Políticas clínicas y de pago

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

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

25-hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157
Acupuncture (PDF)CP.MP.92
Adopted Clinical Practice and Preventive Health Guidelines (PDF)CPG Grid
Air Ambulance (PDF)CP.MP.175
Allergy Testing and Therapy (PDF) CP.MP.100
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108
Ambulatory Surgery Center Optimization (PDF)CP.MP.158
Applied Behavior Analysis (PDF)CP.BH.104
Applied Behavioral Analysis Documentation Requirements (PDF)CP.BH.105
Articular Cartilage Defect Repairs (PDF)CP.MP.26
Bariatric Surgery (PDF)CP.MP.37
Behavioral Health Treatment Document Requirement (PDF)HIM.CP.BH.500
Biofeedback (PDF)CP.MP.168
Bone-Anchored Hearing Aid (PDF)CP.MP.93
Bronchial Thermoplasty (PDF)CP.MP.110
Burn Surgery (PDF)CP.MP.186
Cardiac Biomarker Testing (PDF)CP.MP.156
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164
Clinical Trials (PDF)CP.MP.94
Cochlear Implant Replacements (PDF)CP.MP.14
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V2.2024
Concert Genetic Testing: Cardiac Disorders (PDF)V2.2024
Concert Genetic Testing: Dermatologic Conditions (PDF)V2.2024
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V2.2024
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V2.2024
Concert Genetic Testing: Eye Disorders (PDF)V2.2024
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)V2.2024
Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)V2.2024
Concert Genetic Testing: Hearing Loss (PDF)V2.2024
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)V2.2024
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V2.2024
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V2.2024
Concert Genetic Testing: Kidney Disorders (PDF)V2.2024
Concert Genetic Testing: Lung Disorders (PDF)V2.2024
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V2.2024
ConcertGenetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V2.2024
Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)V2.2024
Concert Genetic Testing: Pharmacogenetics (PDF)V2.2024
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V2.2024
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V2.2024
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)V2.2024
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V2.2024
Concert Genetics Oncology: Algorithmic Testing (PDF)V2.2024
Concert Genetics Oncology: Cancer Screening (PDF)V2.2024
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)V2.2024
Concert Genetics Oncology: Cytogenetic Testing (PDF)V2.2024
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V2.2024
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31
Deep Transcranial Magnetic Stimulation for Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.201
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203
Digital EEG Spike Analysis (PDF)CP.MP.105
Disc Decompression Procedures (PDF)CP.MP.114
Discography (PDF)CP.MP.115
Donor Lymphocyte Infusion (PDF)CP.MP.101
Drugs of Abuse: Definitive Testing  (PDF)CP.MP.50
Durable Medical Equipment and Orthotics and Prosthetics Guidelines  (PDF)CP.MP.107
EEG in the Evaluation of Headache (PDF)CP.MP.155
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.145
Endometrial Ablation (PDF)CP.MP.106
Evoked Potential Testing (PDF)CP.MP.134
Experimental Technologies (PDF)CP.MP.36
Facet Joint Interventions (PDF)CP.MP.171
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248
Fecal Incontinence Treatments (PDF)CP.MP.137
