Ambetter Clinical Policy Reminder

Date: 05/03/22

MHS is publishing its Clinical Policies to remind providers about its clinical medical necessity review methodologies for certain procedures and services. MHS believes that publishing this information will help providers submit requests more efficiently, therefore reducing unnecessary denials and delays in claims processing and payments.

These policies are developed based on medical literature and research, industry standards, and guidelines as published and defined by the American Medical Association’s Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society guidance, unless specifically addressed in the fee-for-service provider manual published by the state or MHS regulations.

We continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you that the below policies have been revised or changed.
Visit mhsindiana.com to find the Payment Policies.

Policy Name	Description	Products Impacted	Policy Revisions: Non-Adherence Consequence
CP.MP.213 Clinical Policy: Post-Acute Care	It is the policy of health plans affiliated with Centene Corporation® that skilled nursing facility (SNF) care is medically necessary when criteria are met for initial admission or continued stay and the appropriate level criteria are met (detail contained in Policy CP.MP.213 Post Acute Care @ mhsindiana.com/CP.MP.213.pdf)	MARKETPLACE	More specific: Criteria must be met for initial admission or continued stay and the appropriate level criteria must be met.