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. 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.
Not all policies found in the Sunflower Health Plan Clinical Policy Manual apply to all Sunflower Health Plan members. Sunflower policies are applied according to member eligibility and medical necessity criteria as defined in policy CP.MP.68. Policies in the Sunflower Health Plan Clinical Policy Manual may have either a Sunflower or a “Centene” heading. Sunflower utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Sunflower 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 Sunflower. In addition, Sunflower 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 Sunflower Health Plan.
If you have any questions regarding these policies, please contact Customer Service and ask to be directed to the Medical Management department.
Clinical Policies
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For Medicare information, please visit our Medicare Prior Authorization website.
Specialty Pharmacy Policies
Please refer to the KDHE website for detailed information regarding clinical prior authorization criteria.
Please refer to the Wellcare By Allwell website for detailed information regarding our Medicare pharmacy policies.
For Ambetter information, please visit our Ambetter website.
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 Sunflower Health Plan Payment Policy Manual apply with respect to Sunflower Health Plan members. Policies in the Sunflower Health Plan Payment Policy Manual may have either a Sunflower Health Plan or a “Centene” heading. In addition, Sunflower Health Plan 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 Sunflower Health Plan.
If you have any questions regarding these policies, please contact Customer Service and ask to be directed to the Medical Management department.
| Policy # | Title | Description |
|---|---|---|
| KS.PP.501 | 15-Day Readmission (PDF) | Aims to incentivize providers to increase quality of care by denying payment to providers for preventable readmissions within 15 days of initial discharge. |
| CP.MP.157 | 25-hydroxyvitamin D Testing in Children and Adolescents (PDF) | |
| CC.PP.500 | 3-Day Payment Window (PDF) | Aims to ensure that payment for the technical component of all outpatient diagnostic services and related non-diagnostic services are bundled with the claim for an inpatient stay when services are furnished within 3 calendar days. |
| CC.PP.030 | Add-on Code Billed Without Primary Code (PDF) | The purpose of this policy is explain the parameters for add-on codes submitted on physician claims. |
| CP.MP.100 | Allergy Testing and Therapy (PDF) | |
| CC.PP.029 | Assistant Surgeon (PDF) | The purpose of this policy is to define payment criteria for procedures which are appropriate to be billed with the assistant surgeon modifier to be used in making payment decisions and administering benefits. |
| CC.PP.037 | Bilateral Procedures (PDF) | The purpose of this policy is to define the appropriate billing criteria for bilateral services. |
| CP.MP.156 | Cardiac Biomarker Testing (PDF) | |
| CC.PP.008 | Cerumen Removal (PDF) | The purpose of this policy is to define separate payment criteria for removal of impacted cerumen to be used by Health Plan in making payment decisions and administering benefits. |
| CC.PP.021 | Clean Claims (PDF) | The purpose of this policy is to define the minimum claim submission requirements for claims submitted to the health plan for processing from all providers, including facilities (e.g., hospitals, ambulatory surgery centers) and professional providers (e... |
| CC.PP.013 | Clinical Validation of Modifier 25 (PDF) | The policy applies to the use of modifier 25; which should only be used to indicate that a “significant, separately identifiable evaluation and management service (was provided) by the same physician on the same day of the procedure or other service.” |
| CC.PP.014 | Clinical Validation of Modifier 59 (PDF) | The policy applies to the use of modifier 59; which should only be used to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. |
| CC.PP.011 | Coding Overview (PDF) | The purpose of this policy is to serve as a reference guide for general coding and claims editing information. |
| CC.PP.024 | Cosmetic Procedures (PDF) | Cosmetic procedures or procedures connected with the cosmetic surgery are not reimbursable. The Centers for Medicare and Medicaid Services (CMS) define cosmetic procedures as “any surgical procedure, directed at improving appearance, except when required ... |
