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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 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.   

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

A-H I-Q R-Z
2019 Novel Coronavirus – COVID-19 (PDF)
Effective Date: 03/20
Infusion Therapy Site of Care Optimization (PDF)
Effective Date: 9/1/2020

Rehabilitative Therapy Site of Care Optimization (PDF)

Effective date: 08/19

Acupuncture Expanded Benefit (PDF)
Effective Date: 07/18
Laser Skin Treatment (PDF)
Effective Date: 1/15/2017
Rituximab (PDF)
Effective Date: 
ADHD Assessment and Treatment (PDF)
Effective Date: 1/15/2017
Low-Frequency Ultrasound 
Wound Therapy (PDF)

Effective Date: 9/1/2017

Thyroid Testing 
in Pediatrics (PDF)

Effective Date: 6/1/2018

Allergy Testing (PDF)
Effective Date: 6/15/2017
Measure Serum 1,25 Vitamin D (PDF)
Effective Date: 6/1/2018
Ultrasound in Pregnancy (PDF)
Effective Date: 7/1/2016

Ambulatory EEG (PDF)
Effective Until: 9/14/2020

Ambulatory EEG (PDF)
Effective Date: 9/14/2020

Mechanical Stretch Devices 
(PDF)

Effective Date: 9/1/2017
Urodynamic Testing (PDF)
Effective Date: 5/1/2016
Bevacizumab (PDF)
Effective Date: 
Paclitaxel (PDF)
Effective Date: 
Vitamin D Testing 
in Children (PDF)

Effective Date: 6/1/2018
Bronchial Thermoplasty (PDF)
Effective Date: 1/15/2017
Proton and Neutron 
Beam Therapy (PDF)

Effective Date: 11/1/2016

Wheelchair Seating (PDF)
Effective Date: 10/1/2018 

Wheelchair Seating (PDF)
Effective Date: 9/30/2018

Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 6/1/2018
 

Wireless Motility Capsule 
(PDF)

Effective Date: 9/1/2017

Diagnosis of Vaginitis (PDF)
Effective Date: 1/15/2017
 

 

Digital Analysis of EEGs (PDF)
Effective Date: 11/1/2016
   

DNA Analysis of Stool (PDF)
Effective Until: 9/14/2020

DNA Analysis of Stool (PDF)
Effective Date: 9/14/2020

   
EEG in Evaluation of Headache (PDF)
Effective Date: 6/1/2018
   
Endometrial Ablation (EA) (PDF)
Effective Date: 11/1/2016
   
EpiFix Wound Treatment (PDF)
Effective Date: 9/1/2017
   
Evoked Potentials (PDF)
Effective Date: 5/1/2017
   
Fecal Calprotectin Assay (PDF)
Effective Date: 5/1/2017
   
FeNo Testing (PDF)
Effective Date: 1/15/2017
   
H Pylori Testing (PDF)
Effective Date: 6/1/2018
   
Holter Monitors (PDF)
Effective Date: 1/15/2017
   

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 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.     

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

A-H I-Q R-Z
3-Day Payment Window (PDF) Leveling of Emergency Room Services  (PDF)
Effective Date: 5/15/2019
Robotic Surgery (PDF)
Effective Date: 9/1/2017

High Complexity Medical Decision-Making (PDF)

Effective  Date:  7/31/2017 

Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: 3/1/2019  Sleep Studies Place of Services (PDF)
Effective Date: 5/1/2017
  Not Medically Necessary Inpatient Services (PDF)Effective Date: 3/1/2019  Status P Bundled Services (PDF)
Effective Date: 4/1/2017
  Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: 3/1/2019  Urine Specimen Validity Testing (PDF)
Effective Date: 12/1/2017
  Physician's Consultation Services (PDF)
Effective Date: 5/15/2019
Wheelchair Accessories (PDF)
Effective Date: 
  Physician's Office Lab Testing (PDF)
Effective Date: 12/1/2017
 
  Place of Service Mismatch (PDF) Effective Date: 3/1/2019   
  Problem Oriented Visits with 
Preventative Visits (PDF)

Effective Date: 5/15/2019
 
  Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 5/15/2019
 
A-H I-Q R-Z
30-Day Readmission (PDF)
Effective Date: 01/01/2015
Inpatient Consultation (PDF) 
Effective Date: 10/1/2017
Reporting Global Maternity Package (PDF)
Effective Date: 
3-Day Payment Window (PDF)
Effective Date: 
Inpatient Only Procedures (PDF) 
Effective Date: 
Same Day Visits (PDF)
Effective Date: 
Add on Code Billed Without Primary Code (PDF)
Effective Date:
Intravenous Hydration (PDF)
Effective Date: 

Short Inpatient Hospital Stay (PDF)

Effective Date: 10/01/2020

ADHD Assessment and Treatment (PDF)
Effective Date: 01/15/2017
Laser Skin Treatment  (PDF)
Effective Date: 01/15/2017
Sleep Studies Place of Services (PDF)
Effective Date: 05/01/2017
Allergy Testing (PDF)
Effective Date: 10/1/2017
Leveling of ER Services (PDF)
Effective Date: 1/1/2018
Status "B" Bundled Services (PDF)
Effective Date: 
Allergy Testing (PDF)
Effective Date: 8/12/2016 - 9/30/2017
Maximum Units of Service (PDF)
Effective Date: 
Status "P" Bundled Services (PDF)
Effective Date: 04/01/2017

Allwell Balance Billing FAQ (PDF)

Effective Date: 

Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: 6/1/2018
Supplies Same Day as Surgery (PDF)
Effective Date:

Ambulatory EEG (PDF)
Effective Until: 9/14/2020

Ambulatory EEG (PDF)
Effective Date: 9/14/2020

Mechanical Stretch Devices (PDF)
Effective Date:  9/1/2017
Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF)
Effective Date: 1/1/2018
Assistant Surgeon (PDF)
Effective Date:
Moderate Conscious Sedation (PDF)
Effective Date: 
Transgender Related Services (PDF)
Effective Date: 
Bevacizumab (Avastin) (PDF)
Effective Date: 8/12/2016
Modifier DOS Validation (PDF)
Effective Date: 
Ultrasound in Pregnancy (PDF)
Effective Date: 7/1/2017
Bilateral Procedures (PDF)
Effective Date: 
Modifier to Procedure Code Validation (PDF)
Effective Date:
Ultrasound in Pregnancy (PDF)
Effective Date: 8/12/2016 - 6/30/2017
Bronchial Thermoplasty (PDF)
Effective Date: 01/15/2017
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: 3/1/2019 Unbundled Professional Services (PDF)
Effective Date: 
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 6/1/2018
Multiple CPT Code (PDF)
Effective Date: 
Unbundled Surgical Procedures (PDF)
Effective Date: 
Cerumen Removal (PDF) 
Effective Date: 
NCCI Unbundling (PDF)
Effective Date: 
Unlisted Procedure Codes (PDF)
Effective Date: 
Clean Claims (PDF)
Effective Date: 
Never Paid Events (PDF)
Effective Date:
Urine Specimen Validity Testing (PDF)
Effective Date: 12/1/2017
Clinical Validation of Modifier 25 (PDF)
Effective Date: 
New Patient (PDF)
Effective Date: 
Urodynamic Testing (PDF)
Effective Date: 1/1/2018
Clinical Validation of Modifier 59 (PDF)
Effective Date: 
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: 3/1/2019 Urodynamic Testing (PDF)
Effective Date: 8/12/2016 -  12/31/2017
Code Editing Overview (PDF)
Effective Date: 
Outpatient Consultation (PDF)
Effective Date: 
Vitamin D Testing in Children and Adolescents (PDF)
Effective Date: 6/1/2018
Cosmetic Procedures (PDF) 
Effective Date:
Paclitaxel (PDF)
Effective Date: 11/1/2017
Wheelchair and Accessories (PDF)
Effective Date: 8/12/2016
Diagnosis of Vaginitis (PDF) 
Effective Date: 1/15/2017 - 9/30/2017
Paclitaxel, protein bound (PDF)
Effective Date: 8/12/2016 - 10/31/2017
Wheelchair Seating (PDF)
Effective Date: 8/12/2016
Diagnosis of Vaginitis (PDF) Effective Date: 10/1/2017 - 12/31/2017 Physician Visit Codes Billed with Labs (PDF)
Effective Date:
Wireless Motility Capsule (PDF)
Effective Date: 9/1/2017
Digital Analysis of EEGs (PDF)
Effective Date: 12/1/2016
Physician's Office Lab Testing (PDF)
Effective Date: 12/1/2017
 
