Clinical & Payment Policies
Provider billing guidance for COVID-19
For information regarding Provider billing guidance for COVID-19 testing please refer to our COVID-19 resources page.
Clinical Policies
Important Notice
The Clinical Policies do not constitute medical advice. 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 Clinical Policy Manual apply to health plan members. The health plan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which health plan clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. In addition, the health plan 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 the health plan.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine. The health plan reserves the right to amend the Policies without notice to providers or Members.
Policies specifically developed to assist the health plan in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other health plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.
The Clinical Policy Manuals may be accessed through the links below.
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) - (Medicaid, Medicare, Marketplace)
- Acupuncture (PDF) - (Medicaid, Medicare, Marketplace)
- ADHD Assessment and Treatment (PDF) - (Medicaid, Medicare, Marketplace)
- Allergy Testing and Therapy (PDF) - (Medicaid, Medicare, Marketplace)
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) - (Medicaid, Medicare, Marketplace)
- Ambulatory EEG (PDF) - (Medicaid, Medicare, Marketplace)
- Ambulatory Surgery Center Optimization (PDF) - (Medicaid, Medicare, Marketplace)
- Antithrombin III (PDF) - (Medicaid, Medicare, Marketplace)
- Applied Behavioral Analysis for Autism (PDF) - (Medicaid, Medicare, Marketplace)
- Arizona Clinical Practice Guidelines and Resources (PDF) - (Medicaid)
- Articular Cartilage Defect Repairs (PDF) - (Medicaid, Medicare, Marketplace)
- Assisted Reproductive Technology (PDF) - (Medicaid, Medicare, Marketplace)
- Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF) - (Medicaid, Medicare, Marketplace)
- Balloon Sinus Ostial Dilation (PDF) - (Medicaid, Medicare, Marketplace)
- Bariatric Surgery (PDF) - (Medicaid, Medicare, Marketplace)
- Biofeedback (PDF) - (Medicaid, Medicare, Marketplace)
- Bone-anchored hearing aid (PDF) - (Medicaid, Medicare, Marketplace)
- Bronchial Thermoplasty (PDF) - (Medicaid, Medicare, Marketplace)
- Cardiac biomarker testing (PDF) - (Medicaid, Medicare, Marketplace)
- Cardiac Rehabilitation (PDF) - (Medicaid, Medicare, Marketplace)
- Carrier Screening in Pregnancy (PDF) - (Medicaid, Medicare, Marketplace)
- Caudal or Interlaminar Epidural Steroid Injections (PDF) - (Medicaid, Marketplace)
- Cell-free Fetal DNA Testing (PDF) - (Medicaid, Medicare, Marketplace)
- Clinical Trials (PDF) - (Medicaid, Medicare, Marketplace)
- Cochlear Implant Replacement (PDF) - (Medicaid, Medicare, Marketplace)
- Cosmetic and Reconstructive Surgery (PDF) - (Medicaid, Medicare, Marketplace)
- Dental Anesthesia (PDF) - (Medicaid, Medicare, Marketplace)
- Diagnostic Testing Guidelines for 2019-Novel Coronavirus (PDF) - (Medicaid, Medicare, Marketplace)
- Digital electroencephalography spike analysis (PDF) - (Medicaid, Medicare, Marketplace)
