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

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

Biopharmacy policies are used to help identify whether clinician administered drugs (CAD) are medically necessary. Pharmacy policies are used to help identify whether medications dispensed by pharmacies and billed through the pharmacy benefit are medically necessary. The criteria used are based on information found in generally accepted standards of medical and pharmacy 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 such as but not limited to the drug package insert. Pharmacy and biopharmacy policies are reviewed and approved by the Centene Pharmacy Services Pharmacy and Theraputic (P&T) Commitee prior to use. This webpage lists biopharmacy policies for Medicaid and biopharmacy and pharmacy policies for Ambetter. 

Consistent with guidance issued by Texas Medicaid for Clinician Administered Drugs (CAD) and the regulation at 42 CFR §438.210 and 42 CFR §457.1230(d), Superior HealthPlan does not use any standard for determining medical necessity that is more restrictive than what is developed by the Vendor Drug Program. For more details on the clinical policy and prior authorization requirements, please review the Outpatient Drug Services Handbook located at: https://www.tmhp.com/resources/provider-manuals/tmppm.

Superior routinely reviews the Texas Medicaid Provider Procedures Manual (TMPPM) to ensure any of our clinical policies for medical necessity are not more restrictive than what is provided for fee-for-service with regards to amount, duration and scope of service. TMPPM is regularly updated to reflect the most recent policy and procedure changes. Advanced notification of upcoming changes appear as banner messages located at the TMHP Banner Messages. 

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

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

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