inpatient Consultation  CC.PP.038 (PDF) Rituximab  CP.PHAR.260 (PDF)
3-Day Payment Window  CC.PP.500 (PDF) Inpatient Only Procedures  CC.PP.018 (PDF) Robotic Surgery  CC.PP.050 (PDF)
Add on Code Billed Without Primary Code  CC.PP.030 (PDF) IV Hydration  CC.PP.012 (PDF) Same Day Visits  CC.PP.040 (PDF)
ADHD Assessment and Treatment  CP.MP.124 (PDF) Laser Skin Treatment  CP.MP.123 (PDF) Scanning Computerized Ophthalmic Diagnostic Imaging  OC.UM.CP.0014 (PDF)
Allergy Testing  CP.MP.100 (PDF) Leveling of ER Services  CC.PP.053 (PDF) Sleep Studies Place of Services  CC.PP.035 (PDF)
Ambulatory EEG  CP.MP.96 (PDF) Low-Frequency Ultrasound Wound Therapy  CP.MP.139 (PDF) Status "B" Bundled Services  CC.PP.046 (PDF)
Assistant Surgeon  CC.PP.029 (PDF) Maximum Units  CC.PP.007 (PDF) Status "P" Bundled Services  CC.PP.049 (PDF)
Bevacizumab  CP.PHAR.93 (PDF) Measure Serum 1,25 Vitamin D  CP.MP.152 (PDF) Supplies Billed on Same Day As Surgery  CC.PP.032 (PDF)
Bilateral Procedures  CC.PP.037 (PDF) Mechanical Stretch Devices  CP.MP.144 (PDF) Thyroid Testing in Pediatrics  CP.MP.154 (PDF)
Bronchial Thermoplasty  CP.MP.110 (PDF) Moderate Conscious Sedation  CC.PP.015 (PDF) Transgender Related Services  CC.PP.047 (PDF)
Cardiac Biomarker Testing for Acute MI  CP.MP.156 (PDF) Modifier -25 clinical validation  CC.PP.013 (PDF) Ultrasound in Pregnancy  CP.MP.38 (PDF)
Cerumen Removal  CC.PP.008 (PDF) Modifier -59 clinical validation  CC.PP.014 (PDF) Unbundled Professional Services  CC.PP.043 (PDF)
Clean Claims  CC.PP.021 (PDF) Modifier DOS Validation  CC.PP.034 (PDF) Unbundled Surgical Procedures  CC.PP.045 (PDF)
CLIA Number  CC.PP.022 (PDF) Modifier to Procedure Code Validation  CC.PP.028 (PDF) Unlisted Procedure Codes  CC.PP.009 (PDF)
Clinic Facility Charge  CC.PP.059 (PDF) Monitored Anesthesia Care for Gastrointestinal Endoscopy  CP.MP.161 (PDF) Urine Specimen Validity Testing  CC.PP.056 (PDF)
Coding Overview  CC.PP.011 (PDF) Multiple CPT Code Replacement  CC.PP.033 (PDF) Urodynamic Testing  CP.MP.98 (PDF)
Cosmetic Procedures  CC.PP.024 (PDF) NCCI Unbundling  CC.PP.031 (PDF) Visual Field Test  OC.UM.CP.0063 (PDF)
Diagnosis of Vaginitis  CP.MP.97 (PDF) Never Paid Events  CC.PP.017 (PDF) Vitamin D Testing in Children  CP.MP.157 (PDF)
Digital Analysis of EEGs  CP.MP.105 (PDF) New Patient  CC.PP.036 (PDF) Wheelchair Accessories  CC.PP.502 (PDF)
Distinct Procedural Modifiers  CC.PP.020 (PDF) Non-obstetrical Pelvic and Transvaginal Ultrasounds  CC.PP.061 (PDF) Wheelchair Seating  CP.MP.99 (PDF)
DNA Analysis of Stool  CP.MP.125 (PDF) Not Medically Necessary IP Services  CC.PP.060 (PDF) Wireless Motility Capsule  CP.MP.143 (PDF)
Duplicate Primary Code Billing  CC.PP.044 (PDF) Outpatient Consultation  CC.PP.039 (PDF)  
E&M Medical Decision-Making  CC.PP.051 (PDF) Paclitaxel  CP.PHAR.176 (PDF)  
EEG in Evaluation of Headache  CP.MP.155 (PDF) Physician Visit Codes Billed with Labs  CC.PP.019 (PDF)  
EM Bundling Edits  CC.PP.010 (PDF) Physician's Consultation Services  CC.PP.054 (PDF)  
Endometrial Ablation (EA)  CP.MP.106 (PDF) Place of Service Mismatch  CC.PP.063 (PDF)  
EpiFix Wound Treatment  CP.MP.140 (PDF) Post-Operative Visits  CC.PP.042 (PDF)  
Evoked Potentials  CP.MP.134  (PDF) Pre-Operative Visits  CC.PP.041 (PDF)  
Extended Ophthalmoscopy  OC.UM.CP.0026 (PDF) Problem Oriented Visits with Preventative Visits  CC.PP.057 (PDF)  
External Ocular Photography  OC.UM.CP.0043 (PDF) Problem Oriented Visits with Surgical Procedures  CC.PP.052 (PDF)  
Fecal Calprotectin Assay  CP.MP.135 (PDF) Professional Component  CC.PP.027 (PDF)  
FeNo Testing  CP.MP.103 (PDF) PROM Testing  CP.MP.149 (PDF)  
Fluorescein Angiography  OC.UM.CP.0028 (PDF) Proton and Neutron Beam Therapy  CP.MP.70 (PDF)  
Fundus Photography  OC.UM.CP.0029 (PDF) Pulse Oximetry  CC.PP.025 (PDF)  
Global Maternity Billing  CC.PP.016 (PDF)    
Gonioscopy  OC.UM.CP.0031 (PDF)    
H Pylori Testing  CP.MP.153 (PDF)    
Holter Monitor  CP.MP.113 (PDF)    
Homocysteine Testing  CP.MP.121 (PDF)    
Hospital Visit Codes Billed with Labs  CC.PP.023 (PDF)