Clinical and Payment Policies

To easily search for a policy, use the Ctrl+F (Command+F on Mac) function on your keyboard to search by keyword, policy number or effective date. 

What are 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 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, including peer-reviewed medical literature, government agency/program approval status, evidence-based guidelines, 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 on the QualChoice Clinical Policy page apply to QualChoice members. Policies on this QualChoice page may have either a “QualChoice” or a “Centene” heading. QualChoice follows care guidelines published by InterQual.
QualChoice 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 policies on this page or within the InterQual criteria is payable by QualChoice.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

What are Payment Policies?

Healthcare 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 healthcare services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include claims processing guidelines referenced by the Centers for Medicare & 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), CPT® guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of healthcare and medical necessity, ClaimsXten™ review, and, at times, state-specific claims reimbursement guidance. More information about ClaimsXten and the way we utilize ClaimsXten with relation to claims payments can be found on our Claims and Payment Information page.

All policies found on this page apply with respect to QualChoice members. These payment policies may have either a “QualChoice” or a “Centene” heading. QualChoice 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 these policies is payable by QualChoice.

Clinical Policies for CT/CTA/CCTA, MRI, MRA, and Pet scans can also be found at the Evolent website.