Overpayment Recovery

Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbur sement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t 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 federal or state cove rage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) wi ll be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Overpayment Recovery-GA MCD-PY-1112 04/01/2023-05/31/2024 Policy Type REIMBURSEMENT T able of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules …………………………………………………………………………………………… 5 G. Review/Revision History …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 5 Overpayment Recovery-GA MCD-PY-1112 Effective Date: 04/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectOverpayment Recovery B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Retrospective review of claims paid to providers assist CareSource with ensuring accuracy in the payment process. CareSource will request voluntar y repayment from providers when an overpayment is identified. Fraud, waste and abuse investigations are an exception to this policy. In these investigations, the look back period may go beyond 2 years. C. Definitions Claims Adjustment Adjustment is defined as a claim that was previously paid and is being updated for one of the following reasons: o Denied as a zero payment, o A partial payment, o A reduced payment, o A penalty applied, o An additional payment or o A supplemental payment. Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 CFR. o A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Explanation of Payment (EOP) The EOP contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the member. Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. Overpayment Recovery-GA MCD-PY-1112 Effective Date: 04/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. Improper Payment A payment that should not have been made or an overpayment was made. Examples include, but are not limited to: o Payments made for an ineligible member; o Ineligible service payments; o Payments made for a service not received; and o Duplicate payments. Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. Provider Level Balancing (PLB) Adjustments to the total check/remit amount occur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment . (Beginning Segment for Payment Order/Remittance Advice (BPR), which means total payment within the EOP). Forwarding Balance (FB) A n adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past claim has been adjusted to a different dollar amount and that funds are owed to CareSource.D. Policy I. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider: A. The name and patient account number of the member to whom the service(s) were provided; B. The date(s) of services provided; C. The amount of overpayment; D. The reason for the recoupment; and E. That the provider has appeal rights. II. Overpayment Recoveries A. Lookback period is 12 months from the last date of service or discharge. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limit s apply to corrected claims being submitted within original claim timely filing guidelines. III. Coordination of Benefit Recoveries A. Lookback period is 12 months from the last date of service or discharge. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. Overpayment Recovery-GA MCD-PY-1112 Effective Date: 04/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. IV.Retro Active Eligibility RecoveriesA. Lookback period is 12 months from date CareSource is notified by Medicaid of the updated eligibility status.B. Advanced notification will occur 30 days in advance of recovery.C. If the recovery occurs outside of original claim timely filing limits, the correct ed c laim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines.V. M anagement of Claim Credit Balances.A. Regular and routine business practices, including, but not limited to, the updati ng and/ or maintenance of a providers record, can create claim credit balances on a pr oviders record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move apr oviders record into a negative balance in which funds would be owed toCareSource.1. This information will be displayed on the EOP in the PLB section.B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy.1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 w hen adj usted, instead of the $2 difference.b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D.IV.2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D.IV.b. The reduced payment will trigger a 30-day advanced notification with t he det ails related to the claim and overpayment.C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated.D. Providers are notified of negative balances through (EOPs) and 835s.1. Providers are expected to use this information to reconcile and maintain theirAccounts Receivable (AR) to account for the reconciliation of negative balances.E. No tification of negative balances and reconciliation of negative balances may not occur concurrently. 1. Providers are expected to maintain their Accounts Receivable (AR) t o ac count for the reconciliation of negative balances when they occur. Overpayment Recovery-GA MCD-PY-1112 Effective Date: 04/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. VI.In the event of any conflict between this policy and any written agreement betw een t he provider and CareSource, that written agreement will be the governi ng doc ument. E.Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting appro ved HCPCS and C PT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules CareSource Provider Agreement, ARTICLE V. CLAIMS AND PAYMENTS G.Review/Revision History DATE ACTION Date Issued 05/05/2020 New policy Date Revised 10/13/2021 10/26/2022 Updated definitions. Added D.V. and D.VI. Updated references. Approved at PGC. No changes to content. Updated references. Date Effective 04/01/2023 Date Archived 05/31/2024This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal doc umented Policy.H.References 1. Georgia Code (2021). Title 33 Insurance Chapter 20A-Managed Health Car e P lans Article 3-Managed Health Care Plans 33-20A-62. Payment. Retriev ed 10/ 14/2022 from www.law.justia.comGA-MED-P-1696350 Issue Date 05/05/2020 Approved DCH 01/10/2023

Obstetrical Care -Total Cost

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Obstetrical Care -Total Cost -GA MCD-PY-0231 04/01/2023 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding bil ling, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursemen t of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management 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, i llness, or injury and without which the patie nt 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 lowe st 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 federal or state coverage mandate, Evidence of Coverage documents, Medical Policy State ments, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy 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 ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. … 2 B. Background ………………………….. ………………………….. ………………………….. ……………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. …….. 6 H. References ………………………….. ………………………….. ………………………….. ………………………. 6 Obstetrical Care -Tot al Cost -GA MCD-PY-0231 Effective Dat e: 04/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectObstetrical Care Total Cost B. BackgroundObstetrical care refers to health care treatment provided in relation to pregnancy and delivery of a newborn child , including care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members receive in a hospital or birthing center , as well all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the provi ders certification of medical necessity for these services. Proper billing and submission guidelines must be followed , including the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and /or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. C. Definitions Prenatal Profile – Initial laboratory services. Initial and Prenatal Visit – Practitioner visit to determine member is pregnant. Total Obstetrical Care – Includes antepartum care, delivery, and postpartum care. High Risk Delivery – Labor management and delivery for an unstable or critically ill pregnant patient. Premature Birth – Delivery before 37 weeks of pregnancy. Pregnancy – For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days. D. PolicyI. Obstetrical Care A. Initial visit and prenatal profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and Management (E/M) codes are utilized when services are provided to diagnose the pregnancy. These are not part of antepartum care. B. Total obstetrical care for uncomplicated care provided to the member including antepartum, delivery, and postpartum care includes: 1. If a member meets all the following criteria, the practitioner designated in the member s medical record must bill for total obstetrical care under th e practitioners number : a. Member i s eligible for Medicaid for the duration of pregnancy; b. Member i s cared for by one practitioner or group practice for the antepartum care, delivery, and postpartum care , and Obstetrical Care -Tot al Cost -GA MCD-PY-0231 Effective Dat e: 04/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.c. The a ttending physician is designated in the medical record with services billed under that practitioner tax identification number. 2. Billing for total obstetrical care cannot be submitted until the date of delivery. 3. Total obstetrical care cannot be billed for a delivery of less than 20 week s gestation. 4. Total obstetrical care codes are as follows: a. A corresponding obstetrical diagnosis with outcome of birth must be listed on the claim. An ICD-10 code from category Z34 should be listed as the first diagnosis for routine obstetric care. b. Reimbursement is provided for one of the following codes per pregnancy: 5. Modifiers a. A modifier UB, UC, and UD appended to the billed delivery procedure code is required or the delivery claim will be denied. b. Deliveries with modifiers UB or UD must show medical necessity and medical documentation may be requested. c. Use appropriate modifiers (this list may not be all inclusive): Modifier Description22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. UB Medically-necessary delivery prior to 39 weeks of gestation . UC Delivery at 39 weeks of gestation or later . UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) 6. Services (this list may not be all inclusive):CPTCode Description 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps and postpartum care), after previous cesarean delivery 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery Obstetrical Care -Tot al Cost -GA MCD-PY-0231 Effective Dat e: 04/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.Services included that may NOT be billed separately Services excluded and therefore may be billed separately Admission history Greater than 13 antepartum visits due to high – risk condition Admission to hospital Complications of pregnancy Artificial rupture of membranes Surgical complications or other problems related to pregnancy Care provided for an uncomplicated pregnancy including delivery as well as antepartum and postpartum Cephalic version Cesarean delivery Ultrasonography Cesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean delivery Fetal nonstress test Classic cesarean section Maternal or fetal echography Each month up to 28 weeks gestation Fetal echocardiography procedures Every other week from 29 to 36 weeks gestation Fetal biophysical profile Fetal heart tones Amniocentesis, any method Hospital/office visits following cesarean section or vaginal delivery Chorionic villus sampling, any method Initial/subsequent history Fetal contraction stress test Low cervical cesarean section Hospital and observation care visits for premature labor prior to 36 weeks of gestation Management of uncomplicated labor High risk pregnancies requiring more visits or more laboratory data Physical Exams Conditions unrelated to pregnancy i.e. , hypertension, glucose intolerance Recording of weight/blood pressures Treatment and management of complications during the postpartum period that require additional services Routine chemical urinalysis Laboratory tests outside of routine chemical urinalysis Routine prenatal visits Cordocentesis Successful vaginal delivery after previous cesarean delivery OB ultrasounds Patients with previous cesarean delivery who present with the expectation of a vaginal delivery RH immune globulin administration Obstetrical Care -Tot al Cost -GA MCD-PY-0231 Effective Dat e: 04/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.Vaginal delivery with or without episiotomy or forcepsWeekly from 36 weeks until deliveryII. Multiple gestationsA. Include diagnosis code for multiple gestations. B. Total obstetrical care billing for multiple gestations should include one procedure code and a delivery only code for each subsequent delivery with the appropriate diagnosis code and modifier for the multiple gestations. C. When all deliveries are performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 may be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. III. High risk deliveriesA. High risk pregnancy with appropriate trimester should be the first listed diagnosis for prenatal outpatient visits and from the ICD-10 category O09 supervision of high-risk pregnancy. B. Modifier 22 may be added to the delivery code to support sub stantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be allinclusive and is subject to updates.Codes Description59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps and postpartum care), after previous cesarean delivery 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum Obstetrical Care -Tot al Cost -GA MCD-PY-0231 Effective Dat e: 04/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued07/01/2017 New Policy. Date Revised 04/01/2020 10/26/2022New title used to be Global Obstetrical Services policy broken into two policies. Updated definitions, reorganized topics, removed unbundled information, updated most content, included modifiers and updated codes. Periodic review. Editorial changes and reference updates only. Date Effective 04/01/2023 Date Archived H. References 1. Georgia Department of Community Health Division of Medicaid. PART II Policies and Procedures for Physician Services. Retrieved October 19, 2022 from www.mmis.georgia.gov 2. The American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redefining the Postpartum Visit. Retrieved October 19, 2022 from www.acog.org 3. The American College of Obstetricians and Gynecologists. (2011, December). 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery. Modifiers Description 22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 51 To indicate that a second and any subsequent vaginal births occurred identifying multiple procedures were performed 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 59 Distinct procedural services UB Medically-necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) Obstetrical Care -Tot al Cost -GA MCD-PY-0231 Effective Dat e: 04/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.Patient Safety Checklist: Scheduling Induction of Labor. Retrieved October 20,2022 , from www.acog.org 4. The American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Planned Cesarean Delivery. Retrieved October 20, 2022 from www.acog.org 5. The American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Care. Retrieved October 20, 2022 from www.acog.org GA-MED-P-1696350 Issue Date 07/01/2017 Approved DCH 01/10/2023

Obstetrical Care-Unbundled Cost

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Obstetrical Care-Unbundled Cost-GA MCD-PY-0924 04/01/2023 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management 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, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as t he Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy 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 ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addi ction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 8 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 8 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 9 Obstetrical Care-Un bun d led Co st-GA MCD-PY-0924 Effective Dat e: 04/01/2023 A. SubjectObstetrical Care Unbundled CostB. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claim s may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and of fice staf f are encouraged to use self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS)/International Classif ication of Disease-10 (ICD-10) code(s) f or the product orservice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Obstetrical care ref ers to the health care treatment given in relation to pregnancy anddelivery of a newborn child. This include s care during the prenatal period, labor, birthing,and the postpartum period. CareSource covers obstetrical services members r e c e i v e i n a h o s p i t al o r b i r t h i n g c e n t er as w e l l as all associated outpatient services. The services provided must be appropriate to the specif ic medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims f or reimbursement will serve as the providers certif ication of themedical necessity f or these services. Proper billing and submission guidelines must be f ollowed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using CPT codes, HCPCS codes , and/or revenue codes. The codes denote servi ces and/or the procedure performed. The billed codes are required to be fully supported in the medical record.. Unless otherwise noted, this policy is applicable to obstetricians-gynecologists (OB/GYNs),obstetricians (OBs), gynecologists (GYNs), and nur se-midwives. Also, this policy applies only to participating providers and f acilities C. Def initions High risk delivery – Labor management and delivery f or an unstable or critically ill pregnant patient. Initial and Prenatal Visit – Practitioner visit to determine whether member is pregnant . Pregnancy – For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was conf irmed and extends f or 280 days. Premature Birth – Delivery bef ore 3 7 weeks of pr egnancy. Prenatal Profile – Initial laboratory services. Unbundled ( Partial) Obstetrical Care – The practitioner bill s delivery, antepartum care, and postpartum care independently of one another. Obstetrical Care-Un bun d led Co st-GA MCD-PY-0924 Effective Dat e: 04/01/2023 o Antepartum Care (Prenatal) – The initial and subsequent history, physical examinations, recording of weight, blood pressures, f etal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and then weekly visits until delivery. o Delivery Services – Admission to the hospital, the admission history and physical examination, management of uncomplicated labor, vagin al delivery (with or without episiotomy, with or without f orceps), or cesarean delivery. o Postpartum Care – Hospital and of f ice visits f ollowing vaginal or cesarean section delivery . The American College of Obstetricians and Gynecologists (ACOG ) recommends contact within the f irst 3 weeks postpartum and ongoing care a re needed , concluding with a postpartum visit no later than 12 weeks af ter birth. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Prof ile 1. The initial visit and prenatal prof ile are reimbursed separately f rom other obstetrical care. These are to be billed immediately af ter f irst contact. 2. Evaluation and management (E/M) codes are utilized when services were provided to diagnos e the pregnancy. These are not part of antepartum care . B. Unbundled Obstetric Care – Report the services performed using the most accurate, most comprehensive procedure code s available based on what services the practitioner performed. The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. 1. Unbundled o bstetric care s hould be billed when any of the following occur : a. The member has a change of insurer during pregnancy b. The member has received part of the obstetrical care ( antenatal care , deliver, or postpartum care) elsewhere (e.g. f rom another group practice ) c. The member leaves the pratitioners group practice before the global obste trical care is complete d. The member must be ref erred to a provider f rom another group practice or a dif f erent licensure (e.g. midwif e to MD) f or a cesarean delivery e. The member has an unattended precipitous delivery f. Termination of pregnancy without delivery (e.g. miscarriage, ectopic pregnancy) 2. Antepartum care only Antepartum care only does not include delivery or postpartum care : a. Use the appropriate CPT and trimester code (s) : CPT Code DescriptionE/M For antepartum care f or 1-3 visits 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits Obstetrical Care-Un bun d led Co st-GA MCD-PY-0924 Effective Dat e: 04/01/2023 b. For E/M codes, bill with a diagnosis code O09.00 O09.93 , Z33.3;Z34.00-Z34.93 . c. E/M codes f or antepartum care are limited to 3. d. Use the appropriate modif ier (This list may not be all inclusive): NOTE: For Federally Qualif ied Health Centers/Rural Health Clinics(FQHC/RHC) members antepartum E/M visit limits do not apply. Modifier Description24 To indicate that the E/M visit was not related to typical postpartum care during the global period e. Only one code, either 59425 or 59426 can be billed per pregnancy.f. Antepartum care only code includes the f ollowing (This list may not be all inclusiv e): 01. Monthly visits up to 28 weeks gestation 02. Biweekly visits to 36 weeks gestation 03. Weekly f rom 36 weeks until delivery 04. Fetal heart tones 05. Initial/subsequent history 06. Physical exams 07. Recording of weight/blood pressures 08. Physician/other qualif ied health care professional providing all or a portion of antepartum/postpartum care, but no delivery 09. Routine chemical urinalysis 10. Termination of pregnancy by abortion 11. Ref erral to another physician f or delivery . 3. Delivery only – Use i f only a delivery was perf ormed a. Deliveries must be greater or equal to 20 weeks gestation to be billed as a delivery. b. Use the appropriate CPT and delivery outcome code (s): CPT Code Description59409 Vaginal delivery only (with or without episiotomy and/or f orceps) 59514 Cesarean delivery only 59612 Vaginal delivery only, af ter previous cesarean delivery (with or without episiotomy and/or f orceps)59620 Cesarean delivery only, f ollowing attempted vaginal delivery af ter previous cesarean deliveryObstetrical Care-Un bun d led Co st-GA MCD-PY-0924 Effective Dat e: 04/01/2023 c. Services (This list may not be all inclusive) Services included that may NOT be bibilled separately Services excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or f orceps Vaginal delivery af ter prior cesarean sectionPrevious cesarean delivery who present with expectation of vaginal deliverySuccessf ul vaginal delivery af ter previous cesarean deliveryCesarean delivery f ollowing an unsuccessf ul vaginal delivery attempt af ter previous cesarean deliveryCesarean deliveryClassic cesarean section Low cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesiaArtif icial rupturing of membranes prior to delivery Insertion of a cervical dilator f or vaginal delivers when occurs on the same date as delivery Delivery of placenta unless it occurs at a separate encounter f rom the deliveryMinor laceration repairsInpatient management af ter delivery/discharge services E/M services provided within 24 hours of deliveryd. Modif iers 1. A modif