- Discography (PDF) - (Medicaid, Medicare, Marketplace)
- Disc Decompression Procedures (PDF) - (Medicaid, Medicare, Marketplace)
- DNA analysis of stool to screen for colorectal cancer (PDF) - (Medicaid, Medicare, Marketplace)
- Donor Lymphocyte Infusion (PDF) - (Medicaid, Medicare, Marketplace)
- Durable Medical Equipment (DME) O&P Criteria (PDF) - (Medicaid, Medicare, Marketplace)
- Electric Tumor Treatment Fields (PDF) - (Medicaid, Medicare, Marketplace)
- Electroencephalography in the evaluation of headache (PDF) - (Medicaid, Medicare, Marketplace)
- Endometrial ablation (PDF) - (Medicaid, Medicare, Marketplace)
- EpiFix Wound Treatment (PDF) - (Medicaid, Medicare, Marketplace)
- Essure Removal (PDF) - (Medicaid, Medicare, Marketplace)
- Evoked Potential Testing (PDF) - (Medicaid, Medicare, Marketplace)
- Experimental Technologies (PDF) - (Medicaid, Medicare, Marketplace)
- Facet Joint Interventions (PDF) - (Medicaid, Marketplace)
- Fecal Incontinence Treatments (PDF) - (Medicaid, Medicare, Marketplace)
- Ferriscan R2-MRI (PDF) - (Medicaid, Medicare, Marketplace)
- Fertility Preservation (PDF) - (Medicaid, Medicare, Marketplace)
- Fetal Surgery in Utero (PDF) - (Medicaid, Medicare, Marketplace)
- Fixed Wing Air Transportation (PDF) - (Medicaid, Medicare, Marketplace)
- Fractional exhaled nitric oxide (PDF) - (Medicaid, Medicare, Marketplace)
- Functional MIRE (PDF) - (Medicaid, Medicare, Marketplace)
- Gastric electrical stimulation (PDF) - (Medicaid, Medicare, Marketplace)
- Gender Affirming Procedures (PDF) - (Medicaid, Medicare, Marketplace)
- Genetic Testing (PDF) - (Medicaid, Medicare, Marketplace)
- H. Pylori serology testing (PDF) - (Medicaid, Medicare, Marketplace)
- Heart-Lung Transplant (PDF) - (Medicaid, Medicare, Marketplace)
- Holter Monitors (PDF) - (Medicaid, Medicare, Marketplace)
- Home Births (PDF) - (Medicaid, Medicare, Marketplace)
- Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) - (Medicaid, Medicare, Marketplace)
- Homocysteine testing (PDF) - (Medicaid, Medicare, Marketplace)
- Hospice Services (PDF) - (Medicaid, Medicare, Marketplace)
- Hyperbaric Oxygen Therapy (PDF) - (Medicaid, Medicare, Marketplace)
- Hyperemesis gravidarum treatment (PDF) - (Medicaid, Medicare, Marketplace)
- Hyperhidrosis treatments (PDF) - (Medicaid, Medicare, Marketplace)
- Implantable Hypoglossal Nerve Stimulation (PDF) - (Medicaid, Medicare, Marketplace)
- Implantable Intrathecal Pain Pump (PDF) - (Medicaid, Medicare, Marketplace)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) - (Medicaid, Medicare, Marketplace)
- Infusion SOC Optimization (PDF) - (Medicaid, Medicare, Marketplace)
- Inhaled nitric oxide (PDF) - (Medicaid, Medicare, Marketplace)
- Injections for Pain Management (PDF) - (Medicaid, Medicare, Marketplace)
- Intensity-Modulated Radiotherapy (PDF) - (Medicaid, Medicare, Marketplace)
- Intestinal and multivisceral transplant (PDF) - (Medicaid, Medicare, Marketplace)
- Intradiscal Steroid Injections for Pain Management (PDF) - (Medicaid, Marketplace)
- Laser therapy for skin conditions (PDF) - (Medicaid, Medicare, Marketplace)
- Long Term Care Placement (PDF) - (Medicaid, Medicare, Marketplace)
- Low-Frequency Ultrasound Therapy for Wound Management (PDF) - (Medicaid, Medicare, Marketplace)
