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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
Policy Title Policy Number Effective Date
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 12/2017
Acupuncture (PDF) CP.MP.92 11/2016
Allergy Testing and Therapy (PDF) CP.MP.100 02/2016
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (PDF) CP.MP.108 03/2016
Ambulatory Electroencephalography EEG (PDF) CP.MP.96 09/2015
Ambulatory Surgery Center Optimization (PDF) CP.MP.158 01/2018
Antithrombin III (Thrombate III, Atryn) (PDF)
CP.MP.179 10/31/2019
Applied Behavioral Analysis for Autism (PDF) CP.MP.104 08/2009
Articular Cartilage Defect Repairs (PDF) CP.MP.26 10/2008
Assisted Reproductive Technology (PDF) CP.MP.55 03/2014
Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis (PDF) CP.MP.119 07/2016
Bariatric Surgery (PDF) CP.MP.37 08/2014
Biofeedback (PDF) CP.MP.168 07/2017
Bone-Anchored Hearing Aid (PDF) CP.MP.93 12/2013
Bronchial Thermoplasty (PDF) CP.MP.110 05/2016
Cardiac Biomarker Testing (PDF) CP.MP.156 12/2017
Carrier Screening in Pregnancy (PDF) CP.MP.83 07/2013
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 08/2018
Cell-free Fetal DNA Testing (PDF) CP.MP.84 08/2013
Clinical Trials (PDF) CP.MP.94 01/2014
Cochlear Implant Replacements (PDF) CP.MP.14 02/2009
Coronavirus (COVID-19) Testing (PDF) CP.MP.183 04/01/2020
Cosmetic and Reconstructive Surgery (PDF) CP.MP.31 03/2009
Dental Anesthesia (PDF) CP.MP.61 06/2013
Digital EEG Spike Analysis (PDF) CP.MP.105 01/2016
Disc Decompression Procedures (PDF) CP.MP.114 07/2016
Discography (PDF) CP.MP.115 07/2016
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) CP.MP.125 09/2016
Donor Lymphocyte Infusion (PDF) CP.MP.101 11/2015
Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines (PDF) CP.MP.107 06/2009
Electric Tumor Treating Fields (Optune) (PDF) CP.MP.145 05/2017
EEG in the Evaluation of Headache (PDF) CP.MP.155 12/2017
Endometrial Ablation (PDF) CP.MP.106 01/2016
EpiFix Wound Treatment (PDF)
Effective 04/2017 - 12/31/2018
CP.MP.140 04/2017 - 12/31/2018
EpiFix Wound Treatment (PDF)
Effective 1/1/2019
CP.MP.140 1/1/2019
Essure Removal (PDF) CP.MP.131 11/2016
Evoked Potential Testing (PDF) CP.MP.134 11/2016
Experimental Technologies (PDF) CP.MP.36 06/2009
Facet Joint Interventions (PDF) CP.MP.171 09/2018
Fecal Incontinence Treatments (PDF) CP.MP.137 12/2016
Ferriscan R2-MRI (PDF) CP.MP.53 11/2012
Fertility Preservation (PDF) CP.MP.130 10/2016
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 10/2016
Fixed Wing Air Transportation (PDF) CP.MP.175 04/2019
Fractional Exhaled Nitric Oxide FeNo (PDF) CP.MP.103 01/2016
Functional MRI (PDF) CP.MP.43 10/2013
Gastric Electrical Stimulation (PDF) CP.MP.40 11/2011
Genetic and Pharmacogenetic Testing (PDF) CP.MP.89 11/2013
Helicobacter Pylori Serology Testing (PDF) CP.MP.153 12/2017
Heart-Lung Transplant (PDF) CP.MP.132 06/2017
Holter Monitors (PDF) CP.MP.113 08/2016
Home Birth (PDF) CP.MP.136 12/2016
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 12/2017
Homocysteine Testing (PDF) CP.MP.121 08/2016
Hospice Services (PDF) CP.MP.54  07/2014
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 03/2009
Hyperhidrosis Treatments (PDF) CP.MP.62 05/2013
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 11/2019
Implantable Intrathecal Pain Pump (PDF) CP.MP.173 02/2019
