Welcome
We know your time is valuable. To help improve access and understanding, we have developed a provider facing Learning Management System. All training on our HealthPlanResources.com platform is developed in-house and is specific to our organization. First Time Access: The first time you visit HealthPlanResources.com , you will use:Username: Yo u r NP IPassword: ProvidersR#1 Single Sign-On for Providers: If you are registered to use our provider portal, you can single sign-on from that platform by choosing HealthPlanResources.com from the left menu bar. No Current Provider Portal Access: Go to HealthPlanResources.com to sign in using your NPI* and the password provided in your Welcome Letter. Office Manager/Administrators: Managing a group of providers? Complete training and manage accounts for all providers in your TIN.*If you do not have an NPI number, you will set up a new account using the unique email address as your username. To use single sign-on in the future, be sure to use the same email address and password when accessing the provider portal. Helpful Information to Get You Started! HealthPlanResources.comAccessing educational materials is easy! Onboarding ExperienceTell us about it! First impressions are vital, and we want to know how we are doing. Your feedback shapes our programs and processes moving forward. Please take a quick five to 10 minutes to tell us about your experience with being introduced to TrueCare. From that first contact to receiving your Welcome Letter, we want to know about any areas where we are doing well or any areas where we need some work. Use the below QR code to link to a short survey. Provider OrientationGoing through the orientation training will provide you with helpful information when working with TrueCare. Completing orientation is required within the first 60 days of receiving your Welcome Letter. Visit our HealthPlanResources.com to take on-demand orientation or to sign up for an in-person or virtual session. Provider Onboarding Survey MS-MED-P-3670500 Health Plan Resources Insert.indd 1MS-MED-P-3670500 Health Plan Resources Insert.indd 1 4/9/25 10:29 AM4/9/25 10:29 AM Provider ConnectionsConnect with Us!Provider Connections is a dedicated, monthly forum for Mississippi providers to directly engage with provider support and operations specialists. In addition to a focus on clean claims submission, monthly topics are selected based on quality improvement initiatives, provider feedback, issue trends, and other indicators of potential provider pain points. Each month we focus on different areas that are impactful to you and sessions are led by subject matter experts who can answer questions and provide guidance. The goal of Provider Connections is to give you a chance to connect with us. To sign up for our next session, visit HealthPlanResources.com. In the CommunityAs part of our on-going education and outreach efforts, we want to meet you where you are! TrueCare participates in many provider-focused conferences and other community events. Visit us online for more information. We are also offering webinars covering a variety of information important to Mississippi providers. These presentations are meant to bring you information that is useful to your practice.For a full list of webinar dates and topics, or to see where you can find us, visit our Provider Training & Events page on MSTrueCare.com. Visit Us at MSTrueCare.com Not Sure Where to Start? Visit our online Provider Welcome Page to see an overview of our tools and resources and to give you a quick overview of what we have to offer!MS-MED-P-3670500 Health Plan Resources Insert.indd 2MS-MED-P-3670500 Health Plan Resources Insert.indd 2 4/9/25 10:29 AM4/9/25 10:29 AMMS-MED-P-3670500 | 2025 TrueCare. All Rights Reserved.
ADMINISTRATIVE POLICY STATEMENTGeorgia D-SNP Policy Name & Number Date Effective Impacted Cerumen Removal-DSNP-AD-1397 12/01/2026 Policy Type ADMINISTRATIVE Administrative Policy Statements contain supplemental information regarding standard benefit administration and coverage details. Administrative Policy Statements do not guarantee an authorization or payment of services. The Members plan contrac t (e.g., E vidence of Coverage, Member Handbook) contains specific terms and conditions, including limitations, exclusions, benefit maximums, eligibility, and other relevant conditions of coverage. Except as otherwise required by law, if there is a conflict between t he Administrative Policy Statement and the plan contract and/or provider agreement, then the plan contract and/or provider agreement will be the controlling document. Reasonable discretion may be used in interpreting and applying this Poli cy Statement to s ervices provided in a particular case, and the policy may be modified at any time. Policy Statements may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Impacted Cerumen Removal-DSNP-AD-1397Effective Dat e: 12/01/20262A. SubjectImpacted Cerumen Removal B. BackgroundCerumen or ear wax is a n aturally occurring substance that cleans, protects, and lubricates the ear canal. The cerumen can block the ear canal causing symptoms such as pain, hearing loss, fullness, itching, and tinnitus. Methods for removal of cerumen include irrigation, manual removal with instrumentation, and cerumenolytic agents. Cerumen removal may require a physician when methods such as irrigation or removal by cotton-tipped applicators are not sufficient. C. Definitions Cerumen Impaction An accumulation of cerumen that is associated with symptoms and/or prevents a necessary ear examination. Modifier 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service. Modifier 50 Bilateral Procedure. National Correct Coding Initiative (NCCI) A program developed by CMS to promote national correct coding and to prevent improper payment when incorrect code combinations are reported. D. PolicyI. Claims submission for cerumen impaction should include the appropriate CPT code and ICD-10 : A. ICD-10 1. impa cted cerumen, unspecified ear 2. impacted cerumen, right ear 3. Impacted cerumen, left ear 4. impacted cerumen, bilateral B. CPT 1. removal impacted cerumen using irrigation/lavage, unilateral 2. removal impacted cerumen requiring instrumentation, unilateral 3. removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing NOTE : Visualization aids, such as, but not limited to binocular microscopy, areincluded in the CPT code and should not be billed separately.II. Evaluation and management (E&M) visitA. Impacted cerumen 1. An E&M service may not be billed when the sole reason for the visit is to remove symptomatic impacted cerumen. Impacted Cerumen Removal-DSNP-AD-1397Effective Dat e: 12/01/202632. An E&M service on the same day as removal of impacted cerumen may not be billed unless it represents and is documented to be a significant, separately identifiable service on the same day.B. Non impacted cerumen For removal of cerumen that is not impacted, use the E&M service code. III. ModifiersA. Use modifier 25 and /or 50, when appropriate. B. Follow NCCI guidelines and use appropriate modifiers, as applicable. C. For bilateral procedures, use Centers for Medicare & Medicaid Services (CMS) guidelines. D. Separate payment is only justified when modifier 25 is appended indicating the following: 1. removal of symptomatic impacted cerumen 2. impacted cerumen impeding a physicians ability to properly evaluate or manage other signs, symptoms , or conditions or 3. impacted cerumen impeding a physicians or audiologists ability to perform covered audiometry NOTE: Documentation confirming impacted cerumen and justification of the use of modifier 25 must be submitted with the claim to support medical necessity.E. Conditions of CoverageNA F. Related Policies/RulesModifier 25 G. Review/Revision HistoryDATE ACTIONDate Issued 10/11/2023 New Policy. Approved at Committee.Date Revised 10/09/2024 10/08/2025 08/26/2026 Updated references. Approved at Committee. Updated references. Approved at Committee Added definition, updated references . Approved at Committee Date Effective 12/01/2026 Date Archived H. References1. CPT for ENT: Cerumen Removal. American Academy of Otolaryngology Head and Neck Surgery. (2023). Accessed August 6, 2026 . www.entnet.org 2. Medicaid NCCI Coding Policy Manual . Centers for Medicare & Medicaid Services; 202 6. Accessed August 6, 2026 . www.cms.gov 3. Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical practice guideline (update): earwax (cerumen impaction). Otolaryngol Head Neck Surg . 2017;156(1_suppl):S1 – S29. doi:10.1177/0194599816671491
ADMINISTRATIVE POLICY STATEMENTGeorgia D-SNP Policy Name & Number Date Effective Esophageal Brush Biopsy-DSNP-AD-1400 12/01/2026 Policy Type ADMINISTRATIVE Administrative Policy Statements contain supplemental information regarding standard benefit administration and coverage details. Administrative Policy Statements do not guarantee an authorization or payment of services. The Members plan contrac t (e.g., E vidence of Coverage, Member Handbook) contains specific terms and conditions, including limitations, exclusions, benefit maximums, eligibility, and other relevant conditions of coverage. Except as otherwise required by law, if there is a conflict between t he Administrative Policy Statement and the plan contract and/or provider agreement, then the plan contract and/or provider agreement will be the controlling document. Reasonable discretion may be used in interpreting and applying this Poli cy Statement to s ervices provided in a particular case, and the policy may be modified at any time. Policy Statements may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Esophageal Brush Biopsy-DSNP-AD-1400Effective Dat e: 12/01/20262A. SubjectEsophageal Brush Biopsy B. BackgroundBarretts esophagus (BE) is a metaplastic change of the distal esophagus, whereby the normal squamous epithelium is replaced by specialized columnar epithelium with goblet cells . This change, where the squamous cell s of the esophagus begin to resemble cell s of the stomach , is associated with chronic gastroesophageal reflux disease (GERD) . It is estimated that 5% 12% of patients with chronic GERD symptoms will also exhibit BE. BE is the only known precursor lesion of esophageal adenocarcinoma (EAC) . In 2026, the American Cancer Society estimates 22,530 new esophageal cancer cases will be diagnosed (17,580 in men, 4950 in women); over 16,000 cases are predicted to be fatal. The most definitive, accurate, and reliable method for diagnosing esophageal lesions isesophageal endoscopy and the Seattle protocol four-quadrant forceps biopsy (FB) .A new er technique for detection of BE is wide-area transepithelial sampling withcomputer-assisted three-dimensional analysis (WATS3D). WATS3D, formerly known asEndoCDx, is a computer-assisted biopsy, adjunct to standard forceps biopsy of the esophagus, which cl aims to increase analysis accuracy of the tissue area sampled and therefore increases the yield of patients tissue identified with