Skip to main content

Clinical and payment policies

Clinical policies

We use clinical policies to help administer health plan benefits, either with prior authorization or payment rules. These policies include, but aren’t limited to, evolving medical technologies and procedures, as well as pharmacy policies. 


Clinical policies help determine whether services are medically necessary based on:


  • Generally accepted standards of medical practice 

  • Peer-reviewed medical literature

  • Government agency/program approval status 

  • Evidence-based guidelines 

  • Positions of leading national health professional organizations 

  • Views of physicians practicing in relevant clinical areas affected by the policy

  • Available clinical information  


We may delegate utilization management of specific services. In these situations, we may use the delegated vendor’s guidelines to support medical necessity and other coverage determinations. 

Payment policies

We use health care claims payment policies to help administer payment rules based on generally accepted principles of correct coding. These policies help determine whether health care services are correctly coded for reimbursement. 


Generally accepted coding principles inform each payment rule. These principles include, but aren’t limited to:


  • Claims processing guidelines referenced by the Centers for Medicare & Medicaid Services (CMS) 

  • Medicare Claims Processing Manual (Publication 100-04) for physicians/nonphysician 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 

  • State-specific claims reimbursement guidance


We may use a vendor that applies payment policies to specific services. In these situations, we may also use the vendor’s guidelines to determine whether a service has been correctly coded. 

Clinical payment, coding and policy changes

We regularly augment our clinical, payment and coding policy positions as part of our ongoing policy review processes. In an effort to keep our providers informed, please see the below chart of upcoming new policies.

Questions about these policies?

Just log in to your secure Provider Portal. Or call us at 1-866-329-4701 (TTY: 711). Then, ask for Medical Management. We’re here from 8:30 AM to 5:00 PM, Monday through Friday.