Ferriscan R2-MRI (PDF)CP.MP.53
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129
Fertility Preservation (PDF)CP.MP.130
Functional MRI (PDF)CP.MP.43
Gastric Electrical Stimulation (PDF)CP.MP.40
Gender-Affirming Procedures (PDF)CP.MP.95
Heart-Lung Transplant (PDF)CP.MP.132
Holter Monitors (PDF)CP.MP.113
Home Births (PDF)CP.MP.136
Home Ventilators (PDF)CP.MP.184
Homocysteine Testing (PDF)CP.MP.121
Hospice Services (PDF)CP.MP.54
Hyperhidrosis Treatments (PDF)CP.MP.62
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173
Implantable Loop Recorder (PDF)CP.MP.243
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.160
Intensity-Modulated Radiotherapy (PDF)CP.MP.69
Intestinal and Multivisceral Transplant (PDF)CP.MP.58
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.167
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61
Lantidra (Donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)CP.MP.250
Laser Therapy for Skin Conditions (PDF)CP.MP.123
Liposuction for Lipedema (PDF)CP.MP.244
Long Term Care Placement (PDF)CP.MP.71
Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.139
Lung Transplantation (PDF)CP.MP.57
Lysis of Epidural Lesions (PDF)CP.MP.116
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.144
Multiple Sleep Latency Testing (PDF)CP.MP.24
Neonatal Abstinence Syndrome Guidelines (PDF)CP.MP.86
Neonatal Sepsis Management (PDF)CP.MP.85
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.170
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.48
NICU Apnea Bradycardia Guidelines (PDF)CP.MP.82
NICU Discharge Guidelines (PDF)CP.MP.81
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.141
Obstetrical Home Care Programs (PDF)CP.MP.91
Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249
Orthognathic Surgery (PDF)CP.MP.202
Osteogenic Stimulation (PDF)CP.MP.194
Outpatient Cardiac Rehabilitation (PDF)CP.MP.176
Outpatient Oxygen Use (PDF)CP.MP.190
Pancreas Transplantation (PDF)CP.MP.102
Panniculectomy (PDF)CP.MP.109
Pediatric Heart Transplant (PDF)CP.MP.138
Pediatric Kidney Transplant (PDF)CP.MP.246
Pediatric Liver Transplant (PDF)CP.MP.120
Pediatric Oral Function Therapy (PDF)CP.MP.188
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.147
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.150
Physical, Occupational, and Speech Therapy Services (PDF)CP.MP.49
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133
Proton and Neutron Beam Therapies (PDF)CP.MP.70
Pulmonary Function Testing (PDF)CP.MP.242
Reduction Mammoplasty and Gynecomastia Surgery (PDF)CP.MP.51
Repair of Nasal Valve Compromise (PDF)CP.MP.210
Sacroiliac Joint Fusion (PDF)CP.MP.126
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)CP.MP.165
Short Inpatient Hospital Stay (PDF)CP.MP.182
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117
Stereotactic Body Radiation Therapy (PDF)CP.MP.22
Substance Use Treatment and Services (PDF)CP.BH.100
Tandem Transplant (PDF)CP.MP.162
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)CP.MP.154
Total Artificial Heart (PDF)CP.MP.127
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163
Transcatheter Closure of Patent Foramen Ovale (PDF)CP.MP.151
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)CP.BH.200
Transplant Service Documentation Requirements (PDF)CP.MP.247
Trigger Point Injections for Pain Management (PDF)CP.MP.169
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142
Vagus Nerve Stimulation (PDF)CP.MP.12
Ventricular Assist Devices (PDF)CP.MP.46
Wireless Motility Capsule (PDF)CP.MP.143

