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-H I-Q R-Z
Acupuncture Expanded Benefit (PDF)
Effective Date: July 2018
Laser Skin Treatment (PDF)
Effective Date: January 15, 2017

Rehabilitative Therapy Site of Care Optimization (PDF)

Effective date: August 2019

ADHD Assessment and Treatment (PDF)
Effective Date: May 1, 2021
Low-Frequency Ultrasound 
Wound Therapy (PDF)

Effective Date: September 1, 2017
Rituximab (PDF)
Effective Date: 
Allergy Testing (PDF)
Effective Date: May 1, 2021
Measure Serum 1,25 Vitamin D (PDF)
Effective Date: June 1, 2018
Scanning Computerized Ophthalmic Diagnostic Imaging  (PDF)
Effective Date: August 15, 2021
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

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

Testing of Select GU Conditions (PDF)

Effective Date: May 1, 2021

Bevacizumab (PDF)
Effective Date: 
PCR Respiratory Viral Panel  Testing - Prepayment Policy (PDF)
Effective Date: August 15, 2021

Thyroid Testing 
in Pediatrics (PDF)

Effective Date: June 1, 2018

Bronchial Thermoplasty (PDF)
Effective Date: January 15, 2017
PROM Testing (PDF)
Effective Date: August 15, 2021
Ultrasound in Pregnancy (PDF)
Effective Date: July 1, 2016

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: May 1, 2021
Diagnosis of Vaginitis (PDF)
Effective Date: January 15, 2017

 

 

Visual Field Testing (PDF)
Effective Date: August 15, 2021
Digital Analysis of EEGs (PDF)
Effective Date: November 1, 2016
  Vitamin D Testing 
in Children (PDF)

Effective Date: June 1, 2018
    Wheelchair Seating (PDF)
Effective Date: August 15, 2021
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: June 1, 2018
 

 

Endometrial Ablation (EA) (PDF)
Effective Date: November 1, 2016
 

 

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

Evoked Potentials (PDF)
Effective Date: May 1, 2021

   
Extended Ophthalmoscopy (PDF)
Effective Date: August 15, 2021
   
External Ocular Photography (PDF)
Effective Date: August 15, 2021
   
Fecal Calprotectin Assay (PDF)
Effective Date: May 1, 2017
   
Fluorescein Angiography (PDF)
Effective Date: August 15, 2021
   
Fundus Photography (PDF)
Effective Date: August 15, 2021
   
Gonioscopy (PDF)
Effective Date: August 15, 2021
   
H Pylori Testing (PDF)
Effective Date: June 1, 2018
   
Holter Monitors (PDF)
Effective Date: January 15, 2017
   
Homocysteine Testing (PDF)
Effective Date: May 1, 2021
   

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-H I-Q R-Z
30 Day Readmission (PDF)
Effective Date: August 15, 2021
Leveling of Care: Evaluation & Management Overcoding (PDF)
Effective Date: August 15, 2021
Renal Hemodialysis (PDF)
Effective Date: August 15, 2021
3-Day Payment Window (PDF) Leveling of Emergency Room Services  (PDF)
Effective Date: May 15, 2019
Robotic Surgery (PDF)
Effective Date: August 15, 2021
    Sepsis Diagnosis (PDF)
Effective Date: March 1, 2016

Durable Medical Equipment, Medical Supplies, Prostheses and Orthoses-MMA (PDF)

Effective Date: March 10, 2021

Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
Effective Date: March 1, 2019 
Sleep Studies Place of Services (PDF)
Effective Date: May 1, 2017

Durable Medical Equipment, Medical Supplies, Prostheses and Orthoses-LTC (PDF)

Effective Date: March 10, 2021

Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)
Effective Date: August 15, 2021
Urine Specimen Validity Testing (PDF)
Effective Date: December 1, 2017

High Complexity Medical Decision-Making (PDF)

Effective  Date: July, 31, 2017 

Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
Effective Date: August 15, 2021
Wheelchair Accessories (PDF)
Effective Date: August 15, 2021
  Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: August 15, 2021
 
  Not Medically Necessary Inpatient Services (PDF)
Effective Date:
 
  Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: May 1, 2021 
 
 

Physician's Consultation Services (PDF)
Effective Date: May 15, 2019

 

 

 

  Physician's Office Lab Testing (PDF)
Effective Date: December 1, 2017
 
  Place of Service Mismatch (PDF)
Effective Date: March 1, 2019 
 
  Problem Oriented Visits with 
Preventative Visits (PDF)

Effective Date: May 15, 2019
 
  Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: May 15, 2019
 
A-H I-Q R-Z
   

Renal Hemodialysis (PDF)

