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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 Ambetter from WellCare of New Jersey Clinical Policy Manual apply to Ambetter from WellCare of New Jersey members. Policies in the Ambetter from WellCare of New Jersey Clinical Policy Manual may have either a Ambetter from WellCare of New Jersey or a “Centene” heading. Ambetter from WellCare of New Jersey utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter from WellCare of New Jersey 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 Ambetter from WellCare of New Jersey. In addition, Ambetter from WellCare of New Jersey 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 Ambetter from WellCare of New Jersey.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- Acupuncture (PDF) Effective Date: 1/1/2022
- Air Ambulance (PDF) Effective Date: 1/1/2022
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF) Effective Date: 1/1/2022
- Ambulatory Surgery Center Optimization (PDF) Effective Date: 1/1/2022
- Articular Cartilage Defect Repairs (PDF) Effective Date: 1/1/2022
- Assisted Reproductive Technology (PDF) Effective Date: 1/1/2022
- Bariatric Surgery (PDF) Effective Date: 1/1/2022
- Biofeedback (PDF) Effective Date: 1/1/2022
- Bone-anchored hearing aid (PDF) Effective Date: 1/1/2022
- Burn Surgery (PDF) Effective Date: 1/1/2022
- Caudal or Interlaminar Epidural Steroid Injections (PDF) Effective Date: 1/1/2022
- Clinical Trials (PDF) Effective Date: 1/1/2022
- Cochlear Implant Replacements (PDF) Effective Date: 1/1/2022
- Cosmetic and Reconstructive Surgery (PDF) Effective Date: 1/1/2022
- Dental Anesthesia (PDF) Effective Date: 1/1/2022
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) Effective Date: 1/1/2022
- Disc Decompression Procedures (PDF) Effective Date: 1/1/2022
- Discography (PDF) Effective Date: 1/1/2022
- Donor lymphocyte infusion (PDF) Effective Date: 1/1/2022
- Drugs of Abuse: Definitive Testing (previously Outpatient Testing for Drugs of Abuse) (PDF) Effective Date: 1/1/2022
- Durable Medical Equipment (DME) (PDF) Effective Date: 1/1/2022
- Electric Tumor Treating Fields (PDF) Effective Date: 1/1/2022
- Essure Removal (PDF) Effective Date: 1/1/2022
- Experimental Technologies (PDF) Effective Date: 1/1/2022
- External Ocular Photography (PDF) Effective Date: 1/1/2022
- Facet Joint Interventions (PDF) Effective Date: 1/1/2022
- Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) Effective Date: 7/1/2023
- Fecal incontinence treatments (PDF) Effective Date: 1/1/2022
- Ferriscan R2-MRI (PDF) Effective Date: 1/1/2022
- Fertility preservation (PDF) Effective Date: 1/1/2022
- Fetal surgery in utero for prenatally diagnosed malformations (PDF) Effective Date: 1/1/2022
- Fluorescein Angiography (PDF) Effective Date: 1/1/2022
- Fundus Photography (PDF) Effective Date: 1/1/2022
- Functional MRI (PDF) Effective Date: 1/1/2022
- Gastric Electrical Stimulation (PDF) Effective Date: 1/1/2022
- Gender Affirming Procedures (PDF) Effective Date: 1/1/2022
- Gonioscopy (PDF) Effective Date: 1/1/2022
- H Pylori Testing (PDF) Effective Date: 1/1/2022
- Heart-Lung Transplant (PDF) Effective Date: 1/1/2022
- Home Birth (PDF) Effective Date: 1/1/2022
- Home phototherapy for neonatal hyperbilirubinemia (PDF) Effective Date: 1/1/2022
- Hospice Services (PDF) Effective Date: 1/1/2022
- Hyperemesis gravidarum treatment (PDF) Effective Date: 1/1/2022
- Hyperhidrosis treatments (PDF) Effective Date: 1/1/2022
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) Effective Date: 1/1/2022
- Implantable Intrathecal Pain Pump (PDF) Effective Date: 1/1/2022
- Implantable Loop Recorder (PDF) Effective Date: 6/22/2022
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) Effective Date: 1/1/2022