| CP.MP.105 | Digital Electroencephalography Spike Analysis (PDF) | |
| CC.PP.020 | Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF) | The policy applies to use of 4 new modifiers to be used in place of modifier 59. |
| CP.MP.50 | Drugs of Abuse: Definitive Testing (PDF) | |
| CC.PP.044 | Duplicate Primary Code Billing (PDF) | The purpose of this policy is to define payment criteria when a primary procedure code is billed in multiple quantities instead of the more appropriate "add-on" code. |
| CP.MP.155 | Electroencephalography in the Evaluation of Headache (PDF) | |
| CP.MP.106 | Endometrial Ablation (PDF) | |
| CC.PP.051 | E&M Medical Decision-Making (PDF) | The policy discusses the appropriate assignment of moderate to high complexity E&M services with an emphasis on medical decision making as a key component of the assignment process. |
| CC.PP.010 | E&M Bundling (PDF) | The purpose of this policy is to define payment criteria for those physician services included in the payment for E/M services to be used by Health Plan in making payment decisions and administering benefits. |
| CP.MP.134 | Evoked Potential Testing (PDF) | |
| CP.MP.209 | Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) | |
| CC.PP.016 | Global Maternity Package (PDF) | The purpose of this policy is to serve as a reference guide for coding global obstetrical package for reimbursement. |
| CP.MP.153 | Helicobacter Pylori Serology Testing (PDF) | |
| CP.MP.113 | Holter Monitors (PDF) | |
| CP.MP.121 | Homocysteine Testing (PDF) | |
| CC.PP.023 | Hospital Visit Codes Billed with Labs (PDF) | The purpose of this policy is to serve as a reference guide for coding hospital visits with laboratory tests. |
| CC.PP.038 | Inpatient Consultation (PDF) | The purpose of this policy is to outline how the health plan evaluates CPT consultation codes 99251-99255 and HCPCS codes G0406-G0408 for reimbursement, particularly identifying those that should have been billed at the appropriate level of subsequent hos... |
| CC.PP.018 | Inpatient Only Procedures (PDF) | The purpose of this policy is to serve as a reference guide on procedures that will reimbursed as inpatient only services. |
| CC.PP.012 | Intravenous Hydration (PDF) | According to the American Medical Association (AMA), CPT code 96360 is used to report intravenous (IV) infusions for hydration purposes. The code is used to report the first 31 minutes to 1 hour of hydration therapy. CPT code 96361 is used to report eac... |
| CP.MP.123 | Laser Therapy for Skin Conditions (PDF) | |
| CP.MP.139 | Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) | |
| CC.PP.007 | Maximum Units (PDF) | The purpose of this policy is to define payment criteria for the maximum units of service billed on a claim to be used by Health Plan in making payment decisions and administering benefits. |
| CP.MP.152 | Measurement of Serum 1,25-dihydroxyvitamin D (PDF) | |
| CC.PP.015 | Moderate Conscious Sedation (PDF) | The purpose of this policy is to serve as a reference guide for coding drug induced depression of consciousness for reimbursement. |
| CC.PP.034 | Modifier DOS Validation (PDF) | Providers append modifiers to procedures and services to indicate that a procedure or service has been altered by some circumstance, but the definition of the procedure or the procedure code itself is unchanged. |
| CC.PP.028 | Modifier to Procedure Code Validation (PDF) | Providers append modifiers to procedures codes to indicate that a procedure or service has been altered by some circumstance, but the definition of the procedure or the procedure code itself is unchanged. This policy is relevant to modifiers identified a... |
| CC.PP.033 | Multiple CPT Code Replacement (PDF) | When a single, more comprehensive procedure code exists to describe a service, the single more comprehensive code should be used versus multiple CPT codes. |
| CC.PP.031 | NCCI Unbundling (PDF) | The health plan administers unbundling edits based on the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI). The NCCI edit reimbursement methodologies dictate that when two relatable procedure codes are billed for... |
| CC.PP.017 | Never Paid Events (PDF) | The purpose of this policy is to serve as a reference guide for Never Events for non-payment. |
