Clinical & Payment Policies

MEDICAID CLINICAL POLICIES 

AMBETTER CLINICAL POLICIES 

For Ambetter information, please visit our Ambetter website.

MEDICAID BEHAVIORAL HEALTH POLICIES 

AMBETTER BEHAVIORAL HEALTH POLICIES 

For Ambetter information, please visit our Ambetter website.

VISION POLICIES 

AMBETTER SPECIALTY PHARMACY POLICIES 

For Ambetter information, please visit our Ambetter website.

MEDICAID SPECIALTY PHARMACY POLICIES

MEDICARE SPECIALTY PHARMACY POLICIES

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

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

AMBETTER PAYMENT POLICIES 

For Ambetter information, please visit our Ambetter website.

MEDICAID PAYMENT POLICIES 

MEDICARE PAYMENT POLICIES