Florida Clinical Payment Policies | Ambetter from Sunshine Health

 

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

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

A-HI-QR-Z
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)
Effective Date: November 30, 2021		  
Acupuncture Expanded Benefit (PDF)
Effective Date: July 2018		Laser Therapy for Skin Conditions (PDF)
Effective Date: March 31, 2022

Rehabilitative Therapy Site of Care Optimization (PDF)

Effective date: August 2019

Adalimumab (Humira), Adalimumab-afzb (Abrilada), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-fkjp (Hulio), Adalimumab-adaz (Hyrimoz) (PDF)
Effective Date: August 2016		  
ADHD Assessment and Treatment (PDF)
Effective Date: February 2, 2022		Low-Frequency Ultrasound 
Wound Therapy (PDF)
Effective Date: September 1, 2017		Rituximab (PDF)
Effective Date: 
Allergy Testing and Therapy (PDF)
Effective Date: May 31, 2022		Measure Serum 1,25 Vitamin D (PDF)
Effective Date: October 31, 2021		Scanning Computerized Ophthalmic Diagnostic Imaging  (PDF)
Effective Date: January 1, 2022
Ambulatory EEG (PDF)
Effective Until: September 14, 2020		Mechanical Stretch Devices 
(PDF)
Effective Date: September 1, 2017

Short Inpatient Hospital Stay (PDF)

Effective Date: August 15, 2021

  Testing for Rupture of Fetal Membranes (PDF)
Effective Date: Retired
Ambulatory EEG (PDF)
Effective Date:  September 14, 2020		Paclitaxel (PDF)
Effective Date: 		Testing of Select GU Conditions (PDF)
Effective Date: March 31, 2022
Bevacizumab (PDF)
Effective Date: 		PCR Respiratory Viral Panel  Testing - Prepayment Policy (PDF)
Effective Date: August 15, 2021

Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: October 31, 2021

 Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
Effective Date: March 31, 2022		 
Bronchial Thermoplasty (PDF)
Effective Date: January 15, 2017		PROM Testing (PDF)
Effective Date: August 15, 2021		Ultrasound in Pregnancy (PDF)
Effective Date: March 31, 2022

Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: June 1, 2018

 

Proton and Neutron 
Beam Therapy (PDF)
Effective Date: November 1, 2016		Urodynamic Testing (PDF)
Effective Date: March 31, 2022
Diagnosis of Vaginitis (PDF)
Effective Date: January 15, 2017

 

 

Visual Field Testing (PDF)
Effective Date: January 1, 2022
Digital Analysis of EEGs (PDF)
Effective Date: 		 Vitamin D Testing 
in Children (PDF)
Effective Date: June 1, 2018
  Wheelchair Seating (PDF)
Effective Date: March 31, 2022
Doc to Doc Review (PDF)
Effective Date: June 1, 2021

 

Wireless Motility Capsule 
(PDF)
Effective Date: September 1, 2017
EEG in Evaluation of Headache (PDF)
Effective Date: October 31, 2021		 

 

Endometrial Ablation (PDF)
Effective Date: April 30, 2022		 

 

EpiFix Wound Treatment (PDF)
Effective Date: September 1, 2017		  

Evoked Potential Testing (PDF)
Effective Date: August 31, 2021

  
Extended Ophthalmoscopy (PDF)
Effective Date: August 15, 2021		  
External Ocular Photography (PDF)
Effective Date: January 1, 2022		  
Fecal Calprotectin Assay (PDF)
Effective Date: May 1, 2017		  
Fluorescein Angiography (PDF)
Effective Date: January 1, 2022		  
Fractional Exhaled Nitric Oxide (PDF)
Effective Date: Retired		  
Fundus Photography (PDF)
Effective Date: 		  
Gonioscopy (PDF)
Effective Date: January 1, 2022		  
H Pylori Testing (PDF)
Effective Date: June 1, 2018		  
Holter Monitors (PDF)
Effective Date: December 31, 2021		  
Homocysteine Testing (PDF)
Effective Date: March 31, 2022		  

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

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

A-HI-QR-Z
30-Day Readmission (PDF)
Effective Date: February 5, 2021		Inpatient Consultation (PDF) 
Effective Date: October 1, 2017		Renal Hemodialysis (PDF)
Effective Date: February 5, 2021
3-Day Payment Window (PDF)
Effective Date: 		Inpatient Only Procedures (PDF) 
Effective Date: November 30, 2021		Reporting Global Maternity Package (PDF)
Effective Date: 
Add on Code Billed Without Primary Code (PDF)
Effective Date:		Intravenous Hydration (PDF)
Effective Date: 		Rituximab (PDF)
Effective Date: November 1, 2017
ADHD Assessment and Treatment (PDF)
Effective Date: January 1, 2022		Laser Skin Treatment  (PDF)
Effective Date: March 31, 2022		Robotic Surgery (PDF)
Effective Date: April 20, 2021
Allergy Testing and Therapy (PDF)
Effective Date: January 1, 2022		Leveling of Care: Evaluation and Management Overcoding (PDF)
Effective Date: February 5, 2021		Same Day Visits (PDF)
Effective Date: 
  Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective Date: January 1, 2022
  Sepsis Diagnosis (PDF)
Effective Date: October 1, 2020

Ambulatory EEG (PDF)
Effective Until: September 14, 2020

Ambulatory EEG (PDF)
Effective Date: September 14, 2020

Leveling of ER (PDF)
Effective Date: August 1, 2018

Short Inpatient Hospital Stay (PDF)