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 04/2018
Inhaled Nitric Oxide (PDF) CP.MP.87 08/2013
Intensity-Modulated Radiotherapy (PDF) CP.MP.69 03/2014
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 02/2014
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 08/2018
Laser Therapy for Skin Conditions (PDF) CP.MP.123 08/2016
Long Term Care Placement (PDF) CP.MP.71 05/2014
Low-Frequency Ultrasound Therapy for Wound Management (PDF) CP.MP.139 02/2017
Lung Transplantation (PDF) CP.MP.57 02/2014
Lysis of Epidural Lesions (PDF) CP.MP.116 07/2016
Measurement of Serum 1, 25-Dihydroxyvitamin D (PDF) CP.MP.152 12/2017
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) CP.MP.144 04/2017
Multiple Sleep Latency Testing (PDF) CP.MP.24 10/2008
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 10/2013
Neonatal Sepsis Management (PDF) CP.MP.85 08/2013
Nerve Blocks for Pain Management (PDF) CP.MP.170 08/2018
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 06/2013
NICU Discharge Guidelines (PDF) CP.MP.81 06/2013
Non-Myeloablative Allogeneic Stem Cell Transplants (PDF) CP.MP.141 04/2017
Obstetrical Home Health Care Programs (PDF) CP.MP.91 01/2014
Optic Nerve Decompression Surgery (PDF) CP.MP.128 09/2016
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 05/2019
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 09/2012
Pancreas Transplant (PDF) CP.MP.102 04/2016
Panniculectomy (PDF) CP.MP.109 04/2016
Pediatric Heart Transplant (PDF) CP.MP.138 01/2017
Pediatric Liver Transplant (PDF) CP.MP.120 04/2018
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147  07/2017
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 04/2011
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 1/31/2020
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 10/2016
Preventive Health and Clinical Practice Guidelines CP.CPC.03 07/2015
Proton and Neutron Beam Therapy (PDF) CP.MP.70 03/2014
Radial Head Implant (PDF) CP.MP.148 08/2017
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 08/2012
Sacroiliac Joint Fusion (PDF) CP.MP.126 09/2016
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 08/2018
Sclerotherapy for Vericose Veins (PDF) CP.MP.146 06/2017
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) CP.MP.174 03/2019
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165 08/2018
Sickle Cell Disease Observation (PDF) CP.MP.88 09/2013
Spinal Cord Stimulation (PDF) CP.MP.117 07/2016
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 03/2014
Tandem Transplant (PDF) CP.MP.162  07/2018
Testing for Rupture of Fetal Membranes (PDF) CP.MP.149 08/2017
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 06/2016
Therapy Services (PT/OT/ST) (PDF) CP.MP.49 04/2011
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) CP.MP.154 12/2017
Total Artificial Heart (PDF) CP.MP.127 12/2016
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 05/2016
Transcatheter Closure of Patent Foramen Ovale (PDF) CP.MP.151 12/2017
Trigger Point Injections for Pain Management (PDF) CP.MP.169 08/2018
Ultrasound in Pregnancy (PDF) CP.MP.38 01/2011
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 04/2017
Urodynamic Testing (PDF) CP.MP.98 10/2015
Vagus Nerve Stimulation (PDF) CP.MP.12 10/2013
Ventricular Assist Devices (PDF) CP.MP.46 12/2009
Ventriculectomy and Cardiomyoplasty (PDF) CP.MP.56 05/2013
