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.
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: February 5, 2021 | Incidental Diagnostic and Laboratory Tests Billed with Evaluation and Management Services (PDF) Effective Date: January 1, 2013 | Renal Hemodialysis (PDF) Effective Date: September, 2022 |
| 3-Day Payment Window (PDF) Effective Date: | Inpatient Consultation (PDF) Effective Date: October 1, 2017 | Reporting Global Maternity Package (PDF) Effective Date: January 1, 2013 |
| Add on Code Billed Without Primary Code (PDF) Effective Date: January 1, 2013 | Inpatient Only Procedures (PDF) Effective Date: November 30, 2021 | Rituximab (PDF) Effective Date: November 1, 2017 |
| ADHD Assessment and Treatment (PDF) Effective Date: January 1, 2022 | Intravenous Hydration (PDF) Effective Date: January 1, 2013 | Robotic Surgery (PDF) Effective Date: April 20, 2021 |
| Allergy Testing and Therapy (PDF) Effective Date: January 1, 2022 | Laser Skin Treatment (PDF) Effective Date: March 31, 2022 | Same Day Visits (PDF) Effective Date: December 1, 2022 |
| Ambulatory EEG (PDF) Effective Until: September 14, 2020 Ambulatory EEG (PDF) Effective Date: September 14, 2020 | Leveling of Care: Evaluation and Management Overcoding (PDF) Effective Date: February 5, 2021 | Scanning Computerized Ophthalmic Diagnostic Imaging (PDF) Effective Date: January 1, 2022 |
| Assistant Surgeon (PDF) Effective Date: January 1, 2014 | Leveling of Emergency Room Services (PDF) Effective Date: May 15, 2019 | Sepsis Diagnosis (PDF) Effective Date: October 1, 2020 |
| Bevacizumab (Avastin) (PDF) Effective Date: August 12, 2016 | Low-Frequency Ultrasound Wound Therapy (PDF) Effective Date: September 1, 2017 | Short Inpatient Hospital Stay (PDF) Effective Date: October 1, 2020 |
| Bilateral Procedures (PDF) Effective Date: January 1, 2014 | Maximum Units of Service (PDF) Effective Date: January 1, 2013 | Sleep Studies Place of Services (PDF) Effective Date: May 1, 2017 |
| Billing Requirements for Transgender Services (PDF) Last Review Date: April 17, 2023 | ||
| Bronchial Thermoplasty (PDF) Effective Date: January 15, 2017 | Measurement of Serum 1,25-dihydroxyvitamin D (PDF) Effective Date: January 1, 2022 | Status "B" Bundled Services (PDF) Effective Date: January 1, 2014 |
| Cardiac Biomarker Testing for Acute MI (PDF) Effective Date: June 1, 2018 | Mechanical Stretch Devices (PDF) Effective Date: September 1, 2017 | Status "P" Bundled Services (PDF) Effective Date: April 1, 2017 |
| Cerumen Removal (PDF) Effective Date: January 1, 2014 | Moderate Conscious Sedation (PDF) Date of Last Revision: June 26, 2023 | Supplies Billed On Same Day as Surgery (PDF) Effective Date: January 1, 2013 |
| Clean Claims (PDF) Effective Date: | Modifier DOS Validation (PDF) Effective Date: January 1, 2013 | Testing for Rupture of Fetal Membranes (PDF) Effective Date: Retired |
| Clean Claim Reviews (PDF) Effective Date: November 1, 2012 | Modifier to Procedure Code Validation (PDF) Effective Date: January 1, 2013 | Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF) Effective Date: January 1, 2022 |
| Clinical Validation of Modifier 25 (PDF) Effective Date: January 1, 2013 | Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: March 1, 2019 | Testing of Select GU Conditions (PDF) Effective Date: March 31, 2022 |
| CMS Correct Coding Initiative Unbundling Edits (PDF) Effective Date: | Thryoid Hormones and Insulin Testing in Pediatrics (PDF) Effective Date: October 31, 2021 | |
| Code Editing Overview (PDF) Effective Date: January 1, 2013 | Multiple CPT Code Replacement (PDF) Effective Date: January 1, 2014 | |
| Cosmetic Procedures (PDF) Effective Date: January 1, 2014 | Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (PDF) Effective Date: February 6, 2021 | Ultrasound in Pregnancy (PDF) Effective Date: March 31, 2022 |