- Inhaled nitric oxide (PDF) Effective Date: 1/1/2022
- Intensity-Modulated Radiotherapy (PDF) Effective Date: 1/1/2022
- Intestinal and Multivisceral Transplant (PDF) Effective Date: 1/1/2022
- Intradiscal Steroid Injections for Pain Management (PDF) Effective Date: 1/1/2022
- Long Term Care Placement Criteria (PDF) Effective Date: 1/1/2022
- Lung Transplantation (PDF) Effective Date: 1/1/2022
- Lysis of Epidural Lesions (PDF) Effective Date: 1/1/2022
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) Effective Date: 1/1/2022
- Multiple Sleep Latency Testing (PDF) Effective Date: 1/1/2022
- Neonatal Abstinence Syndrome Guidelines (PDF) Effective Date: 1/1/2022
- Neonatal Sepsis Management (PDF) Effective Date: 1/1/2022
- Nerve Blocks for Pain Management (PDF) Effective Date: 1/1/2022
- Neuromuscular Electrical Stimulation (NMES) (PDF) Effective Date: 1/1/2022
- NICU Apnea Bradycardia Guidelines (PDF) Effective Date: 1/1/2022
- NICU Discharge Guidelines (PDF) Effective Date: 1/1/2022
- Non-invasive Home Ventilators (PDF) Effective Date: 1/1/2022
- Non-myeloablative Allogeneic Stem Cell Transplants (PDF) Effective Date: 1/1/2022
- Obstetrical Home Health Care Programs (PDF) Effective Date: 1/1/2022
- Optic Nerve Decompression Surgery (PDF) Effective Date: 1/1/2022
- Orthognathic Surgery (PDF) Effective Date: 1/1/2022
- Osteogenic Stimulation (PDF) Effective Date: 1/1/2022
- Outpatient Cardiac Rehabilitation (PDF) Effective Date: 1/1/2022
- Oxygen Use and Concentrators (PDF) Effective Date: 1/1/2022
- Pancreas Transplant (PDF) Effective Date: 1/1/2022
- Panniculectomy (PDF) Effective Date: 1/1/2022
- Pediatric Heart Transplant (PDF) Effective Date: 1/1/2022
- Pediatric Liver Transplant (PDF) Effective Date: 1/1/2022
- Pediatric Oral Function Therapy (PDF) Effective Date: 1/1/2022
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) Effective Date: 1/1/2022
- Physical, Occupational, and Speech Therapy Services (PDF) Effective Date: 1/1/2022
- Post Acute Care (PDF) Effective Date: 1/1/2022
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) Effective Date: 1/1/2022
- Proton and Neutron Beam Therapies (PDF) Effective Date: 1/1/2022
- Pulmonary Function Testing (PDF) Effective Date: 3/1/2023
- Radial Head Implant (PDF) Effective Date: 1/1/2022
- Radiofrequency Ablation of Uterine Fibroids (PDF) Effective Date: 1/1/2022
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) Effective Date: 1/1/2022
- Repair of Nasal Valve Compromise (PDF) Effective Date: 1/1/2022
- Sacroiliac Joint Fusion (PDF) Effective Date: 1/1/2022
- Sacroiliac Joint Interventions for Pain Management (PDF) Effective Date: 1/1/2022
- Scanning computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF) Effective Date: 1/1/2022
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF) Effective Date: 1/1/2022
- Selective Dorsal Rhizotomy (PDF) Effective Date: 1/1/2022
- Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF) Effective Date: 1/1/2022
- Short Inpatient Hospital Stay (PDF) Effective Date: 1/1/2022
- Skilled Nursing Facility Leveling (PDF) Effective Date: 1/1/2022
- Skin Substitutes for Chronic Wounds (PDF) Effective Date: 1/1/2022
- Spinal Cord Stimulation (PDF) Effective Date: 1/1/2022
- Stereotactic Body Radiation Therapy (PDF) Effective Date: 1/1/2022
- Tandem Transplant (PDF) Effective Date: 1/1/2022
- Testing for Select Genitourinary Conditions (previously Diagnosis of Vaginitis) (PDF) Effective Date: 1/1/2022
- Total Artificial Heart (PDF) Effective Date: 1/1/2022
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) Effective Date: 1/1/2022
- Transcatheter Closure of Patent Foramen Ovale (PDF) Effective Date: 1/1/2022
- Trigger Point Injections for Pain Management (PDF) Effective Date: 1/1/2022
- Urinary Incontinence Devices and Treatments (PDF) Effective Date: 1/1/2022
- Vagus Nerve Stimulation (PDF) Effective Date: 1/1/2022
- Ventricular Assist Device (PDF) Effective Date: 1/1/2022
- Wireless Motility Capsule (PDF) Effective Date: 1/1/2022
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 Ambetter from WellCare of New Jersey Payment Policy Manual apply with respect to Ambetter from WellCare of New Jersey members. Policies in the Ambetter from WellCare of New Jersey Payment Policy Manual may have either a Ambetter from WellCare of New Jersey or a “Centene” heading. In addition, Ambetter from WellCare of New Jersey 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 Ambetter from WellCare of New Jersey
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- 25-hydroxyvitamin D Testing in Children and Adolescents (PDF) Effective Date: 1/1/2022
- 3 Day Payment Window (PDF) Effective Date: 6/30/2022
- 30 Day Readmission (PDF) Effective Date: 6/30/2022
- Allergy Testing (PDF) Effective Date: 1/1/2022
- Bronchial Thermoplasty (PDF) Effective Date: 1/1/2022
- Cardiac Biomarker Testing for Acute MI (PDF) Effective Date: 1/1/2022
- Digital EEG Analysis (PDF) Effective Date: 1/1/2022
- EEG in Evaluation of Headache (PDF) Effective Date: 1/1/2022
- Endometrial Ablation (PDF) Effective Date: 1/1/2022
- Extended Ophthalmoscopy (PDF) Effective Date: 1/1/2022
- External Ocular Photography (PDF) Effective Date: 1/1/2022
- Evoked Potential Testing (PDF) Effective Date: 1/1/2022
- Fluorescein Angiography (PDF) Effective Date: 1/1/2022
- Fundus Photography (PDF) Effective Date: 1/1/2022
- GI Pathogen Nucleic Acid DPT (PDF) Effective Date: 1/1/2022
- Gonioscopy (PDF) Effective Date: 1/1/2022
- Holter Monitors (PDF) Effective Date: 1/1/2022
- Homocysteine Testing (PDF) Effective Date: 1/1/2022
- Intravenous Hydration (PDF) Effective Date: 1/1/2013
- Laser Skin Treatment (PDF) Effective Date: 1/1/2022
- Leveling of Care: Evaluation and Management Overcoding (PDF) Effective Date: 1/1/2022
- Low-Frequency Ultrasound Wound Therapy (PDF) Effective Date: 1/1/2022
- Measurement of Serum 1,25 - dihydroxyvitamin D (PDF) Effective Date: 1/1/2022
- Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) Effective Date: 5/30/2022
- Multiple Procedure Payment Reduction for Therapeutic Services (PDF) Effective Date: 5/30/2022
- Multiple Procedure Payment Reduction Ophthalmology Procedures (PDF) Effective Date: 5/30/2022
- Non-Emergent ER Services (Leveling of ER) (PDF) Effective Date: 5/30/2022
- Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF) Effective Date: 5/30/2022
- Office Visits Billed with Treatment Rooms (PDF) Effective Date: 6/30/2022
- Optum Comprehensive Payment Integrity (CPI) (PDF) Effective Date: 4/1/2023
- Physician's Consultation Services (PDF) Effective Date: 6/30/2022
- Physician's Office Lab Testing (POLT) (PDF) Effective Date: 6/30/2022
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) Effective Date: 1/1/2022
- Problem-Oriented Visits with Preventative Visits (PDF) Effective Date: 6/30/2022
- Problem-Oriented Visits with Surgical Procedures (PDF) Effective Date: 6/30/2022
- Renal Hemodialysis (PDF) Effective Date: 5/30/2022
- Robotic Surgery (PDF) Effective Date: 6/30/2023
- Scan Comp Oph Diag Imaging (PDF) Effective Date: 1/1/2022
- Sleep Studies Place of Service (PDF) Effective Date: 6/30/2022
- Thyroid Hormones and Insulin Testing in Pediatrics (PDF) Effective Date: 1/1/2022
- Ultrasound in Pregnancy (PDF) Effective Date: 1/1/2022
- Urine Specimen Validity Testing (PDF) Effective Date: 6/30/2022
- Urodynamic Testing (PDF) Effective Date: 1/1/2022
- Visual Field Testing (PDF) Effective Date: 1/1/2022
- Wheelchairs and Accessories (PDF) Effective Date: 6/30/2022
- Wheelchair Seating (PDF) Effective Date: 1/1/2022