- Lung Transplantation (PDF) - (Medicaid, Medicare, Marketplace)
- Lysis of Epidural Lesions (PDF) - (Medicaid, Medicare, Marketplace)
- Measurement of serum 1,25-dihydroxyvitamin D (PDF) - (Medicaid, Medicare, Marketplace)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) - (Medicaid, Medicare, Marketplace)
- Medical Necessity Criteria (PDF) - (Medicaid, Medicare, Marketplace)
- Multiple Sleep Latency Testing (PDF) - (Medicaid, Medicare, Marketplace)
- Neonatal abstinence syndrome guidelines (PDF) - (Medicaid, Medicare, Marketplace)
- Neonatal sepsis management (PDF) - (Medicaid, Medicare, Marketplace)
- Nerve Blocks for Pain Management (PDF) - (Medicaid, Marketplace)
- NICU Apnea Bradycardia Guidelines (PDF) - (Medicaid, Medicare, Marketplace)
- NICU discharge guidelines (PDF) - (Medicaid, Medicare, Marketplace)
- Non-myeloablative allogeneic stem cell transplants (PDF) - (Medicaid, Medicare, Marketplace)
- Obstetrical Home Health Care Programs (PDF) - (Medicaid, Medicare, Marketplace)
- Optic Nerve Decompression Surgery (PDF) - (Medicaid, Medicare, Marketplace)
- Outpatient testing for drugs of abuse (PDF) - (Medicaid, Medicare, Marketplace)
- Pancreas transplant (PDF) - (Medicaid, Medicare, Marketplace)
- Panniculectomy (PDF) - (Medicaid, Medicare, Marketplace)
- Pediatric Heart Transplant (PDF) - (Medicaid, Medicare, Marketplace)
- Pediatric Liver Transplant (PDF) - (Medicaid, Medicare, Marketplace)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) - (Medicaid, Medicare, Marketplace)
- Preventive Health and Clinical Practice Guideline (PDF) - (Medicaid, Medicare, Marketplace)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) - (Medicaid, Medicare, Marketplace)
- Posterior tibial nerve stimulation for voiding dysfunction (PDF) - (Medicaid, Medicare, Marketplace)
- Proton and Neutron Beam Therapy (PDF) - (Medicaid, Medicare, Marketplace)
- Radial Head Implant (PDF) - (Medicaid, Medicare, Marketplace)
- Reduction mammoplasty and gynecomastia surgery (PDF) - (Medicaid, Medicare, Marketplace)
- Sacroiliac joint fusion (PDF) - (Medicaid, Medicare, Marketplace)
- Sacroiliac Joint Interventions for Pain Management (PDF) - (Medicaid, Marketplace)
- Sclerotherapy for Vericose Veins (PDF) - (Medicaid, Medicare, Marketplace)
- Selective Dorsal Rhizotomy for Spasticity in CP (PDF) - (Medicaid, Medicare, Marketplace)
- Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) - (Medicaid, Marketplace)
- Short inpatient hospital stay (PDF) - (Medicaid, Medicare, Marketplace)
- Sickle cell disease observation (PDF) - (Medicaid, Medicare, Marketplace)
- Skin Substitutes for Chronic Wounds (PDF) - (Medicaid, Medicare, Marketplace)
- Spinal Cord Stimulation (PDF) - (Medicaid, Medicare, Marketplace)
- Stereotactic Body Radiation Therapy (PDF) - (Medicaid, Medicare, Marketplace)
- Tandem Transplant (PDF) - (Medicaid, Medicare, Marketplace)
- Testing for rupture of fetal membranes (PDF) - (Medicaid, Medicare, Marketplace)
- Testing for Select Genitourinary Conditions (PDF) - (Medicaid, Medicare, Marketplace)
- Therapy Services (PT/OT/ST) (PDF) - (Medicaid, Medicare, Marketplace)