Effective Date: May 15, 2021

30-Day Readmission (PDF)
Effective Date: January 1, 2015
Inpatient Consultation (PDF) 
Effective Date: October 1, 2017
Reporting Global Maternity Package (PDF)
Effective Date: 
3-Day Payment Window (PDF)
Effective Date: 
Inpatient Only Procedures (PDF) 
Effective Date: 
Same Day Visits (PDF)
Effective Date: July 15, 2021
    Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective Date: 
    Sepsis Diagnosis (PDF)
Effective Date: March 1, 2016
Add on Code Billed Without Primary Code (PDF)
Effective Date:
Intravenous Hydration (PDF)
Effective Date: 

Short Inpatient Hospital Stay (PDF)

Effective Date: October 1, 2020

ADHD Assessment and Treatment (PDF)
Effective Date: January 1, 2022
Laser Skin Treatment  (PDF)
Effective Date: January 15, 2017
Sleep Studies Place of Services (PDF)
Effective Date: May 1, 2017
 

Leveling of Care Evaluation and Management Overcoding (PDF)

Effective Date: May 15, 2021

 
Allergy Testing and Therapy (PDF)
Effective Date: January 1, 2022
Leveling of ER Services (PDF)
Effective Date: January 1, 2018
Status "B" Bundled Services (PDF)
Effective Date: 
  Maximum Units of Service (PDF)
Effective Date: 
Status "P" Bundled Services (PDF)
Effective Date: April 1, 2017

Allwell Balance Billing FAQ (PDF)

Effective Date: 

  Supplies Same Day as Surgery (PDF)
Effective Date:

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

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

Mechanical Stretch Devices (PDF)
Effective Date:  September 1, 2017
Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF)
Effective Date: January 1, 2022
Assistant Surgeon (PDF)
Effective Date:
Moderate Conscious Sedation (PDF)
Effective Date: 
Transgender Related Services (PDF)
Effective Date: 
Bevacizumab (Avastin) (PDF)
Effective Date: August 12, 2016
Modifier DOS Validation (PDF)
Effective Date: 
Ultrasound in Pregnancy (PDF)
Effective Date: January 1, 2022
Bilateral Procedures (PDF)
Effective Date: 
Modifier to Procedure Code Validation (PDF)
Effective Date:
 
Bronchial Thermoplasty (PDF)
Effective Date: January 15, 2017
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: March 1, 2019 Unbundled Professional Services (PDF)
Effective Date: 
  Multiple CPT Code (PDF)
Effective Date: 
Unbundled Surgical Procedures (PDF)
Effective Date: 
 

Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)

Effective Date: May 15, 2021

Visual Field Testing (PDF)
Effective Date: July 15, 2021
 

Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)

Effective Date: May 15, 2021

 
 

Multiple Procedure Reduction Ophthalmology (PDF)

Effective Date: May 15, 2021

 
Cerumen Removal (PDF) 
Effective Date: 
NCCI Unbundling (PDF)
Effective Date: 
Unlisted Procedure Codes (PDF)
Effective Date: 
Clean Claims (PDF)
Effective Date: 
Never Paid Events (PDF)
Effective Date:
Urine Specimen Validity Testing (PDF)
Effective Date: December 1, 2017
Clinical Validation of Modifier 25 (PDF)
Effective Date: 
New Patient (PDF)
Effective Date: 
Urodynamic Testing (PDF)
Effective Date: January 1, 2018
Clinical Validation of Modifier 59 (PDF)
Effective Date: 
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: May 1, 2021 Urodynamic Testing (PDF)
Effective Date: August 12, 2016 -  December 31, 2017
Code Editing Overview (PDF)
Effective Date: 
Outpatient Consultation (PDF)
Effective Date: 
Visual Field Testing (PDF)
Effective Date: 
    Vitamin D Testing in Children and Adolescents (PDF)
Effective Date: June 1, 2018
Cosmetic Procedures (PDF) 
Effective Date:
Paclitaxel Protein Bound (PDF)
Effective Date: January 1, 2022
Wheelchair and Accessories (PDF)
Effective Date: August 12, 2016
Diagnosis of Vaginitis (PDF) 
Effective Date: January 15, 2017 - September 30, 2017
Paclitaxel, protein bound (PDF)
Effective Date: August 12, 2016 - October 31, 2017
Wheelchair Seating (PDF)
Effective Date: August 12, 2016
Diagnosis of Vaginitis (PDF) Effective Date: October 1, 2017 - December 31, 2017 Physician Visit Codes Billed with Labs (PDF)
Effective Date:
Wireless Motility Capsule (PDF)
Effective Date: September 1, 2017
Digital Analysis of EEGs (PDF)
Effective Date: December1, 2016
Physician's Office Lab Testing (PDF)
Effective Date: January 1, 2022
 
Digital Breast Tomosynthesis (PDF)
Effective Date: December 1, 2016 - December 31, 2017
Place of Service Mismatch (PDF) Effective Date: March 1, 2019   
 

Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)

Effective Date: May 15, 2021

 
Distinct Procedural Modifers (PDF)
Effective Date: 
Post-Operative Visits (PDF)
Effective Date: 
 
  Pre-Operative Visits (PDF)
Effective Date:
 
Duplicate Primary Code Billing (PDF)
Effective Date: 
Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: December 1, 2017
 
E&M Bundling (PDF)
Effective Date: 
Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: December 1, 2017
 
E&M Medical Decision-Making (PDF)
Effective Date: 
Professional Component Modifier (PDF)
Effective Date: 
 
EEG in the Evaluation of Headache (PDF)
Effective Date: January 1, 2022
PROM Testing (PDF)
Effective Date: December 1, 2017
 
Endometrial Ablation (PDF)
Effective Date: December 1, 2016
Proton and Neutron Beam Therapy (PDF)
Effective Date: December 1, 2016
 
EpiFix Wound Treatment (PDF)
Effective Date: September 1, 2017
Pulse Oximetry with Office Visits (PDF)
Effective Date:
 
Evoked Potentials (PDF)
Effective Date: January 1, 2022
   

Extended Ophthalmoscopy (PDF)

Effective Date: May 15, 2021 

   

External Ocular Photography (PDF)

Effective Date: May 15, 2021

   
Fecal Calprotectin Assay (PDF)
Effective Date: May 1, 2017
   

Fluorescein Angiography (PDF)

Effective Date: May 15, 2021

   

Gonioscopy (PDF) 

Effective Date: May 15, 2021

   
Helicobacter Pylori (H. pylori) Serology Testing (PDF)
Effective Date: JUne 1, 2018
   
Holter Monitors (PDF)
Effective Date: January 15, 2017 - Oct. 31, 2017
   
Holter Monitors (PDF)
Effective Date: November 1, 2017
   
Homocysteine Testing (PDF)
Effective Date: January 15, 2017
   
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 
   

 

 

A-H I-Q R-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: 
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: January 15, 2017
Robotic Surgery (PDF)
Effective Date: February 5, 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: July 15, 2021
    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: February 5, 2021
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: February 5, 2021
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:

Cerumen Removal (PDF) 
Effective Date: 
Modifier DOS Validation (PDF)
Effective Date: 
Thryoid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: JUne 1, 2018
Clean Claims (PDF)
Effective Date: 
Modifier to Procedure Code Validation (PDF)
Effective Date: 
Transgender Related Services (PDF)
Effective Date: 
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: January 1, 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 (MDCR) (PDF)
Effective Date: February 5, 2021
Unbundled Professional Services (PDF)
Effective Date: 
Cosmetic Procedures (PDF) 
Effective Date: 
Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: February 5, 2021
Unbundled Surgical Procedures (PDF)
Effective Date: 
Diagnosis of Vaginitis (PDF) 
Effective Date: January 15, 2017 - September 30, 2017
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective Date: February 5, 2021
Unlisted Procedure Codes (PDF)
Effective Date:
Diagnosis of Vaginitis (PDF) Effective Date: October 1, 2017 - December 31, 2017 NCCI Unbundling (PDF)
Effective Date: 
Urine Specimen Validity Testing (PDF)
Effective Date: December 1, 2017
Digital Analysis of EEGs (PDF)
Effective Date: December 1, 2016
Never Paid Events (PDF)
Effective Date: 
Urodynamic Testing (PDF)
Effective Date: May 1, 2021
Digital Breast Tomosynthesis (PDF)
Effective Date: December 1, 2016 - December 31, 2017
New Patient (PDF)
Effective Date: 

Urodynamic Testing (PDF)
Effective Date: August 12, 2016 -  December 31, 2017
    Visual Field Testing (PDF)
Effective Date: July 15, 2021
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: August 12, 2016
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: December 1, 2016
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: February 5, 2021
 
Extended Ophthalmoscopy (PDF)
Effective Date: February 5, 2021
Post-Operative Visits (PDF)
Effective Date: 
 
External Ocular Photography (PDF)
Effective Date: February 5, 2021
Pre-Operative Visits (PDF)
Effective Date: 
 
Fecal Calprotectin Assay (PDF)
Effective Date: May 1, 2017
Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: December 1, 2017
 
  Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: Decmeber 1, 2017
 
Fluorescein Angiography (PDF)
Effective Date: February 5, 2021
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: February 5, 2021
Proton and Neutron Beam Therapy (PDF)
Effective Date: December 1, 2016
 
Holter Monitors (PDF)
Effective Date: January 15, 2017 - October 31, 2017
Pulse Oximetry with Office Visits (PDF)
Effective Date: 
 
Holter Monitors (PDF)
Effective Date: November 1, 2017
   
Homocysteine Testing (PDF)
Effective Date: January 15, 2017
   
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: