Notice Date: December 5, 2024 To: Indiana Medicaid Providers From: CareSource Subject: Excludes1 Edit Effective Date: October 1, 2024 Summary Beginning with claims processed on or after October 1, 2024, CareSource will apply claims editing logic related to Excludes1 notes from ICD-10-CM coding guidelines. To ensure accurate claims processing, providers are advised to review ICD-10-CM coding guidelines when selecting the most appropriate diagnosis for clai ms, and to always code with the highest level of specificity. If a category level indication suggests that a code can be billed with another range of codes, it is crucial to check for Excludes1 notes that may prevent billing certain code combinations. Impact Examples of Excludes1 rule violations include: The diagnosis code for Bronchitis, not specified (J40) has an Excludes1 note specifying that it should not be billed with Acute bronchitis (J20. -); submitting both codes for a single encounter would violate the Excludes1 note and result in a denial. The diagnosis category for Type 2 Diabetes (E11. -) has an Excludes1 note indicating that it should not be billed with codes for Gestational Diabetes (O24.4 -); submitting both codes for a single encounter would violate the Excludes1 note and result in a denial. Providers should review Excludes1 notes carefully to ensure compliance and avoid claim denials. Questions? Please contact Health Partner Services, available Monday through Friday from 7 a.m. Central Time (CT)/ 8 a.m. Eastern Time (ET) to 7 p.m. CT/8 p.m. ET at 1-844-607-2831 with any questions . IN-MED-P -3338122 ; Issued Date: 12/4/2024 OMPP Approved: 12/4/2024
Claim Recovery Refund Check FormPlease mail your refund check, this form and any other required documentation to Common Ground Healthcare Cooperative (CGHC) at the address below. Completion of this form in its entirety is required in order to assist with accurate and timely reprocessing of your claims. A separate form for each refund check is required. Include any required documentation with your submission. Do not use this form for submission of Appeals or Correspondence. Thank you. Claim and Check InformationCheck Enclosed oYes oNo Check Number Check Amount Total Number of Claims Claim Number Check Number Member ID Date of Service Amount of Refund Claim Paid Amount Reason for Refund 123456789XX00 1234567890 1234567890 00/00/0000 $50000.00 $50000.00 Coordination of Benefits Provider Information Provider Name Provider ID Provider Tax ID Provider NPI Remittance (Remit) Address Service A ddress Alternate Remit Address (if different than ProviderRemit) Contact Name Contact Phone WI-EXC-P-3227809Common Ground Healthcare CooperativeATTN: Claim Recovery Department P.O. Box 1394 Dayton, Ohio 45401
Overpayment Recovery Form Complete this form in its entirety and include any required documentation with your submission. We need this information to assist with accurate and timely reprocessing of your claims. Do not use this form for the following: Submission of Appeals or CorrespondenceSending payment WI-EXC-P-3227807 PROVIDER INFORMATION Provider Name Provider Tax ID Provider NPI Remittance Address Service Address Alternate Remit Address (if different than Provider Remit) Contact Name Contact Phone Claim Number Member ID Date of Service Amount of Overpayment Claim Paid Amount Reason for Refund123456789XX00 1234567890 00/00/0000 $50000.00 $50000.00 Coding errorCommon Ground Healthcare CooperativeATTN: Claim Recovery Department P.O. Box 1394 Dayton, Ohio 45401
Notice Date: To: From: Subject: Effective Date: January 1, 2025Wisconsin Medicaid Providers Common Ground Healthcare Cooperative (CGHC) New Address for Refund ChecksJanuary 1, 2025 Summary CGHC has updated the address for refund check submissions. Effective immediately, please send refund checks to: Common Ground Healthcare CooperativeP.O. Box 632457Cincinnati, Ohio 45263-2457Impact The address listed above is for refund check submissions only. Do not send correspondence or anything other than refund checks to this lock box. Doing so will cause delay in the processing refund checks and remaining correspondence.Importance To streamline the process of submitting refund checks, CGHC has created the Claim Recovery Request Form. It is available to download on CommonGroundHealthcare.org. Please submit a separate form with the appropriate documentation for each refund check.Questions? Please contact Provider Services at 1-877-514-2442. Our hours are Monday through Friday, from 8 a.m. to 5 p.m. Central Time (CT). WI-EXC-P-3227804
Provider Portal User Account AdministrationCommon Ground Healthcare Cooperative (CGHC) Provider Portal Administrator The Common Ground Healthcare Cooperative (CGHC) Provider Portal administrator is responsible for maintaining appropriate user account access to the Provider account for which he or she is an administrator. Currently two administrators are permitted per Provider account. The Administrator responsibilities are designed to protect member data and ensure that user accounts associated with the Provider ID are valid and appropriately assigned. NOTE: The first person to register a Provider ID on the CGHC Provider Portal is automatically assigned administrator privileges. The second person to register the same Provider ID will be considered the second administrator for that ID. Otherwise, the initial administrator can grant administrator permissions to one other user. Administrator Responsibilities Administrators have access to the Users > Manage Users page to perform ongoing user account maintenance for the Provider ID. The following tasks can be completed on the Manage Users page: Invite other users up to five invitations can be sent at one time to have access to a specified Provider ID. oNOTE: Invited users will receive a system-generated email with instructions on how to finalize their Provider Portal account and receive the specified permissions granted to them by the administrator. Unique email address each user needs to have a unique email address assigned to their account . Assign roles & permissions set up the appropriate roles and permissions for each invited user (see below for further details) including granting the administrator role and permissions to one other user. You can modify user permissions as needs arise or change . Delete user accounts when a user should no longer have access to the Provider ID, the administrator is responsible for deleting access in a timely manner. Roles User roles are initially assigned when an administrator grants access, or invites, a new user to a Provider ID. An administrator can change a users role later from the Manage Users page. User roles include: User Provider Portal user who can be assigned any combination of permissions. Administrator Automatically assigned to user who first registers the Provider ID on the Provider Portal or is invited to access the Provider account as an administrator. Two administrators are permitted per Provider ID. 3rd Party Billing or Practice Management Company Outside entity who can be granted appropriate permissions by the administrator.Permissions User access permissions can be granted by the administrator regardless of the users assigned role. User account permissions include: Claims and Payment I nquiry allows access to the following: o Claims and payment details o Provider maintenance tasks that are permitted by the individual state portal (this may vary per state) Claims Management allows access to the following: o Claim disputes, appeals and recovery requests o Submit online claims (direct data entry or uploaded claims) o Dental provider login o Radiology benefit manager o Submit prior authorizationso Provider maintenance tasks as permitted by the individual state portal (this may vary per state). Member Eligibility allows access to the following: o Member eligibility o Member information panel (including member benefit and pharmacy data admission, Emergency Room visits, Primary Care Physician, information and more. o Coordination of Benefits (COB) information o Provider maintenance tasks as permitted by the individual state portal (this may v ary per state). Member Health Information allows access to the following : o Member reports o Provider membership lists o Clinical Practice Registry information o Care Management Referrals o Provider maintenance tasks as permitted by the individual state portal (this may vary per state). Member History allows access to the following : o Member benefits o Provider maintenance tasks as permitted by the individual state portal (this may vary per state). Manage Users As described above, administrators can perform ongoing user account management from the Users > Manage Users page. Using the links in the appropriate column, administrators can edit a users role and/or permissions, resend an invitation if needed, and revoke (remove) a user from a Provider ID. WI-EXC-P -3319781
30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 NEW PREFERRED DRUGSTHERAPEUTIC CLASS NO PA REQUIRED PREFERRED Analgesic Agents: Gout Colchicine Tab Probenecid/Colchicine Cardiovascular Agents: Angina, Hypertension and Heart Failure Candesartan Candesartan/HCTZ Levamlodipine Nebivolol Telmisartan Telmisartan/HCTZ Cardiovascular Agents: Antiarrhythmics Amiodarone 100 , 400mg Cardiovascular Agents: Lipotropics Colesevelam Tab Ezetimibe/Simvastatin Fenofibrate 54, 160mg Cardiovascular Agents: Pulmonary Arterial Hypertension* LEGACY CATEGORY Epoprostenol Central Nervous System (CNS) Agents: Alzheimers Agents* LEGACY CATEGORY Donepezil 23mg Tab Memantine ER Central Nervous System (CNS) Agents: Anticonvulsants Rescue Libervant Central Nervous System (CNS) Agents: Antidepressants* LEGACY CATEGORY Vilazodone Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents Focalin XRCentral Nervous System (CNS) Agents: Atypical Antipsychotics* LEGACY CATEGORY Olanzapine ODTRykindoUzedyCentral Nervous System (CNS) Agents: Parkinson’s AgentsRopinirole ERCentral Nervous System (CNS) Agents: Sedative-Hypnotics, Non-Barbiturate BelsomraEszopicloneRamelteonTemazepam 7.5, 22mgZolpidem ERCentral Nervous System (CNS) Agents: Skeletal Muscle Relaxants, Non-BenzodiazepineBaclofen SuspCyclobenzaprine 7.5mgMetaxalone 800mgOrphenadrineTizanidine CapDermatologic Agents: Topical Acne Products Adapalene/Benzoyl PeroxideAzelaic Acid GelRetin-A Micro Pump 0.04%, 0.1%Endocrine Agents: Diabetes Non-Insulin Kombiglyze XR OnglyzaEndocrine Agents: Estrogenic Agents Angeliq30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 ClimaraDivigelElestrinMinivelleVivelle-DotEndocrine Agents: Osteoporosis BoneOssification Enhancers RaloxifeneGastrointestinal Agents: Anti-Emetics Aprepitant TriPacDoxylamine/PyridoxineGranisetron TabGastrointestinal Agents: Bowel Preparations Gavilyte-N Sod Sulf-Potass Sulf-Mag Sulf SolnGastrointestinal Agents: Crohns Disease MercaptopurineGastrointestinal Agents: Proton Pump Inhibitors Esomeprazole Omeprazole TabRabeprazoleGastrointestinal Agents: Ulcerative Colitis Mesalamine Enema , Supp Gastrointestinal Agents: Unspecified GI Linzess 72, 145, 290mcg Genitourinary Agents: Benign Prostatic Hyperplasia SilodosinGenitourinary Agents: Electrolyte Depleter AgentsPhoslyra SolGenitourinary Agents: Urinary Antispasmodics FesoterodineTrospiumInfectious Disease Agents: Antibiotics Cephalosporins Cephalexin SuspInfectious Disease Agents: Antibiotics Inhaled Tobramycin InjInfectious Disease Agents: Antibiotics Tetracyclines Doxycycline 20mgMinocycline IRInfectious Disease Agents: Antibiotics Antifungal s ClotrimazoleItraconazole CapNystatinVoriconazole Susp, TabInfectious Disease Agents: Antivirals HIV* LEGACY CATEGORY Darunavir 600, 800 mg TabEntecavirLamivudine SolNevirapine SolReyataz PowderOphthalmic Agents: Antibiotic and Antibiotic-Steroid Combination Drops and Ointments Tobrex OintOphthalmic Agents: NSAIDs NevanacRespiratory Agents: Antihistamines Second Generation Cetirizine CapDesloratadineFexofenadineLevocetirizine30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 Respiratory Agents: Epinephrine Auto-Injectors Epipen Epipen JRRespiratory Agents: Inhaled Agents BrovanaXopenex HFATopical Agents: Antifungal s ButenafineTopical Agents: Corticosteroids Fluocinolone Acetonide 0.01% Oil Fluocinonide 0.05% Topical Agents: Immunomodulators Elidel Tacrolimus NEW CLINICAL PA REQUIRED PREFERRED DRUGSTHERAPEUTIC CLASS CLINICAL CRITERIA REQUIRED PREFERRED Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors Fulphila Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia A, von Willebrand Disease, and Factor XIII Deficiency* LEGACY CATEGORY Altuviiio Nuwiq Kit Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia B* LEGACY CATEGORY Rebinyn Cardiovascular Agents: Pulmonary Arterial Hypertension* LEGACY CATEGORY Bosentan Gastrointestinal Agents: Anti-Emetics Dronabinol Immunomodulator Agents: Systemic Inflammatory Disease Adalimumab-fkjp (Gen of Hulio) Inflectra (Bio of Remicade) Rinvoq Simlandi (Bio of Humira) Tyenne (Bio of Actemra) Respiratory Agents: Cystic Fibrosis Pulmozyme Respiratory Agents: Hereditary Angioedema Berinert Icatibant Acetate NEW STEP THERAPY REQUIRED PREFERRED DRUGSTHERAPEUTIC CLASS STEP THERAPY REQUIRED PREFERRED Central Nervous System (CNS) Agents: Anti – Migraine Agents, Acute Ubrelvy Central Nervous System (CNS) Agents: Anti – Migraine Agents, Prophylaxis Emgality 120mg/ml Central Nervous System (CNS) Agents: Atypical Antipsychotics* LEGACY CATEGORY Asenapine Gastrointestinal Agents: Pancreatic Enzymes Pertzye NEW NON-PREFERRED DRUGS30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 THERAPEUTIC CLASS PA REQUIRED NON-PREFERRED Analgesic Agents: NSAIDS Fenoprofen 600mg Ketoprofen ER Meclofenamate Analgesic Agents: Opioids Tramadol 100mg Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors Ziextenzo Blood Formation, Coagulation, and Thrombosis Agents: Hematopoietic Agents Mircera Cardiovascular Agents: Angina, Hypertension and Heart Failure Bystolic Entresto Sprinkle Cap Spironolactone Susp Cardiovascular Agents: Lipotropics Icosapent Ethyl Cap Pitavastatin Central Nervous System (CNS) Agents: Anti – Migraine Agents, Acute Tosymra Central Nervous System (CNS) Agents: Antidepressants* LEGACY CATEGORY Caplyta Rexulti Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents Dextroamphetamine SolCentral Nervous System (CNS) Agents: MultipleSclerosis* LEGACY CATEGORY OcrevusCentral Nervous System (CNS) Agents: Neuropathic PainDuloxetine 40mgCentral Nervous System (CNS) Agents: Parkinson’s Agents Amantadine SolCentral Nervous System (CNS) Agents: Sedative-Hypnotics, Non-Barbiturate FlurazepamZolpidem CapCentral Nervous System (CNS) Agents: Skeletal Muscle Relaxants, Non-Benzodiazepine Chlorzoxazone 250mgDermatologic Agents: Topical Acne Products NeuacSodium Sulfacetamide/Sulfur CreamSodium Sulfacetamide/Sulfur Wash SuspTretinoin Pump 0.04%, 0.1%ZMA Clear SuspEndocrine Agents: Androgens Aveed Testosterone Gel 1.62% PacketEndocrine Agents: Diabetes Insulin Insulin DegludecNovolog 70-30Novolog U-100Endocrine Agents: Diabetes Non-Insulin Invokamet InvokanaLiraglutideMetformin IR 625mgSaxagliptinSaxagliptin/Metformin 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 Sitagliptin/Metformin (Gen of Zituvimet)Endocrine Agents: Estrogenic Agents MenestEndocrine Agents: Growth Hormone Zomacton Endocrine Agents: Osteoporosis Bone Ossification Enhancers BinostoEvenityProliaZoledronic AcidGastrointestinal Agents: Anti-Emetics Aprepitant 125mg DiclegisEmendOndansetron 16mgGastrointestinal Agents: Crohns Disease Azathioprine 75, 100mgGastrointestinal Agents: Bowel Preparations Suprep Gastrointestinal Agents: Ulcerative Colitis Mesalamine ER Cap 500mg Mesalamine Enema KitSF RowasaGastrointestinal Agents: Unspecified GI Amitiza Genitourinary Agents: Electrolyte Depleter Agents Fosrenol PowderGen itoruinary Agents: Urinary Antispasmodics ToviazHyperkalemia Agents: Potassium Binders Kionex Susp Immunomodulator Agents: Systemic Inflammatory Disease Adalimumab-aaty (Gen of Yuflyma )Adalimumab-ryvk (Gen of Simlandi)Amjevita 10/0.2ml (Bio of Humira)Avsola (Bio of Remicade )Infliximab (Gen of Remicaide)Renflexis (Bio of Remicade)Infectious Disease Agents: Antibiotics Cephalosporins Cephalexin TabInfectious Disease Agents: Antibiotics Inhaled Tobramycin 300mg/4ml Neb SolnInfectious Disease Agents: Antibiotics Macrolides Clarithromycin ERInfectious Disease Agents: Antibiotics Tetracyclines MinoliraInfectious Disease Agents: Antifungals FlucytosineInfectious Disease Agents: Antivirals HIV* LEGACY CATEGORY EtravirinePrezista Susp , 75, 150mg TabSunlencaTrizivirVocabriaOphthalmic Agents: Glaucoma Agents BetimolTafluprostRespiratory Agents: Antihistamines SecondGeneration Loratadine ChewableFexofenadine/Pseudoephedrine30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 Respiratory Agents: Hereditary Angioedema Haegarda OrladeyoRuconestRespiratory Agents: Monoclonal Antibodies-Anti – IL/Anti-IgE CinqairTopical Agents: Antifungals OxistatTopical Agents: Antiparasitics Crotan Topical Agents: Corticosteroids Derma-Smoothe/FS EnstilarFluocinonide 0.1%TexacortUltravateTHERAPEUTIC CATEGORIES WITH CHANGES IN CRITERIA Analgesic Agents: Gout Analgesic Agents: NSAIDS Analgesic Agents: Opioids Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors Blood Formation, Coagulation, and Thrombosis Agents: Hematopoietic Agents Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia A, von Willebrand Disease, and Factor XIII Deficiency* LEGACY CATEGORY Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia B* LEGACY CATEGORY Blood Formation, Coagulation, and Thrombosis Agents: Heparin-Related Preparations Blood Formation, Coagulation, and Thrombosis Agents: Oral Anticoagulants Cardiovascular Agents: Angina, Hypertension and Heart Failure Cardiovascular Agents: Lipotropics Cardiovascular Agents: Pulmonary Arterial Hypertension* LEGACY CATEGORY Central Nervous System (CNS) Agents: Anti-Migraine Agents, Acute Central Nervous System (CNS) Agents: Anti-Migraine Agents, Cluster Headache Central Nervous System (CNS) Agents: Anti-Migraine Agents, Prophylaxis Central Nervous System (CNS) Agents: Anticonvulsants* LEGACY CATEGORY Central Nervous System (CNS) Agents: Anticonvulsants Rescue Central Nervous System (CNS) Agents: Antidepressants* LEGACY CATEGORY Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents Central Nervous System (CNS) Agents: Atypical Antipsychotics* LEGACY CATEGORY Central Nervous System (CNS) Agents: Fibromyalgia Agents Central Nervous System (CNS) Agents: Medication Assisted Treatment of Opioid Addiction Central Nervous System (CNS) Agents: Movement Disorders Central Nervous System (CNS) Agents: Multiple Sclerosis* LEGACY CATEGORY Central Nervous System (CNS) Agents: Narcolepsy Central Nervous System (CNS) Agents: Neuropathic Pain Central Nervous System (CNS) Agents: Sedative-Hypnotics, Non-Barbiturate Central Nervous System (CNS) Agents: Skeletal Muscle Relaxants, Non-Benzodiazepine Dermatologic Agents: Oral Acne Products Dermatologic Agents: Topical Acne Products 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 Endocrine Agents: Androgens Endocrine Agents: Diabetes Hypoglycemia Treatments Endocrine Agents: Diabetes Insulin Endocrine Agents: Diabetes Non-Insulin Endocrine Agents: Endometriosis Endocrine Agents: Estrogenic Agents Endocrine Agents: Growth Hormone Endocrine Agents: Osteoporosis Bone Ossification Enhancers Endocrine Agents: Uterine Fibroids Gastrointestinal Agents: Anti-Emetics Gastrointestinal Agents: Crohns Disease Gastrointestinal Agents: Hepatic Encephalopathy Gastrointestinal Agents: Irritable Bowel Syndrome (IBS) with Diarrhea Gastrointestinal Agents: Pancreatic Enzymes Gastrointestinal Agents: Proton Pump Inhibitors Gastrointestinal Agents: Ulcerative Colitis Gastrointestinal Agents: Unspecified GI Genitourinary Agents: Benign Prostatic Hyperplasia Genitourinary Agents: Electrolyte Depleter Agents Hyperkalemia Agents: Potassium Binders Immunomodulator Agents: Systemic Inflammatory Disease Infectious Disease Agents: Antibiotics Cephalosporins Infectious Disease Agents: Antibiotics Macrolides Infectious Disease Agents: Antibiotics Quinolones Infectious Disease Agents: Antibiotics Tetracyclines Infectious Disease Agents: Antifungals Infectious Disease Agents: Antivirals Hepatitis CAgents Ophthalmic Agents: Antihistamines & Mast Cell Stabilizers Ophthalmic Agents: NSAIDs Ophthalmic Agents: Ophthalmic Steroids Otic Agents: Antibacterial and Antibacterial/Steroid Combinations Respiratory Agents: Antihistamines Second Generation Respiratory Agents: Cystic Fibrosis Respiratory Agents: Epinephrine Auto-Injectors Respiratory Agents: Hereditary Angioedema Respiratory Agents: Inhaled Agents Respiratory Agents: Leukotriene Receptor Modifiers & Inhibitors Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE Respiratory Agents: Nasal Preparations Topical Agents: Antifungals Topical Agents: Corticosteroids Topical Agents: Immunomodulators REVISED THERAPEUTIC CATEGOR YC RITERIATHERAPEUTIC CLASS SUMMARY OF CHANGE 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 Analgesic Agents: GoutLENG TH OF AUTHO RIZATIONS: 365 days except 180 days for Familial Mediterranean Fever CLINICAL PA CRITERIA: Must have had an inadequate clinical response with an NSAID and oral corticosteroid within the last 30 days for acute gout diagnosis OR Must have had an inadequate clinical response of at least 30 days with the maximally tolerated xanthine oxidase inhibitor dose for chronic gout diagnosis NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 30 days with at least one preferred drug in this UPDL category Analgesic Agents: NSAIDS LENG TH OF AUTHO RIZATIONS: Dependent up on the table below 365 days Authorization Le ngthH. Pylori Treatment 30 days Transdermal /Top ical 90 days All Other Treatments 365 days NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 30 days with at least two preferred drugs in this UPDL category, if indicated for diagnosis Analgesic Agents: Opioids LENGTH OF AUTHORIZATIONS: For the course of therapy, up to 180 days. Initial short-acting and long-acting requests may only be authorized for up to 90 days . For reauthorization , up to 180 days. BUPRENORPHINE TOPICAL (BUTRANS) CRITERIA: For doses greater than 5 mcg/hour must provide documentation of an inadequate clinical response with at least one opioid formulation taken for at least 60 30 of the last 90 60 days MORPHINE SULFATE ER (KADIAN, MS CONTIN) & TAPENTADOL ER (NUCYNTA) CRITERIA: Unless receiving for cancer pain, palliative care, or end-of-life/hospice care , must provide documentation of an inadequate clinical response with at least one opioid formulation taken for at least 60 30 of the last 90 60 days ADDITIONAL SHORT-ACTING OPIOIDS CRITERIA: The system defines an initial request as having no opioid claims in 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 the previous 90 days Initial short-acting requests can be authorized up to 90 days o Length of authorization is dependent on indication, previous patient utilization, and requested length of therapy (could be more restrictive) o To exceed acute opioid limits, documentation of the following must be provided: Diagnosis code which must be for somatic type pain Prescriber attestation that the benefits and risks of opioid therapy have been discussed with patient o Exemptions to the additional criteria: Patients receiving short-acting opioids for active cancer treatment, palliative care, and end-of- life/hospice care, sickle cell, severe burn, traumatic crushing of tissue, amputation, major orthopedic surgery Prescriber attestation that patient is opioid tolerant (i.e., new to Medicaid or was on higher dose in hospital) Subsequent short-acting requests can be authorized up to 180 days o Documentation of the following must be provided: Current treatment plan Demonstrated adherence to treatment plan through progress notes, including pain and function scores, random urine screenings results reviewed, concerns addressed, and no serious adverse outcomes observed o Exemptions to the additional criteria: Patients receiving short-acting opioids for cancer pain, palliative care, or end-of-life/hospice care Patients residing in LTC facilities are exempted from urine drug screening requirements ADDITIONAL LONG-ACTING OPIOIDS CRITERIA: The system defines an initial long-acting request as having no opioid claims in the previous 90 days Initial long-acting requests can be authorized up to 90 days o Documentation of the following must be provided: Request is a daily dose equivalent of 80 MED Inadequate clinical response to both non – opioid pharmacologic and non – pharmacologic treatments Current use of opioids for 60 30 of the last 90 60 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 days Treatment plan including risk assessment, substance abuse history, concurrent therapies, and requirements for random urine screenings (baseline urine drug tests must be submitted) Pain and function scores at each visit Opioid contract required to be in place and submitted with PA form o Exemptions to the additional criteria: Patients receiving long-acting opioids for cancer pain, palliative care, or end-of-life/hospice care Patients residing in LTC facilities are exempted from urine drug screening and opioid contract requirements Subsequent long-acting requests can be authorized up to 180days o Documentation of the following must be provided: Current treatment plan Demonstrated adherence to treatment plan through progress notes, including pain and function scores, random urine screenings results reviewed, concerns addressed, and no serious adverse outcomes observed o Exemptions to the additional criteria: Patients receiving long-acting opioids for cancer pain, palliative care, or end-of-life/hospice care Patients residing in LTC facilities are exempted from urine drug screening and opioid contract requirements Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors LENG TH OF AUTHO RIZATIONS: Dependent upon diagnosis below 30 days or duration of chemotherapy regimen CLINICAL PA CRITERIA: Must provide documentation of diagnosis, patients weight (for weight – based dosed medications only) , and duration of treatment 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 Blood Formation, Coagulation, and Thrombosis Agents: Hematopoietic AgentsLENG TH OF AUTHO RIZATIONS: Dependent upon diag nosis below 180 days; except 365 days for patients with chronic renal failure CLINICAL PA CRITERIA: Must provide documentation of baseline hemoglobin level SUBSEQUENT AUTHORIZATION CRITERIA: Provide current hemoglobin lab result Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia A, von Willebrand Disease, and Factor XIII Deficiency* LEGACY CATEGORY CLINICAL PA CRITERIA: Must provide documentation of patients body weight (for weight – based dosed medications only) Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia B* LEGACY CATEGORY CLINICAL PA CRITERIA: Must provide documentation of patients body weight (for weight – based dosed medications only) Blood Formation, Coagulation, and Thrombosis Agents: Heparin-RelatedPreparations LENG TH OF AUTHO RIZATIONS: Dependent upon criteria below 35 days; except 365 days for patients with cancer, pregnancy, or unable to be converted to an oral anticoagulant ADDITIONAL INFORMATION: For most indications: Guidelines from the Ame rican Coll ege of C hestPhysicians limit du ration of therapy in the o utpatient setting for most ind ications to less than 35 day s and patients should be transitioned to oral anticoagulant as soon as possible For requests over 35 days and/or the patient cannot be transitioned to an oral anticoagulant, prescriber must submit additional documentation for reasoning: o For patients with cancer authorized up to 180 days 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 o For pregnant women authorized up to 280 days o For patients unable to take an oral anticoagulant authorized up to 180 days Blood Formation, Coagulation, and Thrombosis Agents: Oral Anticoagulants AR All drugs Pradaxa Pellet Pak, Xarelto Susp: a PA is required for patients older than 12 years old Cardiovascular Agents: Angina, Hypertension and Heart Failure ADDITIONAL FINERENONE (KERENDIA) CRITERIA: Must be on a maximally tolerated dose of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker AND Must provide documentation of an inadequate clinical response to a SGLT2 Inhibitor OR provide documentation of medical necessity beyond convenience for why the patient cannot try a SGLT2 inhibitor (i.e., chronic kidney disease diagnosis) Cardiovascular Agents: Lipotropics CLINICAL PA CRITERIA: Must provide documentation of baseline labs AND have documented adherence to 90 days of prescribed preferred lipid lowering medications Must have had an inadequate clinical response of at least 90 days AND unable to reach goal LDL-C (see below) despite treatment with maximally tolerated dose of or high-potency statin and ezetimibe (or a clinical reason that these drugs cannot be utilized) Must have had an inadequate clinical response of at least 90 days AND unable to reach goal LDL-C (see below) despite treatment with ezetimibe OR documentation that LDL is >25% above goal despite current statin therapy ADDITIONAL ICOSAPENT ETHYL (VASCEPA) CRITERIA: Must provide documentation of baseline labs indicating triglyceride levels 500mg/dL after an inadequate clinical response to fibrates, niacin, and diet/exercise Must provide documentation of discontinuation of drugs known to increase triglyceride levels (i.e., beta blockers, thiazides, and estrogens), if clinically appropriate ADDITIONAL INFORMATION: High potency statins: atorvastatin (Lipitor) 40-80mg & rosuvastatin(Crestor) 20-40mg LDL goals for Familial Hypercholesterolemia (includes Heterozygous & Homozygous FH): LDL 100mg/dL for adults or LDL 110mg/dL for those 25% BSA ADDITIONAL HIDRADENITIS SUPPURATIVA CRITERIA: Must provide documentation of Hurley Stage III to be classified as severe diseaseADDITIONAL PLAQUE PSORIASIS CRITERIA: For patients currently rece iving phototherapy , initial authorization for preferred drugs requires an inadequate clinical response to at least 90 days of phototherapy To classify as severe disease patient must present at least two of the following: Psoriasis Area and Severity Index (PASI) score 11, BSA 10%, and Static Physician's Global Assessment (sPGA) 3 Infectious Disease Agents: Antibiotics Cephalosporins ADDITIONAL INFORMATION Requests may be authorized if: o The infection is caused by an organism resistant to ALL preferred antibiotics (must provide diagnosis and any culture/sensitivity results) AR Cephalexin Suspension : a PA is required for patients 12 years and olderInfectious Disease Agents: Antibiotics Macrolides ADDITIONAL INFORMATION Requests may be authorized if: o The infection is caused by an organism resistant to ALL preferred antibiotics (must provide diagnosis and any culture/sensitivity results) 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 AR Clarithromycin Suspension : a PA is required for patients 12 years andolderInfectious Disease Agents: Antibiotics Quinolones ADDITIONAL INFORMATION Requests may be authorized if: o The infection is caused by an organism resistant to ALL preferred antibiotics (must provide diagnosis and any culture/sensitivity results) AR Levofloxacin Oral Solution : a PA is required for patients 12 years andolderInfectious Disease Agents: Antibiotics Tetracyclines ADDITIONAL INFORMATION Requests may be authorized if: o The infection is caused by an organism resistant to ALL preferred antibiotics (must provide diagnosis and any culture/sensitivity results) AR Doxycycline Susp Syrup : a PA is required for patients 12 years and olderInfectious DiseaseAgents: Antifungals NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 7 3 days with at least two preferred drugs, if indicated for the diagnosis in this UPDL category ADDITIONAL INFORMATION: Posaconazole can be approved for aspergillosis treatment and prophylaxis without trials of preferred agents Requests may be authorized if: o The infection is caused by an organism resistant to ALL preferred antifungals (must provide diagnosis and any culture/sensitivity results) AR Voriconazole Susp : a PA is required for patients 12 years and olderInfectious Disease Agents: Antivirals Hepatitis CAgents NON-PREFERRED CRITERIA: Must have had an inadequate clinical response defined as not achieving sustained virologic response (SVR) SVR with guideline – recommended preferred drugs in this UPDL category ADDI TIONAL INF ORMAT ION: Requests for p atients established on current therapy with prior payer (i.e., Commercial, Fe e-for-Servi ce, Managed Care Plan, etc) will be authorized with documentation Requests for regimens including p egylated Interferons must include close monitoring with periodic clinical a nd laboratory eva luations Requests for regimens including rib aviri n must include documentation of at le ast tw o reliable forms of contrac eption being used du ring therapy 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 Ophthalmic Agents: Antihistamines & Mast Cell StabilizersNON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 14 7 days with at least two preferred drugs in this UPDL category . Ophthalmic Agents: NSAIDs NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 3 days with at least one two preferred drug s in this UPDL category . Ophthalmic Agents: Ophthalmic Steroids NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 14 7 days with at least two preferred drugs in this UPDL category . Otic Agents: Antibacterial and Antibacterial/ Stero id Combinations NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 7 3 days with at least one two preferred drug s in this UPDL category . Respiratory Agents: Antihistamines Second Generation NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 30 7 days with at least two different preferred drugs in this UPDL category . AR Cetirizine Chewable , Loratadine Chewable : a PA is required for patients6 years and olderRespiratory Agents: Cystic Fibrosis CLINICAL PA CRITERIA: Must be prescribed by or in consultation with a pulmonologist or infectious disease specialist Must provide documentation of the specific Cystic Fibrosis Transmembrane Conductance Regular (CFTR) genetic mutation STEP THERAPY CRITERIA: Must have had an inadequate clinical response of at least 30 days with at least one preferred drug in this UPDL category. SUBSEQUENT AUTHORIZATION CRITERIA: Must provide documentation of patients clinical response to treatment (adherence to treatment demonstrated by claims history AND one or more of the following: FEV1, weight gain, sweat chloride,pulmonary exacerbations, etc.) and ongoing safety monitoring Respiratory Agents: Epinephrine Auto – Injectors SUBSEQUENT AUTHORIZATION CRITERIA: Subsequent reauthorizations for expired, epinephrine auto-injectors are allowable Respiratory Agents: Hereditary Angioedema LENGTH OF AUTHORIZATIONS : Initial: 90 Acute : 30 days; Subsequent: Prophylaxis: 180 Days CLINICAL PA CRITERIA: Acute Treatment o Must provide documentation that diagnosis is verified by a C4 level below the lower limit of normal as defined by laboratory testing AND one of the following: C1 inhibitor (C1-INH) antigenic level below the lower limit of normal as defined by laboratory testing; OR 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 C1-INH functional level below the lower limit of normal as defined by laboratory testing Prophylactic Treatment o Must provide documentation that diagnosis is verified by a C4 level below the lower limit of normal as defined by laboratory testing AND one of the following: C1 inhibitor (C1-INH) antigenic level below the lower limit of normal as defined by laboratory testing; OR C1-INH functional level below the lower limit of normal as defined by laboratory testing; OR Presence of a known HAE-causing C1-INH mutation All indications o History of moderate or severe attacks such as airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, or painful facial distortion Must provide documentation of diagnosis (i.e., C1-INH deficiency or dysfunction (Type I or II HAE)) and whether the drug will be used for prophylaxis or treatment Must provide documentation of at-home administration NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 60 3 days with at least one preferred acute drug in this UPDL category to request a non-preferred acute drug. Must have had an inadequate clinical response of at least 60 14 days with at least one preferred prophylaxis drug to request a non – preferred prophylaxis drug. Respiratory Agents: Inhaled Agents NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 14 days with at least two preferred drugs within the same class and duration of action in this UPDL category . ADDITIONAL STEROID-CONTAINING INHALER CRITERIA Must have had an inadequate clinical re sponse of at least 14 days with at least one preferred steroid-containing drug May be authorized if documentation of one of the following is provided: o Patient is 12 years or younger OR is disabled and is unable to use a preferred inhaler o Patient has been non-compliant on a preferred inhaler due to taste, dry mouth, or infection o Patient is clinically unstable, as defined by current guidelines in terms of oral steroid use or patients current symptomatology AR Budesonide Nebulizer Solution: a PA is required for patients 7 13 yearsand older30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 Respiratory Agents: Leukotriene Receptor Modifiers & InhibitorsSTEP THERAPY CRITERIA: Must have had an inadequate clinical response of at least 90 30 days with at least one preferred drug in this UPDL category . NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 90 30days with at least two preferred drugs in this UPDL category . Respiratory Agents: Monoclonal Antibodies-Anti – IL/Anti-IgE CLINICAL PA CRITERIA: Must be prescribed by or in consultation with an applicable specialist (i.e., allergist/ immunologist, pulmonologist, or otolaryngologist) For Asthma Must have had uncontrolled asthma symptoms and/or exacerbations despite at least 30 days with: o Medium dose preferred ICS/LABA inhaler for 6 years and older OR medium dose preferred ICS/LABA inhaler with tiotropium or high dose ICS/LABA inhaler if 12 years and older For Chronic Rhinosinusitis with Nasal Polyposis Must have had an inadequate clinical response of at least 30 days to at least one oral corticosteroid AND one nasal corticosteroid spray For Chronic Urticaria Must have had an inadequate clinical response to at least 14 days with at least two different second – generation antihistamines at 4 times standard dose Respiratory Agents: Nasal Preparations NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 30 14 days with at least two preferred drugs in th e same class is UPDL category , if available Topical Agents: Antifungals LENG TH OF AUTHO RIZATIONS: Up to 180 days for all agents except 365 days for Jublia ADDITIONAL EFINACONAZOLE (JUBLIA) CRITERIA: Must have had an inadequate clinical response of at least 48 weeks of ciclopirox AND 6 weeks of oral terbinafine (if fingernail) OR 12 weeks of oral terbinafine (if toenail) 365 days with at least one preferred topical drug AND at least 84 days with at least one preferred oral drug indicated for diagnosis ADDITIONAL INFORMATION Requests may be authorized if:o The infection is caused by an organism resistant to preferred antibiotics antifungal drugs (note diagnosis and any culture/sensitivity results) Topical Agents: Corticosteroids LENG TH OF AUTHO RIZATIONS: 3 65 days for low/m ed potency; 90 days for high/very high potency NON-PREFERRED CRITERIA: Must have had an inadequate clinical response of at least 14 days with at least two preferred drug s of similar potency in this UPDL category . 30 Day Change Notic e Effective Date: January 1, 202 5 Date of Notice: 12 /1/202 4 Topical Agents: ImmunomodulatorsSTEP THERAPY CRITERIA: Must have had an inadequate clinical response of at least 30 21 days with at least two topical corticosteroids one preferred agent
Notice Date: December 4, 2024 To: Ohio Medicaid, Marketplace, MyCare, D-SNP Providers From: CareSource Subject: Change in the Timely Filing Rule for EDI Submitted Claims Ef fective Date: March 1, 2025 Summary To ensure providers can continue to serve members to the best of your ability, the Ohio Department of Medicaid (ODM) is extending the timely filing deadline one final time to March 1, 2025. Im pact The Ohio Department of Medicaid (ODM), with the understanding that providers have experienced issues with the ED I, is extending the exception to timely filing requirements by t hree months. We will consider EDI claims timely if submitted up to two years from the service or inpatient discharge date compared to the submitted date if submitted before March 1, 2025. ODM has resolved most claim submission concerns, resulting in a rejection rate of less than 1% for fee-for-service (FFS) and managed care claims. However, approximately 2% of providers have contract issues preventing them from meeting the current timely filing deadline . ODM has a process in place that will be used once we have reached a normal operational capacity for processing these manual exceptions. Therefore, we are extending the timely filing deadline to make sure these impacts do not impede a providers ability to serve Medicaid patients . In order to give providers time to submit any currently held claims, and for those remaining contract updates and affiliation relationships to be in place, ODM is extending the timely filing requirements, outlined in the Ohio Administrative Code rule 5160-1-19 to begin March 1. It is critical that all providers take two actions before the March 1 date : 1.If you have received a denial for a contract or affiliation related issue, please review your Provider Network Management (PNM) data to make sure it is correct. If the PNM data is correct and you received a denial indicating a contract or an affiliation issue, please report this to theIntegrated Help Desk (IHD). 2.Providers should submit all currently held claims even if there is a chance the claims will be denied. If a data fix or system configuration is required to properly adjudicate the claim, ODMwill be able to make these adjustments on all claims successfully received by the system even if it is past the standard timely filing deadline. Even if claims are denied due to data fix issues, we will be able to reprocess your claims as your claims will be in the system and will have met the timely filing deadline. After March 1, any claim NOT in the system that needs to be submitted for a timely filing exemption will be required to follow the medical claims review process by submitting the 6653 form. Submitting all claims before March 1 will avoid this additional manual work and time required to process them. Submission Guidelines for Providers Who Submit Claims Via the Electronic Data Interchange (EDI ): Claims that are greater than 365 days from the date of service submitted before March 1, 2025 must include the appropriate Delay Reason Code in the CLM 20 field. You should select the CLM 20 Delay Reason using the following guidance: A Delay Reason Code = 7 (Third Party Processing Delay). Use this code if the claims could not be submitted through the system at all. BDelay Reason Code = 9 (Original Claim Rejected). Use this code if the original claim was submitted, but it could not be processed through the OMES system at that time. Although ODM extended the timely filing requirements, claims submitted after the standard 365-day limit are still subject to post payment review. ODM may verify evidence of system submission issues, such as reviewing past IHD call logs to verify that provi ders attempted to troubleshoot their issue. If issues are not evident, the claim payment may be reversed. Questions? For additional questions, please contact Provider Services : Medi caid: 1-800-488-0134 (Monday through Friday 7 a.m. to 8 p.m. Eastern Time (ET) )MyCare: 1-800-488-0134 (Monday through Friday 8 a.m. to 6 p.m. ET )Marketplace: 1-833-230-2101 (Monday through Friday 8 a.m. to 6 p.m. ET )D-SNP: 1-833-230-2176 (Monday through Friday 8 a.m. to 6 p .m. ET)OH-Mu lti-P-3390819
Admin istrative Policy StatementOhio MyCare Policy Name Policy Number Date Effective Medicaid-Covered Pharmacy Product Reviews AD-11421 1/1/2025 Policy Type Medical ADMINISTRATIVE Pharmacy Reimbursement Administrative Policy Statement s prepared by CSMG Co. and its affiliates (including CareSource) are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the serv ice(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract ( i.e., Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination . Table of Contents Administrative Policy Statement ……………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 2 F. Related Policies/Rules ………………………………………………………………………………………….. 2 G. Review/Revision History ……………………………………………………………………………………….. 2 H. References …………………………………………………………………………………………………………. 3 Medicaid-Covered Product Reviews Ohio MyCare AD-11421 Effective Date: 1/1/20252A. Subject Medicaid-Covered Pharmacy Product Reviews B. Background Ohio MyCare covers Medicaid-covered drugs and products that are not covered by Medicare Part Dthrough a members Medicaid benefit. Some of these Medicaid-covered products (i.e. OTC products and non-Part Ddrugs) are covered automatically through the required Ohio Additional Demonstration Drug File list, with no restrictions. Some of these products do not carry product-specific review criteria but still require a medical necessity review. CareSource, in partnership with our Pharmacy Benefit Manager, Express Scripts , will review these products per the policy below upon prior authorization request. C. Definitions Hierarchical Ingredient Code List unique primary active ingredient or combination of active ingredients OAC Ohio Administrative Code ORC Ohio Revised Code D. Policy I. If a Medicaid-covered drug or product not covered by Medicare Part Drequires review and product-specific criteria is not present, approval will be provided if the following criteria are met: A. Trial of at least three preferred alternatives within the same Hierarchical Ingredient Code List or Specific Therapeutic Class; AND B. Submission of two peer-reviewed medical articles citing efficacy and safety of the drug or product E. Conditions of Coverage If approval is warranted, authorization will be placed for 1 year. F. Related Policies/Rules OAC 5160-9-03 – Pharmacy services: covered drugs and associated limitations . ORC 5167.12 – Requirements when prescribed drugs are included in care management system. OAC 5160-58-03.1 – MyCare Ohio plans: primary care and utilization management. G. Review/Revision History DATE S ACTIONDate Issued 10/31/2024 Policy ComposedDate Revised Medicaid-Covered Product Reviews Ohio MyCare AD-11421 Effective Date: 1/1/20253Date Effective 01/01/2025 Date Archived H. References N/A
Notice Date: December 2, 2024 To: Ohio D-SNP, Marketplace, Medicaid, MyCare Behavioral Health Providers From: CareSource Subject: CareSource Connections Effective Date: January 1, 2025 Summary The Behavioral Health (BH) Provider Relations team is excited to continue CareSource Connections throughout 2025 , our monthly operational engagement platform. CareSource Connections is dedicated to Behavioral Health Providers , including but not limited to: Community Behavioral Health Centers, BH private practice providers, and Applied Behavioral Analysis (ABA) providers across the state of Ohio. Education and training t opics are specific to Ohio BH operations, such as claims processing trends & education, how to submit a Prior Authorization (PA), portal education, dispute process , contracting & credentialing process, fee schedule inquiries, CareSource.com navigation, operational issues/inquiries, and much more! Impact Ohio BH Providers are welcome to directly engage and connect with the CareSource BH Provider Relations team and fellow BH providers . 2025 schedule* for CareSource Connections below: Date Day of the Week Start End In-Person /Virtual January 16, 2025 Thursday 9:00 a.m. (ET) 10:00 a.m. (ET) Virtual Only **February 20, 2025 Thursday 11:30 a.m. (ET) 12:30 p.m. (ET) Columbus /Virtual March 20, 2025 Thursday 3:00 p.m. (ET) 4:00 p.m. (ET) Virtual OnlyApril 17, 2025 Thursday 9:00 a.m. (ET) 10:00 a.m. (ET) Virtual Only**May 15, 2025 Thursday 11:30 a.m. (ET) 12:30 p.m. (ET) Cleveland /VirtualJune 19, 2025 Thursday 3:00 p.m. (ET) 4:00 p.m. (ET) Virtual OnlyJuly 17, 2025 Thursday 9:00 a.m. (ET) 10:00 a.m. (ET) Virtual Only**August 21, 2025 Thursday 11:30 a.m. (ET) 12:30 p.m. (ET) Dayton /VirtualSeptember 18, 2025 Thursday 3:00 p.m. (ET) 4:00 p.m. (ET) Virtual Only October 16, 2025 Thursday 9:00 a.m. (ET) 10:00 a.m. (ET) Virtual Only November 2025 No Meeting due to holiday December 2, 2025 Tuesday 11:30 a.m. (ET) 12:30 p.m. (ET) Virtual Only * Dates subject to change **Represents in-person option, details to be shared during monthly calls Registration To register for our webinars , email updates & communications from the BH Provider Relations team, please complete this form: CareSource Connections Communications . You may also send an email titled CareSource Connections to Care Source_OH_BH@ Care Source.com requesting to join. Once received, a BH Provider Relations team member will provide you with the link for the Microsoft Teams webinar. Please include the following in your email: Agency Name Email(s) you want added to the meeting invites Agency type: BH Private Practice, Community Mental Health Center (type 84/95), ABA Provider Questions? If you have specific training ideas or BH operational needs, please email in advance of a CareSource Connections meeting for the CareSource BH Provider Relations team to research and provide education and feedback on subsequent webinars. Send your email titled CareSource Connections to CareSource_OH_BH@CareSource.com . OH-Multi-P-3452703
Member Frequently Asked Questions (FAQs)Behavioral Health Services Changes in Macomb County | HAP CareSource MI Health Link (Medicare-Medicaid Plan)1. What is changi ng if you are receiving behavioral health services from Macomb County CommunityMental Health? Your behavioral health services and care you are receiving from Macomb County Community Mental Health (MCCMH) will remain as is . The only difference is that HAP CareSource will manage the services rather than M CCMH. 2. When is the change taking effect?January 1, 2025.3. Will my current behavioral health provider in Macomb County change?HAP CareSource is working to contract with your Behavioral Health providers. 4. Will any of the changes taking place affect your current care and/or services?No. Your benefits are not changing. The only thing that is changing is who manages those benefits.5. Who should I contact for behavioral health care coordination? You can continue to work with your care coordinator at MCCMH through December 31 , 202 4. Your HAP CareSource care coordinator is always available to you. You can call them directly or call HAP CareSource Member Services at 1-833-230-2057 (TTY: 1-833-711-4711 or 711) . 6. Are there any other changes I should be aware of?Yes. You will receive a new HAP CareSource MI Health Link member ID card in the mail in December . Please throw away your current member ID card and use the new one . 7. Who should I contact with general behavioral health services questions?If you have a question before January 1, 202 5, call MCCMH at 1-855-996-2264 (TTY : 711). If you have a question on or after January 1, 2025, call HAP CareSource MI Health Link Member Services at 1-833-230 – 2057 (TTY: 1-833-711-4711 or 711) . 8. Who should I call if I am having a behavioral health related crisis?Call MiCal 988 or 911 for behavioral health related crisis. You can also call HAP CareSource MI Health Link Member Services at 1-833-230-2057 (TTY: 1-833-711-4711 or 711) . 9. What is the process if I need to file a grievance or appeal regarding a behavioral health related service? Grievances and appeals for services that were delivered prior to January 1, 2025, will be handled byMCCMH. Grievances and appeals for services that were delivered on or after January 1, 2025, will be handled by HAP CareSource MI Health Link . 10. Is there a direct line if I need to file a behavioral health related complaint?For complaints for behavioral health services through December 31, 2024, please contact MCCMH. For complaints for services on or after January 1, 2025, please call HAP CareSource MI Health Link. If you have any questions, please call Member Services at 1-833-230-2057 (TTY: 1-833-711-4711 or 711) , 8 a.m. to 8 p.m., Monday through Friday. HAP CareSource MI Health Link (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. H9712_MI-MMP-M- 3402041 | C MS/MDHHS Approved: 11/20/2024HAPCareSource.com
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