Clinical & Payment Policies
To view Superior's latest Clinical and Payment Policy news updates, please visit Superior's Provider News and Information webpage.
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 Superior HealthPlan Clinical Policy Manual apply to Superior HealthPlan members. Policies in the Superior HealthPlan Clinical Policy Manual may have either a Superior HealthPlan or a “Centene” heading. Superior HealthPlan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Superior HealthPlan 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 Superior HealthPlan. In addition, Superior HealthPlan 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 Superior HealthPlan.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
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 Superior HealthPlan Payment Policy Manual apply with respect to Superior HealthPlan members. Policies in the Superior HealthPlan Payment Policy Manual may have either a Superior HealthPlan or a “Centene” heading. In addition, Superior HealthPlan 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 Superior HealthPlan.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Clinical and Payment Polices
- 30-Day Readmission - Effective 9/1/2017 (CC.PP.501) (PDF)
- Add on Code Billed Without Primary Code (CC.PP.030) (PDF)
- ADHD Assessment and Treatment - Effective 5/1/2017 (TX.CP.MP.124) (PDF)
- Allergy Testing - Effective 10/1/2017 (TX.CP.MP.100) (PDF)
- Ambulatory EEG - Effective 8/12/2016 (CP.MP.96) (PDF)
- Assistant Surgeon (CC.PP.029) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Bevacizumab (Avastin) - Effective 6/25/2016 (CP.PHAR.93) (PDF)
- Bilateral Procedures (CC.PP.037) (PDF)
- Bronchial Thermoplasty - Effective 1/15/2017 (CP.MP.110) (PDF)
- Cardiac Biomarker Testing for Acute MI - Effective 8/1/2018 (CP.MP.156) (PDF)
- Cell-free Fetal DNA Testing (CP.MP.84) (PDF)
- Cerumen Removal (CC.PP.008) (PDF)
- Clean Claims (CC.PP.021) (PDF)
- Clinical Validation of Modifier 25 (CC.PP.013) (PDF)
- Clinical Validation of Modifier 59 (CC.PP.014) (PDF)
- Code Editing Overview (CC.PP.011) (PDF)
- Cosmetic Procedures (CC.PP.024) (PDF)
- Digital Analysis of EEGs - Effective 8/15/2016 (CP.MP.105) (PDF)
- Digital Breast Tomosynthesis (DBT) - Effective 12/1/2016 thru 8/31/2017 (CP.MP.90) (PDF)
- Distinct Procedural Modifiers (CC.PP.020) (PDF)
- DNA Analysis of Stool - Effective 5/1/2017 (CP.MP.125) (PDF)
- Duplicate Primary Code Billing (CC.PP.044) (PDF)
- E&M Bundling (CC.PP.010) (PDF)
- E&M Medical Decision-Making (CC.PP.051) (PDF)
- EEG in Evaluation of Headache - Effective 8/1/2018 (CP.MP.155) (PDF)
- Endometrial Ablation (EA) - Effective 8/15/2016 (CP.MP.106) (PDF)
- EpiFix Wound Treatment - Effective 9/1/2017 (CP.MP.140) (PDF)
- Evoked Potentials - Effective 5/1/2017 (CP.MP.134) (PDF)
- Fecal Calprotectin Assay - Effective 5/1/2017 (CP.MP.135) (PDF)
- FeNo Testing - Effective 7/15/2017 (CP.MP.103) (PDF)
- Global Maternity Billing (CC.PP.016) (PDF)
- H Pylori Testing - Effective 8/1/2018 (CP.MP.153) (PDF)
- Holter Monitors - Effective 11/1/2017 (CP.MP.113) (PDF)
- Homocysteine Testing - Effective 1/15/2017 (CP.MP.121) (PDF)
- Hospital Visit Codes Billed with Labs (CC.PP.023) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Inpatient Consultation (CC.PP.038) (PDF)
- Inpatient Only Procedures (CC.PP.018) (PDF)
- Intravenous Hydration (CC.PP.012) (PDF)
- Laser Skin Treatment - Effective 1/15/2017 (CP.MP.123) (PDF)
- Leveling of Emergency Room Services - Effective 11/01/2018 (TX.CC.PP.053) (PDF)
- Low-Frequency Ultrasound Wound Therapy - Effective 9/1/2017 (CP.MP.139) (PDF)
- Maximum Units of Service (CC.PP.007) (PDF)
- Measure Serum 1,25 Vitamin D - Effective 8/1/2018 (CP.MP.152) (PDF)
- Mechanical Stretch Devices - Effective 9/1/2017 (CP.MP.144) (PDF)
- Moderate Conscious Sedation (CC.PP.015) (PDF)
- Modifier DOS Validation (CC.PP.034) (PDF)
- Modifier to Procedure Code Validation (CC.PP.028) (PDF)
- Multiple CPT Code Replacement (CC.PP.033) (PDF)
- NCCI Unbundling (CC.PP.031) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Never Paid Events (CC.PP.017) (PDF)
- New Patient (CC.PP.036) (PDF)
- Non-obstetrical Pelvic and Transvaginal Ultrasounds - Effective 1/15/19 (CC.PP.061) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Paclitaxel - Effective 12/30/2015 (CP.PHAR.176) (PDF)
- Physician Visit Codes Billed with Labs (CC.PP.019) (PDF)
- Place of Service Mismatch - Effective 1/15/19 (CC.PP.063) (PDF)
- Polymerase Chain Reaction (PCR) Testing - Effective 01/01/2020 (TX.PP.150) (PDF)
- Post-Operative Visits (CC.PP.042) (PDF)
- Pre-Operative Visits (CC.PP.041) (PDF)
- Professional Component Modifier (CC.PP.027) (PDF)
- PROM Testing - Effective 12/15/2017 (CP.MP.149) (PDF)
- Proton and Neutron Beam Therapy - Effective 8/15/2016 (CP.MP.70) (PDF)
- Pulse Oximetry with Office Visits (CC.PP.025) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Rituximab - Effective 11/1/2017 (CP.PHAR.260) (PDF)
- Robotic Surgery - Effective 9/1/2017 (CC.PP.050) (PDF)
- Same Day Visits (CC.PP.040) (PDF)
- Status "B" Bundled Services (CC.PP.046) (PDF)
- Status "P" Bundled Services - Effective 4/1/2017 (CC.PP.049) (PDF)
- Supplies Billed on Same Day As Surgery (CC.PP.032) (PDF)
- Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) - Effective 1/1/2018 (CP.MP.97) (PDF)
- Thyroid Testing in Pediatrics - Effective 8/1/2018 (CP.MP.154) (PDF)
- Transgender Related Services (CC.PP.047) (PDF)
- Ultrasound in Pregnancy - Effective 7/1/2017 (CP.MP.38) (PDF)
- Unbundled Professional Services (CC.PP.043) (PDF)
- Unbundled Surgical Procedures (CC.PP.045) (PDF)
- Unlisted Procedure Codes (CC.PP.009) (PDF)
- Urine Specimen Validity Testing - Effective 12/15/2017 (CC.PP.056) (PDF)
- Urodynamic Testing - Effective 1/1/2018 (CP.MP.98) (PDF)
- Vitamin D Testing in Children - Effective 8/1/2018 (CP.MP.157) (PDF)
- Wheelchair and Accessories - Effective 8/12/2016 (CC.PP.502) (PDF)
- Wheelchair Seating - Effective 8/12/2016 (CP.MP.99) (PDF)
- Wireless Motility Capsule - Effective 9/1/2017 (CP.MP.143) (PDF)
Medicaid Clinical and Payment Polices
- Add on Code Billed Without Primary Code (CC.PP.030) (PDF)
- ADHD Assessment and Treatment - Effective 5/1/2017 (TX.CP.MP.124) (PDF)
- Allergy Testing - Effective 10/1/2017 (TX.CP.MP.100) (PDF)
- Assistant Surgeon (CC.PP.029) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Bevacizumab (Avastin) - Effective 6/25/2016 (CP.PHAR.93) (PDF)
- Bilateral Procedures (CC.PP.037) (PDF)
- Bronchial Thermoplasty - Effective 1/15/2017 (CP.MP.110) (PDF)
- Cardiac Biomarker Testing for Acute MI - Effective 8/1/2018 (CP.MP.156) (PDF)
- Cell-free Fetal DNA Testing (CP.MP.84) (PDF)
- Cerumen Removal (CC.PP.008) (PDF)
- Clean Claims (CC.PP.021) (PDF)
- Clinical Validation of Modifier 25 (CC.PP.013) (PDF)
- Clinical Validation of Modifier 59 (CC.PP.014) (PDF)
- Code Editing Overview (CC.PP.011) (PDF)
- Cosmetic Procedures (CC.PP.024) (PDF)
- Digital Analysis of EEGs - Effective 8/15/2016 (CP.MP.105) (PDF)
- Distinct Procedural Modifiers (CC.PP.020) (PDF)
- DNA Analysis of Stool - Effective 5/1/2017 (CP.MP.125) (PDF)
- Duplicate Primary Code Billing (CC.PP.044) (PDF)
- E&M Bundling (CC.PP.010) (PDF)
- E&M Medical Decision-Making (CC.PP.051) (PDF)
- EEG in Evaluation of Headache - Effective 8/1/2018 (CP.MP.155) (PDF)
- Endometrial Ablation (EA) - Effective 8/15/2016 (CP.MP.106) (PDF)
- EpiFix Wound Treatment - Effective 9/1/2017 (CP.MP.140) (PDF)
- Evoked Potentials - Effective 5/1/2017 (CP.MP.134) (PDF)
- Fecal Calprotectin Assay - Effective 5/1/2017 (CP.MP.135) (PDF)
- FeNo Testing - Effective 7/15/2017 (CP.MP.103) (PDF)
- Global Maternity Billing (CC.PP.016) (PDF)
- H Pylori Testing - Effective 8/1/2018 (CP.MP.153) (PDF)
- Holter Monitors - Effective 11/1/2017 (CP.MP.113) (PDF)
- Homocysteine Testing - Effective 1/15/2017 (CP.MP.121) (PDF)
- Hospital Visit Codes Billed with Labs (CC.PP.023) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Inpatient Consultation (CC.PP.038) (PDF)
- Inpatient Only Procedures (CC.PP.018) (PDF)
- Intravenous Hydration (CC.PP.012) (PDF)
- Leveling of Emergency Room Services - Effective 10/01/2017 (TX.CC.PP.053) (PDF)
- Low-Frequency Ultrasound Wound Therapy - Effective 9/1/2017 (CP.MP.139) (PDF)
- Maximum Units of Service (CC.PP.007) (PDF)
- Measure Serum 1,25 Vitamin D - Effective 8/1/2018 (CP.MP.152) (PDF)
- Mechanical Stretch Devices - Effective 9/1/2017 (CP.MP.144) (PDF)
- Moderate Conscious Sedation (CC.PP.015) (PDF)
- Modifier DOS Validation (CC.PP.034) (PDF)
- Modifier to Procedure Code Validation (CC.PP.028) (PDF)
- Multiple CPT Code Replacement (CC.PP.033) (PDF)
- NCCI Unbundling (CC.PP.031) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Never Paid Events (CC.PP.017) (PDF)
- New Patient (CC.PP.036) (PDF)
- Non-obstetrical Pelvic and Transvaginal Ultrasounds - Effective 1/15/19 (CC.PP.061) (PDF)
- Not Medically Necessary Inpatient Professional Services - Effective 1/15/19 (CC.PP.060) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Paclitaxel - Effective 12/30/2015 (CP.PHAR.176) (PDF)
- Place of Service Mismatch - Effective 1/15/19 (CC.PP.063) (PDF)
- Physician Visit Codes Billed with Labs (CC.PP.019) (PDF)
- Polymerase Chain Reaction (PCR) Testing - Effective 01/01/2020 (TX.PP.150) (PDF)
- Post-Operative Visits (CC.PP.042) (PDF)
- Pre-Operative Visits (CC.PP.041) (PDF)
- Professional Component Modifier (CC.PP.027) (PDF)
- PROM Testing - Effective 12/15/2017 (CP.MP.149) (PDF)
- Proton and Neutron Beam Therapy - Effective 8/15/2016 (CP.MP.70) (PDF)
- Pulse Oximetry with Office Visits (CC.PP.025) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Rituximab - Effective 11/1/2017 (CP.PHAR.260) (PDF)
- Robotic Surgery - Effective 9/1/2017 (CC.PP.050) (PDF)
- Same Day Visits (CC.PP.040) (PDF)
- Sleep Studies Place of Services - Effective 5/1/2017 (CC.PP.035) (PDF)
- Status "B" Bundled Services (CC.PP.046) (PDF)
- Status "P" Bundled Services - Effective 4/1/2017 (CC.PP.049) (PDF)
- Supplies Billed on Same Day As Surgery (CC.PP.032) (PDF)
- Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) - Effective 1/1/2018 (CP.MP.97) (PDF)
- Thyroid Testing in Pediatrics - Effective 8/1/208 (CP.MP.154) (PDF)
- Transgender Related Services (CC.PP.047) (PDF)
- Ultrasound in Pregnancy - Effective 7/1/2017 (CP.MP.38) (PDF)
- Unbundled Professional Services (CC.PP.043) (PDF)
- Unbundled Surgical Procedures (CC.PP.045) (PDF)
- Unlisted Procedure Codes (CC.PP.009) (PDF)
- Urine Specimen Validity Testing - Effective 12/15/2017 (CC.PP.056) (PDF)
- Urodynamic Testing - Effective 1/1/2018 (CP.MP.98) (PDF)
- Vitamin D Testing in Children - Effective 8/1/2018 (CP.MP.157) (PDF)
- Wireless Motility Capsule - Effective 9/1/2017 (CP.MP.143) (PDF)
Medicare Clinical and Payment Polices
- 30-Day Readmission - Effective 9/1/2017 (CC.PP.501) (PDF)
- Add on Code Billed Without Primary Code (CC.PP.030) (PDF)
- ADHD Assessment and Treatment - Effective 5/1/2017 (TX.CP.MP.124) (PDF)
- Allergy Testing - Effective 10/1/2017 (TX.CP.MP.100) (PDF)
- Ambulatory EEG - Effective 8/12/2016 (CP.MP.96) (PDF)
- Assistant Surgeon (CC.PP.029) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Bevacizumab (Avastin) - Effective 6/25/2016 (CP.PHAR.93) (PDF)
- Bilateral Procedures (CC.PP.037) (PDF)
- Bronchial Thermoplasty - Effective 1/15/2017 (CP.MP.110) (PDF)
- Cardiac Biomarker Testing for Acute MI - Effective 8/1/2018 (CP.MP.156) (PDF)
- Cell-free Fetal DNA Testing (CP.MP.84) (PDF)
- Cerumen Removal (CC.PP.008) (PDF)
- Clean Claims (CC.PP.021) (PDF)
- Clinical Validation of Modifier 25 (CC.PP.013) (PDF)
- Clinical Validation of Modifier 59 (CC.PP.014) (PDF)
- Code Editing Overview (CC.PP.011) (PDF)
- Cosmetic Procedures (CC.PP.024) (PDF)
- Digital Analysis of EEGs - Effective 8/15/2016 (CP.MP.105) (PDF)
- Distinct Procedural Modifiers (CC.PP.020) (PDF)
- DNA Analysis of Stool - Effective 5/1/2017 (CP.MP.125) (PDF)
- Duplicate Primary Code Billing (CC.PP.044) (PDF)
- E&M Bundling (CC.PP.010) (PDF)
- E&M Medical Decision-Making (CC.PP.051) (PDF)
- EEG in Evaluation of Headache - Effective 8/1/2018 (CP.MP.155) (PDF)
- Endometrial Ablation (EA) - Effective 8/15/2016 (CP.MP.106) (PDF)
- EpiFix Wound Treatment - Effective 9/1/2017 (CP.MP.140) (PDF)
- Evoked Potentials - Effective 5/1/2017 (CP.MP.134) (PDF)
- Fecal Calprotectin Assay - Effective 5/1/2017 (CP.MP.135) (PDF)
- FeNo Testing - Effective 7/15/2017 (CP.MP.103) (PDF)
- Global Maternity Billing (CC.PP.016) (PDF)
- H Pylori Testing - Effective 8/1/2018 (CP.MP.153) (PDF)
- Holter Monitors - Effective 11/1/2017 (CP.MP.113) (PDF)
- Homocysteine Testing - Effective 1/15/2017 (CP.MP.121) (PDF)
- Hospital Visit Codes Billed with Labs (CC.PP.023) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Inpatient Consultation (CC.PP.038) (PDF)
- Inpatient Only Procedures (CC.PP.018) (PDF)
- Intravenous Hydration (CC.PP.012) (PDF)
- Leveling of Emergency Room Services - Effective 10/01/2017 (TX.CC.PP.053) (PDF)
- Laser Skin Treatment - Effective 1/15/2017 (CP.MP.123) (PDF)
- Maximum Units of Service (CC.PP.007) (PDF)
- Measure Serum 1,25 Vitamin D - Effective 8/1/2018 (CP.MP.152) (PDF)
- Mechanical Stretch Devices - Effective 9/1/2017 (CP.MP.144) (PDF)
- Moderate Conscious Sedation (CC.PP.015) (PDF)
- Modifier DOS Validation (CC.PP.034) (PDF)
- Modifier to Procedure Code Validation (CC.PP.028) (PDF)
- Monitored Anesthesia Care for Gastrointestinal Endoscopy - Effective 1/15/19 (CP.MP.161) PDF)
- Multiple CPT Code Replacement (CC.PP.033) (PDF)
- NCCI Unbundling (CC.PP.031) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Never Paid Events (CC.PP.017) (PDF)
- New Patient (CC.PP.036) (PDF)
- Non-obstetrical Pelvic and Transvaginal Ultrasounds - Effective 1/15/19 (CC.PP.061) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Outpatient Consultation (CC.PP.039) (PDF)
- Paclitaxel - Effective 12/30/2015 (CP.PHAR.176) (PDF)
- Place of Service Mismatch - Effective 1/15/19 (CC.PP.063) (PDF)
- Physician Visit Codes Billed with Labs (CC.PP.019) (PDF)
- Polymerase Chain Reaction (PCR) Testing - Effective 01/01/2020 (TX.PP.150) (PDF)
- Post-Operative Visits (CC.PP.042) (PDF)
- Pre-Operative Visits (CC.PP.041) (PDF)
- Professional Component Modifier (CC.PP.027) (PDF)
- PROM Testing - Effective 12/15/2017 (CP.MP.149) (PDF)
- Proton and Neutron Beam Therapy - Effective 8/15/2016 (CP.MP.70) (PDF)
- Pulse Oximetry with Office Visits (CC.PP.025) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Same Day Visits (CC.PP.040) (PDF)
- Sleep Studies Place of Services - Effective 5/1/2017 (CC.PP.035) (PDF)
- Status "B" Bundled Services (CC.PP.046) (PDF)
- Status "P" Bundled Services - Effective 4/1/2017 (CC.PP.049) (PDF)
- Supplies Billed on Same Day As Surgery (CC.PP.032) (PDF)
- Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) - Effective 1/1/2018 (CP.MP.97) (PDF)
- Transgender Related Services (CC.PP.047) (PDF)
- Ultrasound in Pregnancy - Effective 7/1/2017 (CP.MP.38) (PDF)
- Unbundled Professional Services (CC.PP.043) (PDF)
- Unbundled Surgical Procedures (CC.PP.045) (PDF)
- Unlisted Procedure Codes (CC.PP.009) (PDF)
- Urine Specimen Validity Testing - Effective 12/15/2017 (CC.PP.056) (PDF)
- Urodynamic Testing - Effective 1/1/2018 (CP.MP.98) (PDF)
- Wheelchair and Accessories - Effective 8/12/2016 (CC.PP.502) (PDF)
- Wheelchair Seating - Effective 8/12/2016 (CP.MP.99) (PDF)
- Wireless Motility Capsule - Effective 9/1/2017 (CP.MP.143) (PDF)
Archived Polices
- Physician’s Office Lab Testing (CC.PP.055) – IMPLEMENTATION CANCELLED
- Monitored Anesthesia Care for Gastrointestinal Endoscopy - Effective 1/15/19 (CP.MP.161) PDF) - RETIRED (Medicaid and CHIP - 7/18/2019, Medicare - 7/22/2019, MarketPlace - 7/22/2019)
- Rituximab - Effective 11/1/2017 (CP.PHAR.260) (PDF) - RETIRED (Medicaid and CHIP, Medicare, Marketplace - 1/1/ 2019)