Video Electroencephalographic (VEEG) Monitoring (PDF)
Effective 10/31/2019
CP.MP.177 10/2019
Wheelchair Seating (PDF) CP.MP.99 10/2015
Wireless Motility Capsule (PDF) CP.MP.143 04/2017
Zika Virus Testing (PDF) CP.MP.111 06/2016
Pharmacy Policies
Policy Title Policy Number Effective Date
Asenapine (Saphris®) (PDF) NE.PMN.15 01/01/2017
Botulinum Toxins (PDF) NE.PHAR.15 01/01/2017
Brexpiprazole (Rexulti) (PDF) NE.PMN.68 01/01/2017
Bevacizumab (Avastin, Mvasi) (PDF)
Effective 12/01/2011 - 3/31/2017
CP.PHAR.93 12/01/2011 - 3/31/2017
Bevacizumab (Avastin, Mvasi) (PDF)
Effective 4/1/2017 - 12/31/2019
CP.PHAR.93 4/1/2017 - 12/31/2019
Bevacizumab (Avastin, Mvasi) (PDF)
Effective 01/01/2020
CP.PHAR.93 01/01/2020
clobazam (Onfi®) (PDF) NE.PMN.54 01/01/2017
Clozapine ODT (Fazado®) (PDF) NE.PMN.12 01/2017
HER2 Breast Cancer Treatment (PDF) NE.PHAR.67 01/01/2017
Iloperidone (Fanapt®) (PDF) NE.PMN.32 01/01/2017
Linezolid (Zyvox) (PDF) NE.PMN.27 01/01/2017
lurasidone (Latuda®) (PDF) NE.PMN.50 01/01/2017
paliperidone ER (Invega®) (PDF) NE.PMN.30 01/01/2017
Paclitaxel, Protein Bound (Abraxane) (PDF)
Effective 07/01/2015 - 09/30/2019
CP.PHAR.176 07/01/2015 - 09/30/2019
Paclitaxel, Protein Bound (Abraxane) (PDF)
Effective 10/01/2019
CP.PHAR.176 10/01/2019
sodium oxybate (Xyrem®) (PDF) NE.PMN.42 01/01/2017
tedizolid (Sivextro®) (PDF) NE.PMN.62 01/01/2017

 

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
Policy Title Policy Number Effective Date
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 12/2017
3-Day Payment Window (PDF) CC.PP.500 07/01/2014
30-Day Readmission (PDF) CC.PP.501 01/01/2015
Add on Code Billed Without Primary Code (PDF) CC.PP.030 01/01/2013
Allergy Testing and Therapy (PDF) CP.MP.100 02/2016
Ambulatory Electroencephalography EEG (PDF) CP.MP.96 09/2015
Antithrombin III (Thrombate III, Atryn) (PDF)
CP.MP.179 10/31/2019
Assistant Surgeon (PDF) CC.PP.029 01/01/2014
Bilateral Procedures (PDF) CC.PP.037 01/01/2014
Bronchial Thermoplasty (PDF) CP.MP.110 05/2016
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 12/2017
Cerumen Removal (PDF) CC.PP.008 01/01/2014
Clean Claims (PDF) CC.PP.021 01/01/2013
Clinic Facility Charge (PDF) CC.PP.059 01/29/2018
Coding Editing Overview (PDF) CC.PP.011 01/01/2013
Cosmetic Procedures (PDF) CC.PP.024 01/01/2014
Diagnosis of Vaginitis (PDF) CP.MP.97 06/2016
Digital EEG Spike Analysis (PDF) CP.MP.105 01/2016
Distinct Procedural Modifiers (PDF) CC.PP.020 01/01/2013
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) CP.MP.125 09/2016
Duplicate Primary Code Billing (PDF) CC.PP.044 01/01/2014
E&M Medical Decision-Making (PDF) CC.PP.051 6/2017
EEG in Evaluation of Headache (PDF) CP.MP.155 12/2017
EM Bundling Edits (PDF) CC.PP.010 01/01/2013
Endometrial Ablation (EA) (PDF) CP.MP.106 01/2016
EpiFix Wound Treatment (PDF) CP.MP.140 04/2017
Evoked Potential Testing (PDF) CP.MP.134 11/2016
Extended Ophthalmoscopy (PDF) OC.UM.CP.0026 01/01/2018
External Ocular Photography (PDF) OC.UM.CP.0043 10/01/2016
Fractional Exhaled Nitric Oxide FeNo (PDF) CP.MP.103 01/2016
Fluorescein Angiography (PDF) OC.UM.CP.0028 01/01/2018
Fundus Photography (PDF) OC.UM.CP.0029 01/01/2018
Global Maternity Billing (PDF) CC.PP.016 01/01/2013
Gonioscopy (PDF) OC.UM.CP.0031 10/01/2016
Helicobacter Pylori Serology Testing (PDF) CP.MP.153 12/2017
Holter Monitor (PDF) CP.MP.113 08/2016
Homocysteine Testing (PDF)
CP.MP.121 08/2016
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 01/01/2013
Inpatient Consultation (PDF) CC.PP.038 01/01/2014
Incidental Diagnostic and Laboratory Tests Billed with Evaluation and Management Services (PDF) CC.PP.010 01/01/2013
Inpatient Only Procedures (PDF) CC.PP.018 01/01/2013
IV Hydration (PDF) CC.PP.012 01/01/2013
Laser Skin Treatment (PDF) CP.MP.123 08/2016
Leveling of ER Services (PDF) CC.PP.053 10/01/2017
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 02/2017
Maximum Units of Service (PDF) CC.PP.007 01/01/2013
Measurement of Serum 1,25-dihydroxyvitamin D (PDF) CP.MP.152 12/2017
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) CP.MP.144 04/2017
Moderate Conscious Sedation (PDF) CC.PP.015 01/01/2013
Modifier -25 clinical validation (PDF) CC.PP.013 01/01/2013
Modifier -59 clinical validation (PDF) CC.PP.014 01/01/2013
Modifier DOS Validation (PDF) CC.PP.034 01/01/2013
Modifier to Procedure Code Validation (PDF) CC.PP.028 01/01/2013
Multiple CPT Code Replacements (PDF) CC.PP.033 01/01/2014
NCCI Unbundling (PDF) CC.PP.031 01/01/2013
Never Paid Events (PDF) CC.PP.017 01/01/2013
New Patient (PDF) CC.PP.036 01/01/2014
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) CC.PP.061 05/30/18
Not Medically Necessary IP Services (PDF) CC.PP.060 06/01/2018
Outpatient Consultation (PDF) CC.PP.039 01/01/2014
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 01/01/2013
Physician's Consultation Services (PDF) CC.PP.054 11/01/2017
Place of Service Mismatch (PDF) CC.PP.063 09/01/2018
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 1/31/2020
Post-Operative Visits (PDF) CC.PP.042 01/01/2014
Pre-Operative Visits (PDF) CC.PP.041 01/01/2014
Problem Oriented Visits with Preventive Visits (PDF) CC.PP.057 11/1/2017
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/1/2017
Professional Component Modifier -26 (PDF) CC.PP.027 01/01/2013
PROM Testing (PDF) CP.MP.149 08/2017
Pulse Oximetry (PDF) CC.PP.025 01/01/2014
Robotic Surgery (PDF) CC.PP.050 8/2017
Same Day Visits (PDF) CC.PP.040 11/01/2019
Scanning Computerized Ophthalmic Diagnostic Imaging (PDF) OC.UM.CP.0014 01/01/2018
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) CP.MP.174 03/2019
Sleep Studies Place of Services (PDF) CC.PP.035 05/01/2017 
Status "B" Bundled Services (PDF) CC.PP.046 01/01/2014
Status "P" Bundled Services (PDF) CC.PP.049 03/15/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 01/01/2013
Testing for Rupture of Fetal Membranes (PDF) CP.MP.149 08/2017
Testing for Select Genitourinary Conditions (PDF) CP.MP.97  06/2016
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) CP.MP.154 12/2017
Transgender Related Services (PDF) CC.PP.047 01/01/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 01/2011
Unbundled Professional Services (PDF) CC.PP.043 01/01/2014
Unbundled Surgical Procedures (PDF) CC.PP.045 01/01/2014
Unlisted Procedure Codes (PDF) CC.PP.009 01/01/2013
Urine Specimen Validity Testing (PDF) CC.PP.056 11/01/2017 
Urodynamic Testing (PDF) CP.MP.98 10/2015
Visual Field Test (PDF) OC.UM.CP.0063 01/01/2018
Vitamin D Testing in Children (PDF) CP.MP.157 12/2017
Wheelchair Accessories (PDF) CC.PP.502 07/01/2016
Wheelchair Seating (PDF) CP.MP.99  10/2015
Wireless Motility Capsule (PDF) CP.MP.143  04/2017