Clearhealthalliance Coverage Criteria
Latest Clearhealthalliance coverage criteria updates8
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Tear Osmolarity TestingThis policy defines medical necessity, documentation, coding, and utilization requirements for tear osmolarity testing (CPT/HCPCS code 83861) for management of ocular surface disease/dry eye and applies to providers requesting coverage from Clear Health Alliance/Avēsis.All clearhealthalliance updates
- Coverage CriteriaClinical/Medical PolicyCommunity Living and Support (I/DD & TBI) — Telehealth Provisions and Coverage CriteriaDefines coverage, eligibility, clinical criteria, prior authorization, telehealth requirements, and limitations for Community Living and Support services for individuals with I/DD or TBI funded by state funds and administered by the LME/MCO.All clearhealthalliance updates
- Coverage CriteriaClinical/Medical PolicyDay Supports (I/DD & TBI) — Coverage CriteriaDefines coverage, eligibility, and clinical criteria for state-funded Day Supports for individuals age 16 and older with intellectual/developmental disabilities or traumatic brain injury, including telehealth provisions and authorization requirements.All clearhealthalliance updates
- Coverage CriteriaClinical/Medical PolicyDurable Medical Equipment and Supplies Coverage CriteriaThis policy governs coverage, prior approval, documentation, and program rules for durable medical equipment (DME) and related supplies for Clear Health Alliance beneficiaries enrolled in a Prepaid Health Plan (PHP). It affects providers billing DME and members receiving DME and supplies.All clearhealthalliance updates
- Coverage CriteriaClinical/Medical PolicyNC Medicaid Ambulatory Withdrawal Management With Extended On-Site MonitoringDefines NC Medicaid coverage, eligibility, and clinical criteria for Ambulatory Withdrawal Management with Extended On-Site Monitoring (ASAM Level 2 WM) for beneficiaries receiving services in a licensed outpatient setting.All clearhealthalliance updates
- Coverage CriteriaClinical/Medical PolicyNC Medicaid Orthodontic ServicesDefines coverage structure and sections for Clear Health Alliance's NC Medicaid orthodontic services policy; includes table of contents and headings for eligibility, EPSDT exceptions, prior approval, coverage criteria, limitations, documentation, transfers, extensions, and exclusions.All clearhealthalliance updates
- Coverage CriteriaClinical/Medical PolicyNext-generation sequencing (WES/WGS) and related molecular/genetic testing — Clinical coverage criteriaClinical coverage policy describing definitions, general description, and procedural context for next-generation sequencing (including whole exome and whole genome sequencing), plus related definitions and provisions; intended for Clear Health Alliance Medicaid beneficiaries and providers.All clearhealthalliance updates
- Coverage CriteriaClinical/Medical PolicySubstance Abuse Intensive Outpatient (SAIOP)This policy governs coverage, eligibility, and clinical criteria for Medicaid-covered Substance Abuse Intensive Outpatient Program (SAIOP) services (ASAM Level 2.1) for adolescents and adults in the NC Medicaid Program and applies to providers billing Medicaid.All clearhealthalliance updates
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Tool Description
Search Clearhealthalliance coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
Coverage Criteria by Payer
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Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
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