Digital Breast Tomosynthesis (PDF)
Effective Date: 12/1/2016 - 12/31/2017
Place of Service Mismatch (PDF) Effective Date: 3/1/2019   
Distinct Procedural Modifers (PDF)
Effective Date: 
Post-Operative Visits (PDF)
Effective Date: 
 

DNA Analysis of Stool (PDF)
Effective Until: 9/14/2020

DNA Analysis of Stool (PDF)
Effective Date: 9/14/2020

Pre-Operative Visits (PDF)
Effective Date:
 
Duplicate Primary Code Billing (PDF)
Effective Date: 
Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: 12/1/2017
 
E&M Bundling (PDF)
Effective Date: 
Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 12/1/2017
 
E&M Medical Decision-Making (PDF)
Effective Date: 
Professional Component Modifier (PDF)
Effective Date: 
 
EEG in the Evaluation of Headache (PDF)
Effective Date: 6/1/2018
PROM Testing (PDF)
Effective Date: 12/1/2017
 
Endometrial Ablation (PDF)
Effective Date: 12/1/2016
Proton and Neutron Beam Therapy (PDF)
Effective Date: 12/1/2016
 
EpiFix Wound Treatment (PDF)
Effective Date: 9/1/2017
Pulse Oximetry with Office Visits (PDF)
Effective Date:
 
Evoked Potentials (PDF)
Effective Date: 05/01/2017
   
Fecal Calprotectin Assay (PDF)
Effective Date: 05/01/2017
   
FeNo Testing (PDF)
Effective Date: 01/15/2017
   
Helicobacter Pylori (H. pylori) Serology Testing (PDF)
Effective Date: 6/1/2018
   
Holter Monitors (PDF)
Effective Date: 1/15/2017 - 10/31/2017
   
Holter Monitors (PDF)
Effective Date: 11/1/2017
   
Homocysteine Testing (PDF)
Effective Date: 01/15/2017
   
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 
   

 

 

A-H I-Q R-Z
30-Day Readmission (PDF)
Effective Date: 01/01/2015
Inpatient Consultation (PDF) 
Effective Date: 10/1/2017
Reporting Global Maternity Package (PDF)
Effective Date: 
3-Day Payment Window (PDF)
Effective Date: 
Inpatient Only Procedures (PDF) 
Effective Date: 
Rituximab (PDF)
Effective Date: 11/1/2017
Add on Code Billed Without Primary Code (PDF)
Effective Date:
Intravenous Hydration (PDF)
Effective Date: 
Robotic Surgery (PDF)
Effective Date: 9/1/2017
ADHD Assessment and Treatment (PDF)
Effective Date: 01/15/2017
Laser Skin Treatment  (PDF)
Effective Date: 01/15/2017
Same Day Visits (PDF)
Effective Date: 
Allergy Testing (PDF)
Effective Date: 10/1/2017
Leveling of ER (PDF)
Effective Date: 8/1/2018
Short Inpatient Hospital Stay (PDF)
Effective Date: 8/21/2020
Allergy Testing (PDF)
Effective Date: 8/12/2016 - 9/30/2017
Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 9/1/2017
Status "B" Bundled Services (PDF)
Effective Date: 

Ambulatory EEG (PDF)
Effective Until: 9/14/2020

Ambulatory EEG (PDF)
Effective Date: 9/14/2020

Maximum Units of Service (PDF)
Effective Date: 
Status "P" Bundled Services (PDF)
Effective Date: 04/01/2017
Assistant Surgeon (PDF)
Effective Date:
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: 6/1/2018
Supplies Same Day as Surgery (PDF)
Effective Date:
Bevacizumab (Avastin) (PDF)
Effective Date: 8/12/2016
Mechanical Stretch Devices (PDF)
Effective Date:  9/1/2017
Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF)
Effective Date: 1/1/2018
Bilateral Procedures (PDF)
Effective Date: 
Moderate Conscious Sedation (PDF)
Effective Date: 
Thryoid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: 6/1/2018
Bronchial Thermoplasty (PDF)
Effective Date: 01/15/2017
Modifier DOS Validation (PDF)
Effective Date: 
Transgender Related Services (PDF)
Effective Date: 
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 6/1/2018
Modifier to Procedure Code Validation (PDF)
Effective Date: 
Ultrasound in Pregnancy (PDF)
Effective Date: 7/1/2017
Cerumen Removal (PDF) 
Effective Date: 
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: 3/1/2019  Ultrasound in Pregnancy (PDF)
Effective Date: 8/12/2016 - 6/30/2017
Clean Claims (PDF)
Effective Date: 
Multiple CPT Code (PDF)
Effective Date: 
Unbundled Professional Services (PDF)
Effective Date: 
Clinical Validation of Modifier 25 (PDF)
Effective Date: 
NCCI Unbundling (PDF)
Effective Date: 

Unbundled Surgical Procedures (PDF)
Effective Date: 
Clinical Validation of Modifier 59 (PDF)
Effective Date: 
Never Paid Events (PDF)
Effective Date: 
Unlisted Procedure Codes (PDF)
Effective Date: 
Code Editing Overview (PDF)
Effective Date: 
New Patient (PDF)
Effective Date: 
Urine Specimen Validity Testing (PDF)
Effective Date: 12/1/2017
Cosmetic Procedures (PDF) 
Effective Date: 
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: 3/1/2019  Urodynamic Testing (PDF)
Effective Date: 1/1/2018
Diagnosis of Vaginitis (PDF) 
Effective Date: 1/15/2017 - 9/30/2017
Outpatient Consultation (PDF)
Effective Date: 
Urodynamic Testing (PDF)
Effective Date: 8/12/2016 -  12/31/2017
Diagnosis of Vaginitis (PDF) Effective Date: 10/1/2017 - 12/31/2017 Paclitaxel (PDF)
Effective Date: 11/1/2017
Vitamin D Testing in Children and Adolescents (PDF)
Effective Date: 6/1/2018
Digital Analysis of EEGs (PDF)
Effective Date: 12/1/2016
Paclitaxel, protein bound (PDF)
Effective Date: 8/12/2016 - 10/31/2017
Wheelchair and Accessories (PDF)
Effective Date: 8/12/2016
Digital Breast Tomosynthesis (PDF)
Effective Date: 12/1/2016 - 12/31/2017
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 
Wheelchair Seating (PDF)
Effective Date: 8/12/2016
Distinct Procedural Modifers (PDF)
Effective Date:
Physician's Consultation Services (PDF)
Effective Date: 12/1/2017
Wireless Motility Capsule (PDF)
Effective Date: 9/1/2017

DNA Analysis of Stool (PDF)
Effective Until: 9/14/2020

DNA Analysis of Stool (PDF)
Effective Date: 9/14/2020

Physician's Office Lab Testing (PDF)
Effective Date: 12/1/2017
 
Duplicate Primary Code Billing (PDF)
Effective Date: 
Place of Service Mismatch (PDF) Effective Date: 3/1/2019   
E&M Bundling (PDF)
Effective Date: 
Post-Operative Visits (PDF)
Effective Date: 
 
E&M Medical Decision-Making (PDF)
Effective Date: 
Pre-Operative Visits (PDF)
Effective Date: 
 
EEG in the Evaluation of Headache (PDF)
Effective Date: 6/1/2018
Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: 12/1/2017
 
Endometrial Ablation (PDF)
Effective Date: 12/1/2016
Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 12/1/2017
 
EpiFix Wound Treatment (PDF)
Effective Date: 9/1/2017
Professional Component Modifier (PDF)
Effective Date: 
 
Evoked Potentials (PDF)
Effective Date: 05/01/2017
PROM Testing (PDF)
Effective Date: 12/1/2017
 
Fecal Calprotectin Assay (PDF)
Effective Date: 05/01/2017

Proton and Neutron Beam Therapy (PDF)
Effective Date: 12/1/2016
 
FeNo Testing (PDF)
Effective Date: 01/15/2017
Pulse Oximetry with Office Visits (PDF)
Effective Date: 
 
Holter Monitors (PDF)
Effective Date: 1/15/2017 - 10/31/2017
   
Holter Monitors (PDF)
Effective Date: 11/1/2017
   
Homocysteine Testing (PDF)
Effective Date: 01/15/2017
   
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: