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Clinical & Payment 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 Arkansas Total Care Clinical Policy Manual apply to Arkansas Total Care members. Policies in the Arkansas Total Care Clinical Policy Manual may have either a Arkansas Total Care or a “Centene” heading.  Arkansas Total Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Arkansas Total Care 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 Arkansas Total Care. In addition, Arkansas Total Care 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 Arkansas Total Care. 

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 Arkansas Total Care Payment Policy Manual apply with respect to Arkansas Total Care members. Policies in the Arkansas Total Care Payment Policy Manual may have either a Arkansas Total Care or a “Centene” heading.  In addition, Arkansas Total Care 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 Arkansas Total Care. 

Arkansas Total Care Policies

Policy Title Policy Number Effective Date
Acupuncture (PDF) CP.MP.92 03/17/17
Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) CP.MP.108 5/1/19
Ambulatory Surgery Center Optimization (PDF) CP.MP.158 04/16/18
Applied Behavioral Analysis for Autism (PDF) CP.MP.104 6/1/2019
Articular Cartilage Defect Repairs (PDF) CP.MP.26 10/19/18
Assistive Reproductive Technology (PDF) CP.MP.55 6/1/2019
Balloon Sinus Ostial Dilation (PDF) CP.MP.119 04/18/17
Biofeedback (PDF) CP.MP.168 11/07/17
Bone-Anchored Hearing Aid (PDF) CP.MP.93 5/1/19
Carrier Screening in Pregnancy (PDF) CP.MP.83 11/07/17
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 12/10/18
Cell-Free Fetal DNA Testing (PDF) CP.MP.84 03/16/17
Clinical Policy Committee (PDF) CP.CPC.01 04/17/17
Clinical Policy Web Posting (PDF) CP.CPC.02 04/17/17
Clinical Trials (PDF) CP.MP.94 12/01/17
Cochlear Implant Replacements (PDF) CP.MP.14 5/1/2019
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 03/15/17
Dental Anesthesia (PDF) CP.MP.61 03/15/17
Disc Decompression Procedures (PDF) CP.MP.114 10/19/18
Discography (PDF) CP.MP.115 10/19/18
Donor lymphocyte infusion (PDF) CP.MP.101 5/1/2019
Durable Medical Equipment (DME) (PDF) CP.MP.107 5/1/2019
Fixed Wing Air Transportation (PDF) CP.MP.175 1/1/2020
Electric Tumor Treatment Fields (PDF) CP.MP.145 09/08/17
Essure Removal (PDF) CP.MP.131
04/18/17
Experimental Technologies (PDF) CP.MP.36
03/15/17
Facet Joint Interventions (PDF) CP.MP.171 12/10/18
Fecal incontinence treatments (PDF) CP.MP.137 3/5/19
Ferriscan R2-MRI (PDF) CP.MP.53
5/1/19
Fertility Preservation (PDF) CP.MP.130 1/1/2020
Fetal surgery in utero for prenatally diagnosed malformations (PDF) CP.MP.129 5/1/19
Flu and Strep Testing (PDF) CP.MP.112
04/17/17
Functional MRI (PDF) CP.MP.43
03/15/17
Gastric Electrical Stimulation (PDF) CP.MP.40
03/15/17
Gender reassignment surgery (PDF) CP.MP.95 5/1/19
Genetic Testing (PDF) CP.MP.89
03/16/17
Heart-Lung Transplant (PDF) CP.MP.132 10/19/18
Home Birth (PDF) CP.MP.136 04/18/17
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150
12/31/17
Hospice Clinical Coverage (PDF) CP.MP.54
03/15/17
Hyperbaric Oxygen Therapy (PDF) CP.MP.27
5/1/19
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34
6/1/2019
Hyperhidrosis Treatments (PDF) CP.MP.62 6/1/2019
Implantable Intrathecal Pain Pump (PDF) CP.MP.173 6/1/2019
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 1/1/2020
Inhaled Nitric Oxide (PDF) CP.MP.87
03/16/17
Injections for Pain Management (PDF) CP.MP.118 12/19/18
Intensity Modulated Radiation Therapy (PDF) CP.MP.69 6/1/2019
Intestinal & Multivisceral Transplant (PDF) CP.MP.58
03/15/17
Intradiscal Steroid Injections (PDF) CP.MP.167 12/10/18
Long Term Care Placement Criteria (PDF) CP.MP.71
03/16/17
Lung Transplantation (PDF) CP.MP.57 10/19/18
Lysis of Epidural Lesions (PDF) CP.MP.116
04/18/17
Medical Necessity Criteria (PDF) CP.MP.68
03/16/17
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) CP.MP.161  10/19/18
Multiple Sleep Latency Testing (PDF) CP.MP.24 10/19/18
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86
03/16/17
Neonatal Sepsis Management Guidelines (PDF) CP.MP.85
03/16/17
Nerve Blocks for Pain Management (PDF) CP.MP.170 12/10/18
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82
5/1/19
NICU Discharge Guidelines (PDF) CP.MP.81
03/16/17
Nonmyeloablative allogeneic stem cell transplant (PDF) CP.MP.141
6/1/2019
OB Home Health Programs (PDF) CP.MP.91
03/17/17
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 1/1/2020
Optic Nerve Decompression Surgery (PDF) CP.MP.128
04/18/17
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 12/10/18
Pain Management Procedures (PDF) CP.MP.63
03/16/17
Pancreas Transplantation (PDF) CP.MP.102
6/1/2019
Panniculectomy (PDF) CP.MP.109
04/17/17
Pediatric Heart Transplant (PDF) CP.MP.138
04/18/17
Pediatric Liver Transplant (PDF) CP.MP.120 6/1/19
Percutaneous LAAD Stroke Prevention (PDF) CP.MP.147 10/19/18
Posterior Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133
04/18/17
Preventive Health and Clinical Practice Guideline Policy (PDF) CP.CPC.03 12/10/18
Radial Head Implant (PDF) CP.MP.148
5/1/19
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 12/10/18
Sacroiliac Joint Fusion (PDF) CP.MP.126
04/18/17
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 12/10/18
Selective Dorsal Rhizotomy (PDF) CP.MP.174 1/1/2020
Selective Nerve Root Blocks and Transforaminal Epidural (PDF) CP.MP.165 12/10/18
Sickle Cell Disease Observation (PDF) CP.MP.88
03/16/17
Spinal Cord Stimulation (PDF) CP.MP.117
04/18/17
Stereotactic Body Radiation Therapy (PDF) CP.MP.22
05/01/19
Tandem Transplant (PDF) CP.MP.162 5/1/19
Therapy Services (PT/OT/ST) (PDF) CP.MP.49
5/1/19
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 1/1/2020
Transcatheter Closure of Patent Foramen Ovale (PFO) (PDF) CP.MP.151 10/19/18
Transcatheter closure of patent foramen ovale (PDF) CP.MP.151 5/1/19
Transcranial Magnetic Stimulation(PDF) CP.MP.172 5/1/19
Trigger Point Injections for Pain Management (PDF) CP.MP.169 12/10/18
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142
09/08/17
Vagus Nerve Stimulation for Epilepsy (PDF) CP.MP.12 12/10/18
Ventricular Assist Devices (PDF) CP.MP.46 6/1/2019
Ventriculectomy and Cardiomyoplasty (PDF) CP.MP.56
04/17/17
Wheelchair seating (PDF) CP.MP.99 10/1/18
Zika Virus Testing (PDF) CP.MP.111 10/19/18
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 7/1/2014
Add on Code Billed Without Primary Code (PDF) CC.PP.030 10/18/2016
ADHD Assessment and Treatment (PDF) CP.MP.124 4/1/2017
Allergy Testing (PDF) CP.MP.100 5/1/2019
Ambulatory EEG (PDF) CP.MP.96 8/12/2016
Assistant Surgeon (PDF) CC.PP.029 2/7/2017
Bevacizumab (PDF) CP.PHAR.93 2/10/2017
Bilateral Procedures (PDF) CC.PP.037 2/7/2017
Bronchial Thermoplasty (PDF) CP.MP.110 4/1/2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 5/21/2018
Cerumen Removal (PDF) CC.PP.008 8/12/2016
Clean Claims (PDF) CC.PP.021 10/18/2016
Coding Overview (PDF) CC.PP.011 10/18/2016
Cosmetic Procedures (PDF) CC.PP.024 10/18/2016
Diagnosis of Vaginitis (PDF) CP.MP.97 4/1/2017
Digital Analysis of EEGs (PDF) CP.MP.105 2/10/2017
Distinct Procedural Modifiers (PDF) CC.PP.020 10/18/2016
DNA Analysis of Stool (PDF) CP.MP.125 6/17/2017
Duplicate Primary Code Billing (PDF) CC.PP.044 2/7/2017
E&M Medical Decision-Making (PDF) CC.PP.051 7/25/2017
EEG in Evaluation of Headache (PDF) CP.MP.155 5/21/2018
EM Bundling Edits (PDF) CC.PP.010 8/12/2016
Endometrial Ablation (PDF) CP.MP.106 12/10/2018
EpiFix Wound Treatment (PDF) CP.MP.140 11/1/2017
Evoked Potentials (PDF) CP.MP.134 6/17/2017
Fecal Calprotectin Assay (PDF) CP.MP.135 6/17/2017
FeNo Testing (PDF) CP.MP.103 4/1/2017
Global Maternity Billing (PDF) CC.PP.016 10/18/2016
H Pylori Testing (PDF) CP.MP.153 5/21/2018
Holter Monitors (PDF) CP.MP.113 4/1/2017
Homocysteine Testing (PDF) CP.MP.121 4/1/2017
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 10/18/2016
Inpatient Consultation (PDF) CC.PP.038 2/7/2017
Inpatient Only Procedures (PDF) MP.PP.018 10/18/2016
IV Hydration (PDF) CC.PP.012 10/18/2016
Laser Skin Treatment (PDF) CP.MP.123 4/1/2017
Leveling of Emergency Room (PDF) CC.PP.053  1/1/2019
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 11/1/2017
Maximum Units (PDF) CC.PP.007 8/12/2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 5/21/2018
Mechanical Stretch Devices (PDF) CP.MP.144 11/1/2017
Moderate Conscious Sedation (PDF) CC.PP.015 10/18/2016
Modifier -25 clinical validation (PDF) CC.PP.013 10/18/2016
Modifier -59 clinical validation (PDF) CC.PP.014 10/18/2016
Modifier DOS Validation (PDF) CC.PP.034 10/18/2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 10/18/2016
Monitored Anesthesia Care (PDF) CP.MP.161 12/15/18
Multiple CPT Code Replacement (PDF) CC.PP.033 10/18/2016
NCCI Unbundling (PDF) CC.PP.031 10/18/2016
Never Paid Events (PDF) CC.PP.017 10/18/2016
New Patient (PDF) CC.PP.036 2/7/2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  12/15/2018
Outpatient Consultation (PDF) CC.PP.039 2/7/2017
Paclitaxel (PDF) CP.PHAR.176 5/16/2016
Physician’s Consultation Services (PDF)  CC.PP.054 9/1/2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 10/18/2016
Place of Service Mismatch (PDF) CC.PP.063  12/15/2018
Post-Operative Visits (PDF) CC.PP.042 2/7/2017
Pre-Operative Visits (PDF) CC.PP.041 2/7/2017
Problem Oriented Visits with Preventative Services CC.PP.057 11/1/2018
Problem Oriented Visits with Surgical Procedures CC.PP.052 11/1/2018
Professional Component (PDF) CC.PP.027 10/18/2016
PROM Testing (PDF) CP.MP.149 11/8/2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 6/1/2019
Pulse Oximetry (PDF) CC.PP.025 10/18/2016
Rituximab (PDF) CP.PHAR.260 2/10/2017
Robotic Surgery (PDF) CC.PP.050 11/1/2017
Same Day Visits (PDF) CC.PP.040 2/7/2017
Status "B" Bundled Services (PDF) CC.PP.046 2/7/2017
Status P Bundled Services (PDF) CC.PP.049 6/17/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 10/18/2016
Thyroid Testing in Pediatrics (PDF) CP.MP.154 5/21/2018
Transgender Related Services (PDF) CC.PP.047 2/22/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 2/10/2017
Unbundled Professional Services (PDF) CC.PP.043 4/6/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 4/6/2017
Unlisted Procedure Codes (PDF) CC.PP.009 8/12/2016
Urine Specimen Validity Testing (PDF) CC.PP.056 11/8/2017
Urodynamic Testing (PDF) CP.MP.98 8/12/2016
Vitamin D Testing in Children (PDF) CP.MP.157 5/21/2018
Wheelchair Accessories (PDF) CC.PP.502 8/12/2016
Wireless Motility Capsule (PDF) CP.MP.143 11/1/2017