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

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

Many of the Clinical Policies presented became effective July 1, 2021. Please refer to the tracking log in each document for more specific details on timeline, changes, and/or implementation.

*Note regarding Tailored Plan providers: Trillium Health Resources Tailored Plan Physical Health providers are subject to the applicable physical health Clinical Policies for Carolina Complete Health below. Trillium Health Resources Behavioral Health (BH) Tailored Plan providers should defer to Trillium’s website for clinical coverage policy information for BH services.

Partners Health Management Tailored Plan Providers should refer to Partners’ website for both physical health and behavioral health policies.

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