| CC.PP.036 | New Patient (PDF) | The purpose of this policy is to define payment criteria and appropriate use of the new patient evaluation and management (E&M) procedure codes. |
| CC.PP.060 | Not Medically Necessary Inpatient Professional Services (PDF) | The purpose of this policy is to define payment criteria for medical professional services when the inpatient facility admission is denied as not medically necessary. |
| CC.PP.039 | Outpatient Consultations (PDF) | The purpose of this policy is to outline how the health plan evaluates CPT consultation codes 99241-99245 and HCPS codes G0425-G0427 for reimbursement, particularly identifying those that should have been billed at the appropriate level of office visit, e... |
| CP.MP.181 | Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) | |
| CP.MP.242 | Pulmonary Function Testing (PDF) | |
| CC.PP.041 | Pre-operative Visits (PDF) | The purpose of this policy is to define payment criteria for E&M services when billed with surgical procedures having a 000, 010 or 090, MMM, and ZZZ global period to be used in making payment decisions and administering benefits. |
| CC.PP.042 | Post-operative Visits (PDF) | The purpose of this policy is to define payment criteria for E&M services when billed with surgical procedures having a 000, 010 or 090, MMM, and ZZZ global period to be used in making payment decisions and administering benefits. |
| CC.PP.027 | Professional Component (PDF) | Certain procedure codes represent both the technical and professional component of a procedure or service. |
| CC.PP.019 | Professional Services (Visit Codes) Billed With Labs (PDF) | Providers may receive reimbursement for visit codes (evaluation and management services) in addition to a laboratory test, but only when the provider performs a distinct and separately identifiable service in addition to the test. |
| CC.PP.025 | Pulse Oximetry (PDF) | The purpose of this policy is to define payment criteria for pulse oximetry testing when billed separately from an office visit. |
| CC.PP.206 | Skilled Nursing Facility Leveling | |
| CC.PP.035 | Sleep Studies Place of Service (PDF) | The purpose of this policy is to define the appropriate place of service for sleep studies. |
| CC.PP.049 | Status B Bundled Services (PDF) | The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another procedure or service to be used in making payment decisions and administering benefits. |
| CC.PP.046 | Status P Bundled Services (PDF) | The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another physician's procedure or service to be used in making payment decisions and administering benefits. |
| CC.PP.032 | Supplies Billed on Same Day As Surgery (PDF) | The purpose of this policy is to define payment criteria for supplies billed on the same date as a surgical procedure to be used by the health plan in making payment decisions. |
| CP.MP.154 | Thyroid Hormones and Insulin Testing in Pediatrics (PDF) | |
| CP.MP.38 | Ultrasound in Pregnancy (PDF) | |
| KS.CP.MP.38 | Ultrasound in Pregnancy - KS (PDF) | This policy outlines the medical necessity criteria for ultrasound use in pregnancy. |
| CC.PP.043 | Unbundled Professional Services (PDF) | The purpose of this policy is to define payment criteria for national specialty society surgical code pair edit relationships to be used in making payment decisions and administering benefits |
| CC.PP.045 | Unbundled Surgical Procedures (PDF) | The purpose of this policy is to define payment criteria for national specialty society surgical code pair edit relationships to be used in making payment decisions and administering benefits |
| CC.PP.009 | Unlisted Procedure Codes (PDF) | Outlines the parameters and documentation requirements necessary when an unlisted or unspecified procedure code is utilized. |
| CP.MP.98 | Urodynamic Testing (PDF) | |
| CC.PP.040 | Visits On Same Day As Surgery (PDF) | For purposes of this policy, “same day visits” address evaluation and management services that occur on the same day as the surgical procedure. |
| CP.MP.99 | Wheelchair Seating (PDF) | |
| CC.PP.502 | Wheelchairs and Accessories (PDF) | The purpose of this policy is to define coverage criteria for options and accessories for manual and powered wheelchairs to be used by the Health Plan in making coverage decisions and administering benefits. |
| CP.MP.143 | Wireless Motility Capsule (PDF) |
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