- Thyroid hormones and insulin testing in pediatrics (PDF) - (Medicaid, Medicare, Marketplace)
- Total Artificial Heart (PDF) - (Medicaid, Medicare, Marketplace)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) - (Medicaid, Medicare, Marketplace)
- Transcatheter Closure of Patent Foramen Ovale (PDF) - (Medicaid, Medicare, Marketplace)
- Transcranial Magnetic Stimulation (PDF) - (Medicaid, Medicare, Marketplace)
- Trigger Point Injections for Pain Management (PDF) - (Medicaid, Medicare)
- Ultrasound in Pregnancy (PDF) - (Medicaid, Medicare, Marketplace)
- Urinary Incontinence Devices and Treatments (PDF) - (Medicaid, Medicare, Marketplace)
- Urodynamic testing (PDF) - (Medicaid, Medicare, Marketplace)
- Vagus Nerve Stimulation (PDF) - (Medicaid, Medicare, Marketplace)
- Ventricular Assist Devices (PDF) - (Medicaid, Medicare, Marketplace)
- Ventriculectomy and cardiomyoplasty (PDF) - (Medicaid, Medicare, Marketplace)
- Video Electroencephalographic (VEEG) Monitoring (PDF) - (Medicaid, Medicare, Marketplace)
- Wheelchair seating (PDF) - (Medicaid, Medicare, Marketplace)
- Wireless Motility Capsule (PDF) - (Medicaid, Medicare, Marketplace)
- Zika Virus Testing (PDF) - (Medicaid, Medicare, Marketplace)
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 Arizona Complete Health Payment Policy Manual apply with respect to Arizona Complete Health members. Policies in the Arizona Complete Health Payment Policy Manual may have either a Arizona Complete Health or a “Centene” heading. In addition, Arizona Complete 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 Arizona Complete Health.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- Add on Code Billed Without Primary Code (PDF) - (Medicaid, Medicare, Marketplace)
- ADHD Assessment and Treatment (PDF) - (Medicaid, Medicare)
- Ambulatory EEG (PDF) - (Medicaid, Medicare)
- Assistant Surgeon (PDF) (PDF) - (Medicaid, Medicare, Marketplace)
- Bevacizumab (PDF) - (Medicaid, Medicare)
- Bilateral Procedured (PDF) - (Medicaid, Medicare, Marketplace)
- Bronchial Thermoplasty (PDF) - (Medicaid, Medicare)
- Cardiac Biomarker Testing for Acute MI (PDF) - (Medicaid, Marketplace)
- Cerumen Removal (PDF) - (Medicaid, Medicare, Marketplace)
- Coding Overview (PDF) - (Medicaid, Medicare)
- Diagnosis of Vaginitis (PDF) - (Medicaid, Medicare)
- Digital Analysis of EEGs (PDF) - (Medicaid, Medicare)
- Distinct Procedural Modifiers (PDF) - (Medicaid, Medicare, Marketplace)
- DNA Analysis of Stool (PDF) - (Medicaid, Medicare)
- Duplicate Primary Code Billing (PDF) - (Medicaid, Medicare, Marketplace)
- E&M Medical Decision-Making (PDF) - (Medicaid)
- EEG in Evaluation of Headache (PDF) - (Medicaid, Marketplace)
- Emergency Department (ED) Evaluation and Management (E&M) Coding for Facility Claims (PDF) - (Medicaid, Medicare, Marketplace)
- Endometrial Ablation (EA) (PDF) - (Medicaid, Medicare)
- EpiFix Wound Treatment (PDF) - (Medicaid)
- Evoked Potentials (PDF) - (Medicaid, Medicare)
- FeNo Testing (PDF) - (Medicaid, Medicare)
- Global Maternity Billing (PDF) - (Medicaid, Medicare, Marketplace)
- H Pylori Testing (PDF) - (Medicaid, Marketplace)
- Holter Monitors (PDF) - (Medicaid, Medicare)
- Homocysteine Testing (PDF) - (Medicaid, Medicare)
