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What are 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 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, including 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, and other available clinical information. 

All policies found in the Arkansas Health & Wellness Clinical Policy Manual apply to Arkansas Health & Wellness members. Policies in the Arkansas Health & Wellness Clinical Policy Manual may have either an “Arkansas Health & Wellness” or a “Centene” heading.  Arkansas Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures, or pharmaceutical treatments for which an Arkansas Health & Wellness clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual SmartSheets™ for adult and pediatric procedures, durable medical equipment, and imaging procedures by logging in to our Secure Provider Portal or calling Arkansas Health & Wellness at 1-877-617-0390 (TTY 1-877-617-0392).

Arkansas Health & Wellness 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 Arkansas Health & Wellness.

What are Payment Policies?

Healthcare 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 healthcare services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include claims processing guidelines referenced by the Centers for Medicare & 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), CPT® guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of healthcare and medical necessity, and, at times, state-specific claims reimbursement
guidance.

All policies found in the Arkansas Health & Wellness Payment Policy Manual apply with respect to Arkansas Health & Wellness members. Policies in the Arkansas Health & Wellness Payment Policy Manual may have either an “Arkansas Health & Wellness” or a “Centene” heading. Arkansas Health & Wellness 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 Arkansas Health & Wellness. 

Prior Authorization Requests

Beginning January 1, 2021, Ambetter from Arkansas Health & Wellness has partnered with National Imaging Associates (NIA) for prior authorization requests for the following services:

• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Spinal Epidural Injections
• Paravertebral Facet Joint Injections or Blocks
• Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)
• Sacroiliac Joint Injections

Clinical Policies for these procedures can be found at the NIA website.

Clinical Policies for CT/CTA/CCTA, MRI, MRA, and Pet scans can also be found at the NIA website.