| Cost to Charge Adjustments on Clean Claim Reviews (PDF) Effective Date: September 1, 2022 | Multiple Procedure Reduction: Ophthalmology (PDF) Effective Date: August 23, 2021 | Unbundled Professional Services (PDF) Effective Date: January 1, 2014 |
| 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 | Unbundled Surgical Procedures (PDF) Effective Date: |
| Diagnosis of Vaginitis (PDF) Effective Date: October 1, 2017 - December 31, 2017 | NCCI Unbundling (PDF) Effective Date: | Unbundling Adjustments on Clean Claim Reviews (PDF) Effective Date: September 1, 2022 |
| Digital Analysis of EEGs (PDF) Effective Date: October 31, 2021 | Never Paid Events (PDF) Effective Date: January 1, 2013 | Unlisted Procedure Codes (PDF) Effective Date: January 1, 2013 |
| Digital Breast Tomosynthesis (PDF) Effective Date: December 1, 2016 - December 31, 2017 | New Patient (PDF) Effective Date: January 1, 2014 | Urine Specimen Validity Testing (PDF) Effective Date: April 20, 2021 |
| Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF) Effective Date: January 1, 2013 | Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: March 1, 2019 | Urodynamic Testing (PDF) Effective Date: March 31, 2022 |
| Distinct Procedural Service: Modifier 59 (PDF) Effective Date: January 1, 2013 | Outpatient Consultation (PDF) Effective Date: January 1, 2014 | Visual Field Testing (PDF) Effective Date: January 1, 2022 |
| Duplicate Primary Code Billing (PDF) Effective Date: January 1, 2014 | Paclitaxel Protein Bound (PDF) Effective Date: January 1, 2022 | Vitamin D Testing in Children and Adolescents (PDF) Effective Date: June 1, 2018 |
| EEG in the Evaluation of Headache (PDF) Effective Date: January 1, 2022 | Physician Visit Codes Billed with Labs (PDF) Effective Date: | Wheelchair and Accessories (PDF) Effective Date: August 12, 2016 |
| Endometrial Ablation (PDF) Effective Date: April 30, 2022 | Physician's Consultation Services (PDF) Effective Date: December 1, 2017 | Wheelchair Seating (PDF) Effective Date: March 31, 2022 |
| EpiFix Wound Treatment (PDF) Effective Date: September 1, 2017 | Physician's Office Lab Testing (PDF) Effective Date: January 1, 2022 | Wireless Motility Capsule (PDF) Effective Date: September 1, 2017 |
| Evaluation and Management Services Billed with Treatment Rooms (PDF) Effective Date: January 1, 2022 | Place of Service Mismatch (PDF) Effective Date: March 1, 2019 | |
| 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: January 1, 2014 | |
| External Ocular Photography (PDF) Effective Date: January 1, 2022 | Pre-Operative Visits (PDF) Effective Date: January 1, 2014 | |
| Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) | Problem Oriented Visits Billed with Preventative Visits (PDF) Effective Date: September 2, 2022 | |
| Facility Charges for Hospital-Based Outpatient Clinics (PDF) Effective: September 2022 | Problem Oriented Visits with Surgical Procedures (PDF) Effective Date: December 1, 2017 | |
| Fecal Calprotectin Assay (PDF) Effective Date: May 1, 2017 | Professional Component Modifier 26 (PDF) Effective Date: January 1, 2013 | |
| Fluorescein Angiography (PDF) Effective Date: January 1, 2022 | Professional Services (Visit Codes) Billed With Labs (PDF) Effective Date: January 1, 2013 | |
| 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 | Proton and Neutron Beam Therapy (PDF) Effective Date: December 1, 2016 | |
| Gonioscopy (PDF) Effective Date: January 1, 2022 | Pulse Oximetry with Evaluation & Management Services (PDF) Effective Date: January 1, 2014 | |
| High Complexity Medical Decision-Making (PDF) Effective Date: June 2017 | ||
| Holter Monitors (PDF) Effective Date: December 31, 2021 | ||
| Homocysteine Testing (PDF) Effective Date: March 31, 2022 |