Clinical, Payment & Pharmacy Policies

Clinical policies are one set of guidelines used to assist in administering Iowa Total Care benefits, either by prior authorization or payment rules. These 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 listed here apply to Iowa Total Care members. These policies may have either an Iowa Total Care or a Centene heading. Iowa Total Care utilizes InterQual^® criteria for those medical technologies, procedures, or services for which an Iowa Total Care 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 and durable medical equipment by logging into the secure provider portal or by calling Iowa Total Care. In addition, Iowa Total Care 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 Iowa Total Care.     

If you have any questions regarding these policies, please contact Provider Services.

Payment policies are guidelines used to administer payment rules that are generally based on accepted principles of correct coding. These policies are used to determine whether health care services are correctly coded for reimbursement. Many payment policies are implemented through pre-payment claims editing. Each payment rule is sourced to a generally accepted coding principle including, but not limited to, claims processing guidelines published by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04 Claims Processing Manual, the CMS National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits, Medically Unlikely Edits (MUE), and policy manual, Current Procedural Terminology (CPT) guidance published by the American Medical Association (AMA), health plan clinical policies based on medical necessity, and at times state-specific claims reimbursement guidance.

All policies published on the Iowa Total Care website apply to Iowa Total Care members. Policies may have either an Iowa Total Care or a Centene heading. In addition, Iowa Total Care 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 a payment policy is payable by Iowa Total Care.     

The Payment Policies may be accessed through the links below.  

If you have any questions regarding these policies, please contact Provider Services.