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

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

Policy NamePolicy NumberEffective Date
3-Day Payment Window (PDF)CC.PP.500July 1, 2014
Add on Code Billed Without Primary Code (PDF)CC.PP.030January 1, 2013
Assistant Surgeon (PDF)CC.PP.029January 1, 2014
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.124May 30, 2024
Bilateral Procedures (PDF)CC.PP.037January 1, 2014
Cerumen Removal (PDF)CC.PP.008January 1, 2014
Coding Overview (PDF)CC.PP.011January 1, 2013
Concert Laboratory Payment Policy (PDF)CG.CC.PP.01June 1, 2024
Cosmetic Procedures (PDF)CC.PP.024January 1, 2014
Distinct Procedural Modifiers (PDF)CC.PP.020January 1, 2013
Duplicate Primary Code Billing (PDF)CC.PP.044January 1, 2014
E&M Medical Decision-Making (PDF)CC.PP.051June 1, 2017
EM Bundling Edits (PDF)CC.PP.010January 1, 2013
Extended Ophthalmoscopy (PDF)CP.VP.26May 30, 2024
Fluorescein Angiography (PDF)CP.VP.28May 30, 2024
Fundus Photography (PDF)CP.VP.29May 30, 2024
Global Maternity Billing (PDF)CC.PP.016January 1, 2013
Gonioscopy (PDF)CP.VP.31May 30, 2024
Hospital Visit Codes Billed with Labs (PDF)CC.PP.023January 1, 2018
Infectious Disease: Dermatologic Lab TestingCG.CP.MP.03June 1, 2024
Infectious Disease: Gastroenterologic Lab Testing (PDF)CG.CP.MP.04June 1, 2024
Infectious Disease: Genitourinary Lab Testing (PDF)CG.CP.MP.07June 1, 2024
Infectious Disease: Multisystem Lab Testing (PDF)CG.CP.MP.02June 1, 2024
Infectious Disease: Primary Care & Preventive Lab Screening (PDF)CG.CP.MP.05June 1, 2024
Infectious Disease: Respiratory Lab Testing (PDF)CG.CP.MP.01June 1, 2024
Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (PDF)CG.CP.MP.06June 1, 2024
Inpatient Consultation (PDF)CC.PP.038January 1, 2014
Inpatient Only Procedures (PDF)CC.PP.018January 1, 2013
IV Hydration (PDF)CC.PP.012January 1, 2013
Leveling of ER Services (PDF)CC.PP.053January 1, 2017
Maximum Units (PDF)CC.PP.007January 1, 2013
Moderate Conscious Sedation (PDF)CC.PP.015January 1, 2013
Modifier -25 clinical validation (PDF)CC.PP.013January 1, 2013
Modifier -59 clinical validation (PDF)CC.PP.014January 1, 2014
Modifier DOS Validation (PDF)CC.PP.034January 1, 2013
Modifier to Procedure Code Validation (PDF)CC.PP.028January 1, 2013
Multiple CPT Code Replacement (PDF)CC.PP.033January 1, 2014
NCCI Unbundling (PDF)CC.PP.031January 1, 2013
Never Paid Events (PDF)CC.PP.017January 1, 2013
New Patient (PDF)CC.PP.036January 1, 2014
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)CC.PP.061June 1, 2018
Outpatient Consultation (PDF)CC.PP.039January 1, 2014
Optum Comprehensive Payment Integrity (PDF)CC.PP.074June 1, 2023
Place of Service Mismatch (PDF)CC.PP.063September 1, 2018
Physician Visit Codes Billed with Labs (PDF)CC.PP.019January 1, 2013
Physician's Consultation Services (PDF)CC.PP.054November 1. 2017
Physician's Office Lab Testing (PDF)CC.PP.055November 1. 2017
Post-Operative Visits (PDF)CC.PP.042January 1, 2014
Pre-Operative Visits (PDF)CC.PP.041January 1, 2014
Problem Oriented Visits with Preventative Visits (PDF)CC.PP.057January 1, 2018
Professional Component (PDF)CC.PP.027January 1, 2018
Pulse Oximetry (PDF)CC.PP.025January 1, 2014
Same Day Visits (PDF)CC.PP.040March 1, 2018
Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)CP.VP.14May 30, 2024
Skilled Nursing Facility Leveling (PDF)CC.PP.206 
Status "B" Bundled Services (PDF)CC.PP.046January 1, 2014
Supplies Billed on Same Day As Surgery (PDF)CC.PP.032January 1, 2013
Transgender Related Services (PDF)CC.PP.047January 1, 2017
Ultrasound in Pregnancy (PDF)CP.MP.38 
Unbundled Professional Services (PDF)CC.PP.043January 1, 2014
Unbundled Surgical Procedures (PDF)CC.PP.045January 1, 2014
Unlisted Procedure Codes (PDF)CC.PP.009January 1, 2014
Urine Specimen Validity Testing (PDF)CC.PP.056January 1, 2018
Visual Field Testing (PDF)CP.VP.63May 30, 2024
Wheelchair Seating (PDF)CP.MP.99May 30, 2024