Clinical Payment Policies | Ambetter from Arizona Complete Health


Clinical & Payment Policies

Clinical & Payment Policies

Clinical Policies

Important Notice

The Clinical Policies do not constitute medical advice.  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 Clinical Policy Manual apply to health plan members. The health plan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which health plan clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  In addition, the health plan 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 the health plan.   

The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine. The health plan reserves the right to amend the Policies without notice to providers or Members.

Policies specifically developed to assist the health plan in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other health plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

The Clinical Policy Manuals may be accessed through the links below.

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

Adopted Clinical Practice and Preventive Health Guidelines (PDF)CPG Grid
Air Ambulance (PDF)CP.MP.175
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108
Ambulatory Surgery Center Optimization (PDF)CP.MP.158
Applied Behavior Analysis (PDF)CP.BH.104
Assisted Reproductive Technology (PDF)CP.MP.55
Bariatric Surgery (PDF)CP.MP.37
Behavioral Health Treatment Document Requirement (PDF)CP.BH.500
Biofeedback (PDF)CP.MP.168
Bone-Anchored Hearing Aid (PDF)CP.MP.93
Clinical Trials (PDF)CP.MP.94
Concert Genetic Testing Aortopathies and Connective Tissue Disorders (PDF)V2.2023
Concert Genetic Testing Cardiac Disorders (PDF)V2.2023
Concert Genetic Testing Dermatologic Conditions (PDF)V2.2023
Concert Genetic Testing Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V2.2023
Concert Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V2.2023
Concert Genetic Testing Eye Disorders (PDF)V2.2023
Concert Genetic Testing Gastroenterologic Disorders (non-cancerous) (PDF)V2.2023
Concert Genetic Testing General Approach to Genetic Testing (PDF)V2.2023
Concert Genetic Testing Hearing Loss (PDF)V2.2023
Concert Genetic Testing Hematologic Condition (non-cancerous) (PDF)V2.2023
Concert Genetic Testing Hereditary Cancer Susceptibility (PDF)V2.2023
Concert Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders (PDF)V2.2023
Concert Genetic Testing Kidney Disorders (PDF)V2.2023
Concert Genetic Testing Lung Disorders (PDF)V2.2023
Concert Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V2.2023
Concert Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V2.2023
Concert Genetic Testing Non-Invasive Prenatal Screening (NIPS) (PDF)V2.2023
Concert Genetic Testing Pharmacogenetics (PDF)V2.2023
Concert Genetic Testing Preimplantation Genetic Testing (PDF)V2.2023
Concert Genetic Testing Prenatal and Preconception Carrier Screening (PDF)V2.2023
Concert Genetic Testing Prenatal Diagnosis via Amniocentesis, CVS or PUBS and Pregnancy Loss (PDF)V2.2023
Concert Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (PDF)V2.2023
Concert Genetics Oncology Algorithmic Testing (PDF)V2.2023
Concert Genetics Oncology Cancer Screening (PDF)V2.2023
Concert Genetics Oncology Circulating Tumor DNA and Circulating Tumor Cells Liquid Biopsy (PDF)V2.2023
Concert Genetics Oncology Cytogenetic Testing (PDF)V2.2023
Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V2.2023
Cosmetic and Reconstructive Surgery (PDF)CP.MP.31
Deep Transcranial Magnetic Stimulation for Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.201
Diaphragmatic Phrenic Nerve Stimulation (PDF)CP.MP.203
Disc Decompression Procedures (PDF)CP.MP.114
Discography (PDF)CP.MP.115
Donor Lymphocyte Infusion (PDF)CP.MP.101
Drugs of Abuse: Definitive Testing (PDF)CP.MP.50
Durable Medical Equipment (DME) (PDF)CP.MP.107
Electric Tumor Treating Fields (PDF)CP.MP.145
Evoked Potential Testing (PDF)CP.MP.134
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248
Ferriscan R2-MRI (PDF)CP.MP.53
Fertility Preservation (PDF)CP.MP.130
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)CP.MP.209
Gender-Affirming Procedures (PDF)CP.MP.95
Heart-Lung Transplant (PDF)CP.MP.132
Holter Monitors (PDF)CP.MP.113
Home Births (PDF)CP.MP.136
Home Ventilators (PDF)CP.MP.184
Hospice (PDF)CP.MP.54
Hyperhidrosis Treatments (PDF)CP.MP.62
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173
Implantable Loop Recorder (PDF)CP.MP.243
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.160
Intensity- Modulated Radiotherapy (PDF)CP.MP.69
Intestinal and Multivisceral Transplant (PDF)CP.MP.58
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61
Liposuction for Lipedema (PDF)CP.MP.244
Long Term Care Placement (PDF)CP.MP.71
Lysis of Epidural Lesions (PDF)CP.MP.116
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.144
Multiple Sleep Latency Testing (PDF)CP.MP.24
Neonatal Sepsis Management (PDF)CP.MP.85
NICU Discharge Guidelines (PDF)CP.MP.81
Obstetrical Home Care Programs (PDF)CP.MP.91
Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249
Orthognathic Surgery (PDF)CP.MP.202
Outpatient Cardiac Rehabilitation (PDF)CP.MP.176
Outpatient Oxygen Use (PDF)CP.MP.190
Panniculectomy (PDF)CP.MP.109
Pediatric Heart Transplant (PDF)CP.MP.138
Pediatric Oral Function Therapy (PDF)CP.MP.188
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.147
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.150
Physical, Occupational, and Speech Therapy Services (PDF)CP.MP.49
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)CP.MP.181
Proton and Neutron Beam Therapies (PDF)CP.MP.70
Pulmonary Function Testing (PDF)CP.MP.242
Repair of Nasal Valve Compromise (PDF)CP.MP.210
Sacroiliac Joint Fusion (PDF)CP.MP.126
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174
Short Inpatient Hospital Stay (PDF)CP.MP.182
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185
Stereotactic Body Radiation Therapy (PDF)CP.MP.22
Substance Use Treatment and Services (PDF)CP.BH.100
Tandem TransplantCP.MP.162
Testing Select GU Conditions (PDF)CP.MP.97
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87
Total Artificial Heart (PDF)CP.MP.127
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163
Transcatheter Closure of Patent Foramen Ovale (PDF)CP.MP.151
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)CP.BH.200
Transplant Service Documentation Requirements (PDF)CP.MP.247
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142

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

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