- Inpatient Consultation (PDF)- (Medicaid, Medicare, Marketplace)
- Inpatient Only Procedures (PDF) - (Medicaid, Medicare, Marketplace)
- IV Hydration (PDF) - (Medicaid, Medicare, Marketplace)
- Laser Skin Treatment (PDF) - (Medicaid, Medicare)
- Leveling of ER Services (PDF) - (Medicaid, Medicare, Marketplace)
- Low-Frequency Ultrasound Wound Therapy (PDF) - (Medicaid)
- Measure Serum 1,25 Vitamin D (PDF) - (Medicaid, Marketplace)
- Mechanical Stretch Devices (PDF) - (Medicaid, Medicare)
- Moderate Conscious Sedation (PDF) - (Medicaid, Medicare)
- Modifier -25 clinical validation (PDF) - (Medicaid, Medicare, Marketplace)
- Modifier -59 clinical validation (PDF) - (Medicaid, Medicare, Marketplace)
- Modifier to Procedure Code Validation (PDF) - (Medicaid, Medicare, Marketplace)
- Never Paid Events (PDF) - (Medicaid, Medicare, Marketplace)
- New Patient (PDF) - (Medicaid, Medicare, Marketplace)
- Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF) - (Medicaid, Medicare, Marketplace)
- Not Medically Necessary Inpatient Services (PDF) - (Medicaid, Medicare, Marketplace)
- Outpatient Consultation (PDF) - (Medicaid, Medicare, Marketplace)
- Paclitaxel (PDF) - (Medicaid, Medicare)
- Physician Visit Codes Billed with Labs (PDF) - (Medicaid, Medicare, Marketplace)
- Physician's Consultation Services (PDF) - (Medicaid, Medicare, Marketplace)
- Physician's Office Lab Testing (PDF) - (Medicaid, Medicare, Marketplace)
- Place of Service Mismatch (PDF) - (Medicaid, Medicare, Marketplace)
- Post-Operative Visits (PDF) - (Medicaid, Medicare, Marketplace)
- Pre-Operative Visits (PDF) - (Medicaid, Medicare, Marketplace)
- Preventive health and CPG Policy Grid (PDF) - (Medicaid, Medicare, Marketplace)
- Problem Oriented Visits with Preventative Visits (PDF) - (Medicaid, Medicare, Marketplace)
- Problem Oriented Visits with Surgical Procedures (PDF) - (Medicaid, Medicare, Marketplace)
- Professional Component (PDF) - (Medicaid, Medicare, Marketplace)
- PROM Testing (PDF) - (Medicaid)
- Pulse Oximetry (PDF) - (Medicaid, Medicare, Marketplace)
- Rituximab (PDF) - (Medicaid, Medicare)
- Robotic Surgery (PDF) - (Medicaid)
- Same Day Visits (PDF) - (Medicaid, Medicare, Marketplace)
- Sleep Studies Place of Services (PDF) - (Medicaid, Medicare)
- Status "B" Bundled Services (PDF) - (Medicaid, Medicare, Marketplace)
- Status P Bundled Services (PDF) - (Medicaid, Medicare)
- Supplies Billed on Same Day As Surgery (PDF) - (Medicaid, Medicare, Marketplace)
- Thyroid Testing in Pediatrics (PDF) - (Medicaid, Marketplace)
- Transgender Related Services (PDF) - (Medicaid, Medicare, Marketplace)
- Ultrasound in Pregnancy (PDF) - (Medicaid, Medicare)
- Unbundled Professional Services (PDF) - (Medicaid, Medicare, Marketplace)
- Unbundled Surgical Procedures (PDF) - (Medicaid, Medicare, Marketplace)
- Unlisted Procedure Codes (PDF) - (Medicaid, Medicare, Marketplace)
- Urine Specimen Validity Testing (PDF) - (Medicaid)
- Urodynamic Testing (PDF) - (Medicaid, Medicare)
- Vitamin D Testing in Children (PDF) - (Medicaid, Marketplace)
- Wheelchair Seating (PDF) - (Medicaid, Medicare)
- Wireless Motility Capsule (PDF) - (Medicaid, Medicare)
Pharmacy Policies can be found in the Pharmacy section of this website.