abnormality in the esophagus. Unlike standard cytology brushes that are typically soft and primarily designed to gently remove spontaneously exfoliated squamous cells in the esophagus, the WATS3D biopsy is specifically designed using an abrasive brush which is deployed during endoscopy to consistently sample deeper layers of the more firmly attached glandular epithelium found in Barretts esophagus. WATS3D has been criticized for its susceptibility to false-negative or false-positivefindings that could lead to the delay of appropriate therapy or to the administration of unnecessary therapy respectively, which represents a potential safety concern. Monitoring patients over time is needed to address th ese concerns. C. Definitions Barretts Esophagus (BE) A pre-malignant condition that places patients at risk for esophageal adenocarcinoma (EAC) . Esophageal Adenocarcinoma (EAC) One of the two most common types of esophageal cancer along with squamous cell carcinoma . Gastroesophageal Reflux Disease (GERD) A condition occurring when a muscle at the end of the esophagus does not close properly , allowing stomach contents to leak back, or reflux, into the esophagus and irritate it. D. PolicyI. Due to insufficient evidence, CareSource considers esophageal brush biopsy using wide-area transepithelial sampling with computer-assisted three-dimensional analysis (WATS3D) experimental and investigational for screening, diagnosis , or surveillance of cancerous or pre-cancerous esophageal lesions . Esophageal Brush Biopsy-DSNP-AD-1400Effective Dat e: 12/01/20263II. Any claims for esophageal brush biopsy will be denied. III. CareSource may request documentation of services performed. Appropriateand complete documentation must be presented at the time of review to validate medical necessity. If medical necessity is not confirmed based on the received documentation, recoupment may occur. E. Conditions of CoverageNA F. Related Policies/RulesExperimental or Investigational Item or Service G. Review/Revision HistoryDATE ACTIONDate Issued 09/14/2022 New Policy. Approved at CommitteeDate Revised 10/23/2024 10/22/2025 08/26/2026 Updated references. Approved at Committee Updated references. Approved at Committee Updated statistics, minor edits. Approved at Committee. Date Effective 12/01/2026 Date Archived H. References1. American Cancer Society. Key Statistics for Esophageal Cancer . Accessed August 11, 2026 . www.cancer.org 2. Health Technology Evaluation. Wide-Area Transepithelial Sampling Biopsy for Detection of Barretts Esophagus/Esophageal Dysplasia. Hayes, u pdated June 13, 2025 . Accessed August 11, 2026 . www. evidence.hayesinc.com 3. National Cancer Institute. Esophageal Cancer Screening (PDQ) Health Professional Version. Updated March 2024. Accessed August 11, 2026 . www. cancer.go v 4. Odze RD, Goldblum J, Kaul V. Role of Wide-Area Transepithelial Sampling With 3D Computer-Assisted Analysis in the Diagnosis and Management of Barrett’s Esophagus. Clin Transl Gastroenterol. 2021;12(12):e00422. doi:10.14309/ctg.0000000000000422 5. Shaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and Management of Barrett’s Esophagus: An Updated ACG Guideline. Am JGastroenterol . 2022;117(4):559-587. doi:10.14309/ajg.0000000000001680 6. Spechler SJ. Barrett’s esophagus: Surveillance and management . UpToDate . Updated December 4, 2025 . Accessed August 11, 2026 . www.uptodate.com 7. Suresh Kumar VC, Harne P, Patthipati VS, et al. Wide-area transepithelial sampling in adjunct to forceps biopsy increases the absolute detection rates of Barrett’s oesophagus and oesophageal dysplasia: a meta-analysis and systematic review. BMJ Open Gastroenterol. 2020;7(1):e000494. doi:10.1136/bmjgast-2020-000494 Esophageal Brush Biopsy-DSNP-AD-1400Effective Dat e: 12/01/202648. Yip HC, Chiu PW. Endoscopic diagnosis and management of early squamous cell carcinoma of esophagus. JThorac Dis . 2017;9(Suppl 8):S689-S696. doi:10.21037/jtd.2017.06.57
Notice Date: October 1, 2026 To: CareSource Wisconsin Marketplace Providers From: CareSource Subject: October 2026 Policy Updates Effective Date: December 1, 2026 Summary At CareSource, we listen to our providers, and we streamline our business practices to make it easier for you to work with us. We have worked to create a predictable cycle for releasing administrative, medical, and reimbursement policies, so you know what to expect. Check back each month for a consolidated network notification of policy updates from CareSource. How to Use This Network Notification Reference the list of policy updates. Note the effective date and impacted plans for each policy. Evaluate whether the policy is new or revised and determine whether its implementation or any revisions affect prior authorization requirements. Click the hyperlinked policy title to open the webpage with the full policy. Find Our Policies Online To access all CareSource policies, visit CareSource.com > Providers > Tools & Resources > Provider Policies. Select your plan and state, then the type of policy. Each revised policy has a previous version that can be referenced on the corresponding archived policy webpage. Policies Policy Name and Number Policy Type Plan Effective Date New or Revised Policy Impacts to Prior A uthorization Inhaled Nitric Oxide MM-1627 MEDICAL MARKETPLACE DECEMBER 1, 2026 REVISION NO Pre – Exposure Prophylaxis Preventive Services PY-1507 REIMBURSEMENT MARKETPLACE DECEMBER 1, 2026 REVISION NO Impacted Cerumen Removal AD-1515 ADMINISTRATIVE MARKETPLACE DECEMBER 1, 2026 REVISION NO Policy Name and Number Policy Type Plan Effective Date New or Revised Policy Impacts to Prior A uthorization Esophageal Brush Biopsy AD-1500 ADMINISTRATIVE MARKETPLACE DECEMBER 1, 2026 REVISION NO Pharma – cogenomics and Biomarker Testing AD-1666 ADMINISTRATIVE MARKETPLACE DECEMBER 1, 2026 NEW NO Sacroiliac Joint Procedures MM-1620 MEDICAL MARKETPLACE DECEMBER 1, 2026 REVISION NO Left Ventricular Assist Device (LVAD) Supplies PY-1741 REIMBURSEMENT MARKETPLACE DECEMBER 1, 2026 REVISION NO WI-EXC-P -6233851
Notice Date: October 1, 2026 To: CareSource West Virgina Marketplace Providers From: CareSource Subject: October 2026 Policy Updates Effective Date: December 1, 2026 Summary At CareSource, we listen to our providers, and we streamline our business practices to make it easier for you to work with us. We have worked to create a predictable cycle for releasing administrative, medical, and reimbursement policies, so you know what to expect. Check back each month for a consolidated network notification of policy updates from CareSource. How to Use This Network Notification Reference the list of policy updates. Note the effective date and impacted plans for each policy. Evaluate whether the policy is new or revised and determine whether its implementation or any revisions affect prior authorization requirements. Click the hyperlinked policy title to open the webpage with the full policy. Find Our Policies Online To access all CareSource policies, visit CareSource.com > Providers > Tools & Resources > Provider Policies. Select your plan and state, then the type of policy. Each revised policy has a previous version that can be referenced on the corresponding archived policy webpage. Policies Policy Name and Number Policy Type Plan Effective Date New or Revised Policy Impacts to Prior Authorization Inhaled Nitric Oxide MM-1321 MEDICAL MARKETPLACE DECEMBER 1, 2026 REVISION NO Pre – Exposure Prophylaxis Preventive Services PY-1450 REIMBURSEMENT MARKETPLACE DECEMBER 1, 2026 REVISION NO Impacted Cerumen Removal AD-1253 ADMINISTRATIVE MARKETPLACE DECEMBER 1, 2026 REVISION NO Policy Name and Number Policy Type Plan Effective Date New or Revised Policy Impacts to Prior Authorization Esophageal Brush Biopsy AD-1398 ADMINISTRATIVE MARKETPLACE DECEMBER 1, 2026 REVISION NO Sacroiliac Joint Procedures MM-1314 MEDICAL MARKETPLACE DECEMBER 1, 2026 REVISION NO Left Ventricular Assist Device (LVAD) Supplies PY-1465 REIMBURSEMENT MARKETPLACE DECEMBER 1, 2026 REVISION NO WV-EXC-P -6233951
Notice Date: October 1, 2026 To: CareSource Georgia Marketplace Providers From: CareSource Subject: October 2026 Policy Updates Effective Date: December 1, 2026 Summary At CareSource, we listen to our providers, and we streamline our business practices to make it easier for you to work with us. We have worked to create a predictable cycle for releasing administrative, medical, and reimbursement policies, so you know what to expect. Check back each month for a consolidated network notification of policy updates from CareSource. How to Use This Network Notification Reference the list of policy updates. Note the effective date and impacted plans for each policy. Evaluate whether the policy is new or revised and determine whether its implementation or any revisions affect prior authorization requirements. Click the hyperlinked policy title to open the webpage with the full policy. Find Our Policies Online To access all CareSource policies, visit CareSource.com > Providers > Tools & Resources > Provider Policies. Select your plan and state, then the type of policy. Each revised policy has a previous version that can be referenced on the corresponding archived policy webpage. Policies Policy Name and Number Policy Type Plan Effective Date New or Revised Policy Impacts to Prior Authorization Inhaled Nitric Oxide MM-1321 MEDICAL MARKETPLACE DECEMBER 1, 2026 REVISION NO Pre – Exposure Prophylaxis Preventive Services PY-1450 REIMBURSEMENT MARKETPLACE DECEMBER 1, 2026 REVISION NO Impacted Cerumen Removal AD-1253 ADMINISTRATIVE MARKETPLACE DECEMBER 1, 2026 REVISION NO Policy Name and Number Policy Type Plan Effective Date New or Revised Policy Impacts to Prior Authorization Esophageal Brush Biopsy AD-1398 ADMINISTRATIVE MARKETPLACE DECEMBER 1, 2026 REVISION NO Pharmaco – genomics and Biomarker Testing AD-1665 ADMINISTRATIVE MARKETPLACE DECEMBER 1, 2026 NEW NO Sacroiliac Joint Procedures MM-1314 MEDICAL MARKETPLACE DECEMBER 1, 2026 REVISION NO Left Ventricular Assist Device (LVAD) Supplies PY-1465 REIMBURSEMENT MARKETPLACE DECEMBER 1, 2026 REVISION NO GA-EXC-P -6233802
Notice Date: October 1, 2026 To: CareSource Indiana Marketplace Providers From: CareSource Subject: October 2026 Policy Updates Effective Date: December 1, 2026 Summary At CareSource, we listen to our providers, and we streamline our business practices to make it easier for you to work with us. We have worked to create a predictable cycle for releasing administrative, medical, and reimbursement policies, so you know what to expect. Check back each month for a consolidated network notification of policy updates from CareSource. How to Use This Network Notification Reference the list of policy updates. Note the effective date and impacted plans for each policy. Evaluate whether the policy is new or revised and determine whether its implementation or any revisions affect prior authorization requirements. Click the hyperlinked policy title to open the webpage with the full policy. Find Our Policies Online To access all CareSource policies, visit CareSource.com > Providers > Tools & Resources > Provider Policies. Select your plan and state, then the type of policy. Each revised policy has a previous version that can be referenced on the corresponding archived policy webpage. Policies Policy Name and Number Policy Type Plan Effective Date New or Revised Policy Impacts to Prior Authorization Inhaled Nitric Oxide MM-1321 MEDICAL MARKETPLACE DECEMBER 1, 2026 REVISION NO Pre – Exposure Prophylaxis Preventive Services PY-1450 REIMBURSEMENT MARKETPLACE DECEMBER 1, 2026 REVISION NO Impacted Cerumen Removal AD-1253 ADMINISTRATIVE MARKETPLACE DECEMBER 1, 2026 REVISION NO Policy Name and Number Policy Type Plan Effective Date New or Revised Policy Impacts to Prior Authorization Esophageal Brush Biopsy AD-1398 ADMINISTRATIVE MARKETPLACE DECEMBER 1, 2026 REVISION NO Sacroiliac Joint Procedures MM-1314 MEDICAL MARKETPLACE DECEMBER 1, 2026 REVISION NO Left Ventricular Assist Device (LVAD) Supplies PY-1465 REIMBURSEMENT MARKETPLACE DECEMBER 1, 2026 REVISION NO IN-EXC-P -6233801
MEDICAL POLICY STATEMENTArkansas PASSE Policy Name & Number Date Effective Sacroiliac Joint Procedures-AR PASSE-MM-1507 12/01/2026 Policy Type MEDICAL Medical Policy Statements are developed from a review of the available evidence-based, clinical information based on and supported by clinical guidelines from medical specialties, peer-reviewed medical and scientific studies, nationally recognized utilizat ion and technology assessment guidelines, and other medical management industry standards to aid in determining the medical necessity of a service. Medically necessary services are defined in the plan-specific Evidence of Coverage, Member Handbooks, Provid er Manuals, Medical Policy Statements, and/or other plan policies and procedures. Medical Policy Statements do not guarantee an authorization or payment of services. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced in the Medical Policy Statement. Except as otherwise required by law, if there is a conflict between the Medical Policy Statement and the plan contract and/or provider agreement, then the plan contract and/or provider agreement will be the controlling document.Reasonable discretion may be used in interpreting and applying this Policy Statement to services provided in a particular case, and the policy may be modified at any time. Medical Policy Statements may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between t he Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 5Sacroiliac Joint Procedures-AR PASSE-MM-1507 Effective Date: 12/01/20262A. Subject Sacroiliac Joint Procedures B. Background Over 80% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are persistent. Persistent pain is categorized as subacute when lasting between 4 and 12 weeks , and chronic when persisting for at least 3 months. Up to 10% to 30% of patients with persistent low back pain may have a component of pain related to sacroiliac joints (SIJ). Comprehensive pain management care plans are most effective in managing a patients chronic pain. These plans focus on a person-centered approach and incorporate conservative treatment with other modalities. These multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patients daily life, even if the pain cannot be relieved completely. In addition to conservative therapy, additional treatment options may include nonpharmacologic or pharmacologic treatments, nonsurgical interventions, and surgical interventions. Interventional procedures for the management of pain unresponsive to conservative t reatment should be provided only by physicians qualified to deliver these health services. Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be effective for diagnostic purposes but provide limited short-term relief from pain resulting from SI Jdysfunction. Long-term use has not been adequately studied to establish standards of care. Radiofrequency ablation (RFA) is another treatment method, which uses heat to destroy nerves. RFA for the treatment of low back pain has inconsistent results in the peer-reviewed medical literature with limited follow-up. However, clinical experience suggests that some patients obtain more significant relief from these procedures, making it reasonable to offer SIJ injections and/or RFA when conservative management has failed. C. Definitions Conservative Therapy A multimodal plan of care including both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen supporting muscle groups and target key spinal structures, including physical therapy, occupational therapy, physician supervised home exercise program (HEP), and/or chiropractic care. HEP A prescribed plan that includes specific goals, frequency, and expected duration, along with a clearly defined timeframe for reassessment ( eg, 6-12 weeks). Ongoing continuation must be supported by documented clinical progress Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, Transcutaneous Electrical Nerve Stimulator ( TENS) use, and/or Sacroiliac Joint Procedures-AR PASSE-MM-1507 Effective Date: 12/01/20263pharmacotherapy (prescription or over the counter [non-steroidal anti-inflammatory drugs, acetaminophen]) . Functional Disability Acquired difficulty in performing basic everyday tasks or more complex tasks needed for independent living. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. Sacroiliac Joint (SIJ) Injections Corticosteroid and local anesthetic therapeutic injections into the SIJ to treat pain that has not responded to conservative therapies. D. Policy I. Sacroiliac Joint Injections A. Diagnostic injections : CareSource considers up to 2 diagnostic SIJ injections for the treatment of chronic low back pain medically necessary when ALL the following criteria are met: 1. somatic or nonradicular low back pain at the SIJ region and/or lower extremity pain experienced for at least 3 months 2. severe pain (ie. at least a 6 out of 10 on pain scale) and tenderness located in the SIJ region that cause functional disability 3. positive response to at least 3 SIJ pain provocation test (eg, distraction, compression, thigh thrust, Gaenslens test , Patricks test/FABER test, sacral thrust) 4. failure of conservative therapy, as evidenced by ALL the following: a. documentation in the medical record of at least 4 weeks of active conservative therapy ( as defined above) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increase pain, or intolerance b. documentation in the medical record of at least 4 weeks of inactive conservative therapy ( as defined above) within the past 6 months 5. if a second diagnostic injection is requested, at least 1 week has passed since the initial injection B. Therapeutic injections: CareSource considers therapeutic SIJ injections medically necessary when ALL the following criteria are met: 1. m ost recent SIJ injection at the same side led to at least 75% pain relief and functional improvement 2. m ember experiences return of severe pain or deterioration in function 3. injection is used in conjunction with conservative therapy (as defined above) 4. injection is repeated at a frequency of no greater than every 2 months 5. no more than 4 injections total (diagnostic and therapeutic) have been administered at the same site in the last 12 months . C. Exclusions/Limitations: 1. Codes 64451 and 27096 may not be billed together (on the same date for the same side of the body) . Only one code will be reimbursed. 2. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately. 3. If neural blockade is applied for different regions or different sides, injections are performed at least one week apart. Sacroiliac Joint Procedures-AR PASSE-MM-1507 Effective Date: 12/01/202644. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated injections of the SIJ to be effective as a long-term management modality. Long-term continuation may be subject to medical necessity review. 5. Monitored anesthesia and conscious sedation are not medically necessary. 6. The use of SI Jinjections for the treatment of pain as a result of Herpes Zoster is considered not medically necessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. II. Radiofrequency Ablation of the SIJ A. Initial radiofrequency ablation of the SIJ 1. Radiofrequency ablation is considered medically necessary when ALL the following have been met in the last 6 months: a. The clinical criteria above for failed conservative therapy (I.A.4.a. and I.A.4.b.) has been met. b. One diagnostic injection per joint to evaluate pain and attain therapeutic effect has been performed with a reported 75% or greater reduction in pain after injection. B. Repeat radiofrequency ablation of the SIJ 1. Conservative therapy and diagnostic injections are not required if there has been a reduction in pain for at least 12 months or more from the initial RFA within the last 36 months. 2. When there has not been a repeat RFA in the last 36 months, a diagnostic injection is required. 3. A maximum of 1 RFA for SI Jpain per side per 1 2 months is considered medically necessary. C. Exclusions/Limitations 1. The use of cooled RFA for SI J-mediated low back pain is considered not medically necessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. 2. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated the effectiveness of RFA as a long-term management modality. Long-term continuation may be subject to medical necessity review. III. Implantable Spinal Cord Stimulators Member s with indwelling implanted spinal cord stimulators or pain pumps should have a device interrogation report submitted with medical records for a prior authorization request for proposed interventional pain injections. If a device is not functioning properl y, an escalation in pain may warrant evaluation and management of the implanted device. E. Conditions of Coverage NA F. Related Policies/Rules Trigger Point Injections Sacroiliac Joint Procedures-AR PASSE-MM-1507 Effective Date: 12/01/20265G. Review/Revision HistoryDATE ACTIONDate Issued 09/13/2023 New policy, approved at Committee.Date Revised 01/31 /2024 01/29/2025 12/17/2025 09/09/2026Annual review: updated references and formatting ,approved at Committee. Review: updated references, approved at Committee. Review: added pain level criteria, increased number of provocation test positives and updated references . A pproved at Committee. Review: updated HEP definition, changed 6 week conservative therapy to 4 weeks, and added related policies. Approved at Committee. Date Effective 12/01/2026 Date Archived H. References1. Chou R, Cohen SP. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated January 27, 2026. Accessed July 6, 2026. www.uptodate.com 2. Cine HS, Uysal E, Demirkol M, Cetin E. Under what conditions is the intra-articular steroid injection superior to nonsteroidal anti-inflammatory drugs for treating sacroiliac joint pain? Eur Rev Med Pharmacol Sci . 2023;27(21):10539-10546. d oi:10.26355/eurrev_202311_34331 3. Jamjoom AM, Saeedi RJ, Jamjoom AB. Placebo effect of sham spine procedures in chronic low back pain: a systematic review. JPain Res. 2021;14:3057-3065. doi:10.2147/JPR.S317697 4. Janapala RN, Knezevic E, Knezevic NN, et al. Systematic review and meta-analysis of effectiveness of therapeutic sacroilic joint injections. Pain Phys ician. 2023;26:E413-E435. Accessed August 7, 2026. www.painphysicianjournal.com 5. Lee DW, Pritzlaff S, Jung MJ, et al. Latest evidence-based application for radiofreqneucy neurotomy (LEARN): best practice guidelines from the American Society of Pain and Neuroscience (ASPN). JPain Res. 2021;14:2807-2831. doi:10.2147/JPR.S235665 6. Li D, Tafti D, Varacallo, M. Sacroiliac joint injection. StatPeals . StatPearls Publishing; 2026. Updated February 25, 2026. Accessed August 7, 2026. 7. Liu Y, Suvithayasiri S, Kim JS. Comparative efficacy of clinical interventions for sacroiliac joint pain: systematic review and network meta-analysis with preliminary design of treatment algorithm. Neurospine. 2023 Sep;20(3):997-1010. doi: 10.14245/ns.2346586.293. 8. Manchikanti L, Sanapati M, Albers S , et al. Updated 2026 comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Phys ician. 2026; 29(3S):S1-S228. Accessed August 7, 2026 . www.painphysicianjournal.com 9. Sacroiliac Joint Injection: A-1048 (AC). MCG. 30th ed. Updated January 25, 2026 . Accessed July 6, 2026. www.careweb.careguidelines.com 10. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience Sacroiliac Joint Procedures-AR PASSE-MM-1507 Effective Date: 12/01/20266(ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 11. Szadek K, Cohen SP, de Andres Ares J, et al. Sacroiliac joint pain. Pain Pract. 2023;00:1-20. d oi:10.1111/papr.13338 Independent Medical Review January 2025
MEDICAL POLICY STATEMENTArkansas PASSE Policy Name & Number Date Effective Residential Community Reintegration-AR PASSE-MM-1855 12/01/2026 Policy Type MEDICAL Medical Policy Statements are developed from a review of the available evidence-based, clinical information based on and supported by clinical guidelines from medical specialties, peer-reviewed medical and scientific studies, nationally recognized utilizat ion and technology assessment guidelines, and other medical management industry standards to aid in determining the medical necessity of a service. Medically necessary services are defined in the plan-specific Evidence of Coverage, Member Handbooks, Provid er Manuals, Medical Policy Statements, and/or other plan policies and procedures. Medical Policy Statements do not guarantee an authorization or payment of services. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced in the Medical Policy Statement. Except as otherwise required by law, if there is a conflict between the Medical Policy Statement and the plan contract and/or provider agreement, then the plan contract and/or provider agreement will be the controlling document.Reasonable discretion may be used in interpreting and ap plying this Policy Statement to services provided in a particular case, and the policy may be modified at any time. Medical Policy Statements may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between t he Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Residential Community Reintegration-AR PASSE-MM-1855Effective Dat e: 12/01/20262A. SubjectResidential Community Reintegration B. BackgroundThe Residential Community Reintegration (RCR) program offers 24-hour intensive therapeutic care in small group homes for children and youth with emotional or behavioral issues not resolved by less intensive treatments. It serves as an intermediate care level between psychiatric facilities and community services, aiming to prevent hos pitalization or incarceration and acting as a step-down to prepare youth for lower – intensity care. RCRs must be certified by the Arkansas Dep t of Human Services (DHS) to ensure quality and safety and provide educational services either on-site or through approved off-campus schooling per the Arkansas Dep t of Education. C. DefinitionsN/A D. PolicyI. General Guidance A. Providers must follow all certification, inspection and accreditation standards set forth by the State of Arkansas. B. Programs must adhere to all treatment planning and records requirements located in the RCR Program Certification Manual or other state resources. CareSource reserves the right to request documentation. C. RCR programs must adhere to the States policies and requirements regarding incident reporting, staff training, and facility environments. II. Program Admission CriteriaCareSource will review requests for medical necessity on a case-by-case basis. Initial authorizations are typically approved for 60-90 days with an expected length of stay of 6-9 months. Continuous assessment of medical necessity is essential, and authorization periods may be adjusted as needed. If there is no demonstrated progress after 3 months and the treatment plan remains unchanged or the family is unwilling to engage, the criteria fo r medical necessity may no longer be satisfied. Members must meet ALL of the following criteria for program admission: A. Child or youth must be ages 4-20 with a confirmed diagnosis of a mental health disorder, substance use disorder (SUD), and/or an intellectual or developmental disabilit y (IDD) diagnosis. B. A completed mental health evaluation determines if the program is appropriate . C. Services are necessary to reduce a risk of readmission to higher levels of care or assist in maintaining a current living situation. D. The p resence of moderate to severe psychiatric, behavioral problems result in difficulties with daily living . E. Conditions, barriers, or environmental factors interfere with stability of underlying psychiatric disorder, as indicated by 1 or more of the following: 1. Current environment (eg, home, school) prevents stabilization of underlying psychiatric or SUD (eg, inability to cope with stressors). Residential Community Reintegration-AR PASSE-MM-1855Effective Dat e: 12/01/202632. Member lacks social supports to assist in care, OR supports are not capable of assisting in care management without therapeutic intervention. F. Lower levels of care do or have not met members treatment needs ( ie, multiple outpatient treatment episodes without long-term success). G. Current or recent involvement with systems (eg, child welfare , juvenile justice ) and documented difficulties in engaging with previous treatments is noted . H. An i ndividual treatment plan from the provider , signed by the mental health professional, and Person-Centered Support Plan (PCSP) documenting service needs is completed OR a recommendation letter from a licensed mental health professional if the treatment plan is unavailable. I. Educational services plan for on-or off-campus education per Ark. Dept of Education guidelines is submitted. III. Continuation of Benefits CriteriaContinuous assessment of medical necessity is essential, and authorization periods may be adjusted as needed. Continuation will be considered for members meeting the following criteria : A. requirements in D.II.A-H above , which include s submission of 1. the most recent treatment plan 2. progress notes from the last 30 days, including all therapy notes 3. psychotherapy (ie, family or individual therapy) notes conducted quarterly at a minimum unless higher standards are promulgated within provider manuals B. 1 of the following progress/revision requirements: 1. The member/family is making satisfactory progress towards meeting goals, and there is documentation supporting that continuation of services will be effective in addressing treatment plan goals . 2. The member/family is making some progress, but specific interventions in the treatment plan need to be modified to yield more success. 3. The member/family has yet to make progress or has demonstrated regression in meeting treatment plan goals . The members diagnosis will be reassessed and treatment plan revised. Alternative or additional services will also be considered and documented in the members record. IV. Discharge Criteria:The member meets criteria for discharge if support systems are in place and any 1 of the following applies: A. Member achieved treatment plan goals . B. The members level of functioning improved with respect to goals in treatment plan, and the member is ready to step down to a lower level of car e. Note: Any child transitioning to a permanent family setting should be considered for Family Centered Treatment . C. If there is no demonstrated progress and the treatment plan remains unchanged or the member is unwilling to engage, the criteria for medical necessity may no longer be satisfied . Residential Community Reintegration-AR PASSE-MM-1855Effective Dat e: 12/01/20264E. Conditions of CoverageI. Members must be eligible for Intensive Level Services as determined by the Arkansas Independent Assessment (ARIA). II. One unit is equivalent to 1 day . Minimum of 15 treatment hours/week . 5 hours a week may be community enrichment activities . A t least 3 hours/encounters per week must be with a licensed mental health professional with a t least 1 hour/encounter per week of individual therapy . A m inimum of 1 encounter per month must occur with a qualified physician, advanced practice registered nurse, or other prescriber . F. Related Policies/RulesMedical Necessity Determinations Nonmedical Community Supports and Services Person-Centered Service Plans Documenting Self-Harm in Residential Setting s G. Review/Revision HistoryDATE ACTIONDate Issued 10/08/2025 New policy. Approved by Committee.Date Revised 09/09 /2026 Annual review. Added D.II.I. & E.II. Updated H. Approved at Committee. Date Effective 12/01/2026 Date Archived H. References1. Contents of Request for a Waiver, 42 C .F.R. 441.301. (2024). 2. Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Provider Manual , Section II . Arkansas Dept of Human Services. Accessed August 25, 2026 . www.humanservices.arkansas.gov 3. Home and Community-Based Setting, 42 C .F.R. 441.530. (2014). 4. Outpatient Behavioral Health Service Update 1-17, Inpatient Psychiatric Services for Persons under Age 21 Update1-17 and Residential Community Reintegration Program Certification. 016.06.17 ARK . CODE R. 015 (2025). 5. Residential Community Reintegration Program. ARK . ADMIN . CODE 016.06.17-015 (2025). 6. Residential Community Reintegration Program Certification Manual . Arkansas Dept of Human Services. Accessed August 25, 2026 . www.humanservices.arkansas.gov 7. Rules for the Division of Medical Services Licensure Manual for Community Support System Providers . Arkansas Dept of Human Services. Accessed August 25, 2026 . www.humanservices.arkansas.gov 8. State Plan Home and Community-Based Services under Section 1915(i)(1) of the Act, 42 C .F.R. 441.710. (2014). 9. Therapeutic Behavioral On-Site Services B-815-T. MCG 30 th ed. Updated January 25, 2026. Accessed August 25, 2026 . www.careweb.caregudelines.com
© Copyright CareSource 2026. All rights reserved.
System Details