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

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

For Medicare information, please visit our Medicare Prior Authorization 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 Wellcare Payment Policy Manual apply with respect to Ambetter of Oklahoma members. Policies in the Wellcare Payment Policy Manual may have either a Wellcare or a “Centene” heading.  In addition, Wellcare 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 Wellcare.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.


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3 Day Payment Window (PDF) - last updated Dec 21, 2023
Effective Date: 1/1/2022
Leveling of Care: Evaluation and Management Overcoding (PDF) - last updated Apr 20, 2023
Effective Date: 1/1/2022
Renal Hemodialysis - last updated Dec 21, 2023
Effective Date: 1/1/2022
30 Day Readmission (PDF) - last updated Dec 21, 2023
Effective Date: 1/1/2022
 
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) - last updated Apr 20, 2023
Effective Date: 1/1/2022
Scanning computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF) - last updated Jan 4, 2019
Effective Date: 1/1/2022
340B Drug Payment Reduction (PDF) - last updated Feb 7, 2022
Effective Date: 1/1/2022
Multiple Procedure Payment Reduction for Therapeutic Services (PDF) - last updated Dec 21, 2023
Effective Date: 1/1/2022
Skilled Nursing Facility Leveling (CC.PP.206) (PDF) Effective Date: January 1, 2024
Extended Ophthalmoscopy (PDF) - last updated Jan 12, 2021
Effective Date: 1/1/2022
Multiple Procedure Reduction: Ophthalmology (PDF) - last updated Dec 21, 2023
Effective Date: 1/1/2022
Sleep Studies Place of Service (PDF) - last updated Jan 17, 2023
Effective Date: 1/1/2022
External Ocular Photography (PDF) - last updated Jan 12, 2021
Effective Date: 1/1/2022
Non-Emergent ER Services (fka Leveling of ER Services) (PDF) - last updated Dec 21, 2023
Effective Date: 1/1/2022
Urine Specimen Validity Testing (PDF) - last updated Apr 20, 2023
Effective Date: 1/1/2022
Fluorescein Angiography (PDF) - last updated Jan 12, 2021
Effective Date: 1/1/2022
Non-Obstetrical and OB Pelvic and Transvaginal Ultrasounds (PDF) - last updated Dec 21, 2023
Effective Date: 1/1/2022

Visual Field Testing (PDF) - last updated Jan 4, 2019
Effective Date: 1/1/2022

Fundus Photography (PDF) - last updated Jan 12, 2021
Effective Date: 1/1/2022
Physician's Consultation Services (PDF) - last updated Apr 20, 2023
Effective Date: 1/1/2022
Wheelchair Accessories (PDF) - last updated Dec 21, 2023
Effective Date: 1/1/2022
Gonioscopy (PDF) - last updated Jan 12, 2021
Effective Date: 1/1/2022
Physician's Office Lab Testing (POLT) - last updated Dec 21, 2023
Effective Date: 1/1/2022
 
  Problem-Oriented Visits with Preventative Visits (PDF) - last updated Dec 21, 2023
Effective Date: 1/1/2022
 
  Problem-Oriented Visits with Surgical Procedures (PDF) - last updated Apr 20, 2023
Effective Date: 1/1/2022