Effective Date: October 1, 2020

Assistant Surgeon (PDF)
Effective Date:		Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: September 1, 2017		Status "B" Bundled Services (PDF)
Effective Date: 
Bevacizumab (Avastin) (PDF)
Effective Date: August 12, 2016		Maximum Units of Service (PDF)
Effective Date: 		Status "P" Bundled Services (PDF)
Effective Date: April 1, 2017

Bilateral Procedures (PDF)
Effective Date: 

Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: January 1, 2022		Supplies Same Day as Surgery (PDF)
Effective Date:
Bronchial Thermoplasty (PDF)
Effective Date: January 15, 2017		Mechanical Stretch Devices (PDF)
Effective Date:  September 1, 2017		Testing for Rupture of Fetal Membranes (PDF)
Effective Date: Retired
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: June 1, 2018		Moderate Conscious Sedation (PDF)
Effective Date: 		Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF)
Effective Date: January 1, 2022
  

Testing of Select GU Conditions  (PDF)

Effective Date: March 31, 2022

Cerumen Removal (PDF) 
Effective Date: 		Modifier DOS Validation (PDF)
Effective Date: 		Thryoid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: October 31, 2021
Clean Claims (PDF)
Effective Date: 		Modifier to Procedure Code Validation (PDF)
Effective Date: 		Transgender Related Services (PDF)
Effective Date: 
Clean Claim Reviews (PDF)
Effective Date: November 1, 2012		  
Clinical Validation of Modifier 25 (PDF)
Effective Date: 		Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: March 1, 2019 Ultrasound in Pregnancy (PDF)
Effective Date: March 31, 2022
 

Multiple Diagnostic Cardiovascular Procedure (PDF)

Effective Date:

 
Clinical Validation of Modifier 59 (PDF)
Effective Date: 		Multiple CPT Code (PDF)
Effective Date: 		 
Code Editing Overview (PDF)
Effective Date: 

Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)

Effective Date: February 6, 2021

Unbundled Professional Services (PDF)
Effective Date: 
Cosmetic Procedures (PDF) 
Effective Date: 		Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: August 23, 2021		Unbundled Surgical Procedures (PDF)
Effective Date: 
Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022		 Unbundling Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
Diagnosis of Vaginitis (PDF) 
Effective Date: January 15, 2017 - September 30, 2017		Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective Date: August 23, 2021		Unlisted Procedure Codes (PDF)
Effective Date:
Diagnosis of Vaginitis (PDF) Effective Date: October 1, 2017 - December 31, 2017NCCI Unbundling (PDF)
Effective Date: 		Urine Specimen Validity Testing (PDF)
Effective Date: April 20, 2021
Digital Analysis of EEGs (PDF)
Effective Date: October 31, 2021		Never Paid Events (PDF)
Effective Date: 		Urodynamic Testing (PDF)
Effective Date: March 31, 2022
Digital Breast Tomosynthesis (PDF)
Effective Date: December 1, 2016 - December 31, 2017		New Patient (PDF)
Effective Date: 		 
  Visual Field Testing (PDF)
Effective Date: January 1, 2022
Distinct Procedural Modifers (PDF)
Effective Date:		Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: March 1, 2019 Vitamin D Testing in Children and Adolescents (PDF)
Effective Date: June 1, 2018
 Outpatient Consultation (PDF)
Effective Date: 		Wheelchair and Accessories (PDF)
Effective Date: August 12, 2016
Doc to Doc Review (PDF)
Effective Date: June 1, 2021		 Wheelchair Seating (PDF)
Effective Date: March 31, 2022
Duplicate Primary Code Billing (PDF)
Effective Date: 		Paclitaxel Protein Bound (PDF)
Effective Date: January 1, 2022		Wireless Motility Capsule (PDF)
Effective Date: September 1, 2017
E&M Bundling (PDF)
Effective Date: 		  
E&M Medical Decision-Making (PDF)
Effective Date: 		Physician Visit Codes Billed with Labs (PDF)
Effective Date: 		 
EEG in the Evaluation of Headache (PDF)
Effective Date: January 1, 2022		Physician's Consultation Services (PDF)
Effective Date: December 1, 2017		 
Endometrial Ablation (PDF)
Effective Date: April 30, 2022		Physician's Office Lab Testing (PDF)
Effective Date: January 1, 2022		 
EpiFix Wound Treatment (PDF)
Effective Date: September 1, 2017		Place of Service Mismatch (PDF) Effective Date: March 1, 2019  
Evaluation and Management Services Billed with Treatment Rooms (PDF)
Effective Date: January 1, 2022 		  

Evoked Potentials (PDF)
Effective Date: January 1, 2022

Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)

Effective Date: March 31, 2022

 

Extended Ophthalmoscopy (PDF)

Effective Date: May 15, 2021 

Post-Operative Visits (PDF)
Effective Date: 		 
External Ocular Photography (PDF) 
Effective Date: January 1, 2022		Pre-Operative Visits (PDF)
Effective Date: 		 
Fecal Calprotectin Assay (PDF)
Effective Date: May 1, 2017		Problem Oriented Visits Billed with Preventative Visits (PDF)
Effective Date: September 2, 2022		 
 Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: Decmeber 1, 2017		 

Fluorescein Angiography (PDF)

Effective Date: January 1, 2022

Professional Component Modifier (PDF)
Effective Date: 		 
Fundus Photography (PDF)
Effective Date: February 5, 2021		PROM Testing (PDF)
Effective Date: December 1, 2017		 
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
Effective Date: January 1, 2022		  

Gonioscopy (PDF)

Effective Date: January 1, 2022

Proton and Neutron Beam Therapy (PDF)
Effective Date: December 1, 2016		 
Holter Monitors (PDF)
Effective Date: December 31, 2021		Pulse Oximetry with Office Visits (PDF)
Effective Date: 		 
Homocysteine Testing (PDF)
Effective Date: March 31, 2022		  
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: