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 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.   

Sunshine Health may also use Medicare National Coverage Determination (NCDs), Local Coverage Determinations (LCDs), or InterQual® for clinical decisions.  Medicare NCDs and LCDs are applied to the Medicare population and can be found at the following address: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

The Clinical Policy Manuals may be accessed through the link below.  This site allows you to:

Search by keyword by selecting the “Search” tab in the upper left hand corner and enter a key word, or Browse by topic by selecting the “Catalog” tab in the upper left hand corner and click on the + sign next to the Clinical Policy icon.

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

Sunshine Health Clinical 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 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.  

Sunshine Health's payment policies may also use or be based on Medicare National Coverage Determination (NCDs), or Local Coverage Determinations (LCDs), for payment policy decisions.  Medicare NCDs and LCDs are applied to the Medicare population and can be found at the following address: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.  

The Payment Policy Manuals may be accessed through the link below.  This site allows you to:

Search by keyword by selecting the “Search” tab in the upper left hand corner and enter a key word, or Browse by topic by selecting the “Catalog” tab in the upper left hand corner and click on the + sign next to the Payment Policy icon.

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

Sunshine Health Payment Policies