ier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. Obstetrical Care-Un bun d led Co st-GA MCD-PY-0924 Effective Dat e: 04/01/2023 2. Deliveries with modif iers UB or UD must show medical necessity and medical documentation may be request ed . e. Use the appropriate modif ier (This list may not be all inclusive):CPT Code DescriptionUB Medically-necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) 4. Delivery and postpartum care only – If only delivery and postpartum care were provided a. Use the appropriate CPT and outcome code: CPT Code Description59410 Vaginal delivery only (with or without episiotomy and/or f orceps);including postpartum care 59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, af ter previous cesarean delivery (with or without episiotomy and/or f orceps); including postpartum care 59622 Cesarean delivery only, f ollowing attempted vaginal delivery af ter previous cesarean delivery including postpartum care b. Modif iers1. A modif ier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 2. Deliveries with modif iers UB or UD must show medical necessity and medical documentation may be requested. c. Services included in the delivery only and postpartum care codes; and theref ore are NOT allowed to be billed separately (This list may not be all inclusive): 1. Admission history 2. Admission to hospital 3. Artif icial rupture of membranes 4. Care provided f or uncompli cated pregnancy including delivery, antepartum, and postpartum care 5. Hospital/of f ice visits f ollowing cesarean section or vaginal delivery 6. Management of uncomplicated labor 7. Physical exam 8. Vaginal delivery with or without episiotomy or f orceps 9. Caesarean deli very 10. Classic cesarean section 11. Low cesarean section 12. Successf ul vaginal delivery af ter previous cesarean delivery Obstetrical Care-Un bun d led Co st-GA MCD-PY-0924 Effective Dat e: 04/01/2023 13. Previous cesarean delivery who present with the expectation of a vaginal delivery14. Caesarean delivery f ollowing unsuccessful vaginal delivery att empt af ter previous cesarean delivery a. Postpartum care only – If postpartum care only was provided: 1. Use code 59430 postpartum care only. 2. Only one 59430 can be billed per pregnancy as this includes all E/M pregnancy related visits provided for postpartum care. 3. There is no specif ied number of visits included in the postpartum code. This includes h ospital and of fice visits f ollowing vaginal or cesarean section delivery. ACOG recommends contact within the f irst 3 weeks postpartum. 4. Postpartum care may include; and theref ore are NOT allowed to be billed separately (This list may not be all inclusive) : a. Hospital, of f ice and outpatient visits f ollowing cesarean section or vaginal delivery b. Qualif ied health care prof essional providing all or portion of antepartum/postpartum care, but no delivery due to ref erral to another physician f or delivery or termination of pregnancy by abortion 5. The f ollowing are billable separately during the postpartum period (This list may not be all inclusive): a. Co nditions unrelated t o pregnancy i.e. respiratory tract inf ection b. Treatment and management of complications during the postpartum period that require additional services II. Member EligibilityA. If a member was not eligible f or Medicaid f or the 9 months before delivery, the practitioner MUST use the appropriate delivery only or delivery and postpartum code to be reimbursed. Charges f or hospital admission, history and physical or normal hospital ev aluation and management services are not reimbursable. B. If a member becomes eligible f or Medicaid due to a live birth, no prenatal services including laboratory services are reimbursable . III. Multiple Gestations.A. Include diagnosis code f or multiple gesta tions . B. Modif ier 51 should be added to the second and any subsequent vaginal births identif ying multiple procedures were performed . C. When all deliveries were perf ormed by a cesarean section, only a single cesarean delivery code is to be reported regardless o f how many cesarean births. D. Modif ier 22 should be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided . IV . High Risk DeliveriesA. High risk pregnancy should be the f irst listed diagnosis for prenatal outpatient visits and f rom the category O09 Supervision of high-risk pregnancy. Obstetrical Care-Un bun d led Co st-GA MCD-PY-0924 Effective Dat e: 04/01/2023 B. Modif ier 22 may be added to the delivery code to support substantial additional work. Documentation must be submit ted with the claim demonstrating the reason and the additional work provided . E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule f or appropriate codes. For antepartum care only (e.g. 59425, 59426) please bill only the f inal date of service rather than the f ull date span; f ailure to do so may result in a timely f iling denial . The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code DescriptionE/M For antepartum care f or 1-3 visits59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59514 Cesarean delivery only 59612 Vaginal delivery only, af ter previous cesarean delivery (with or without episiotomy and/or f orceps) 59620 Cesarean delivery only, f ollowing attempted vaginal delivery af ter previous cesarean delivery 59410 Vaginal delivery only (with or without episiotom y and/or f orceps);including postpartum care 59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, af ter previous cesarean delivery (with or without episiotomy and/or f orceps); including postpartum care 59622 Cesarean delivery only, f ollowing attempted vaginal delivery af ter previous cesarean delivery including postpartum care 59430 Postpartum care only. F. Related Policies/Rules Obs tetrical Care – Hospital Admissions Obstetrical Care – Total Cost G. Review/Revision HistoryDATE ACTIONDate Issued 07/01/2017 New Policy. Date Revised 04/01/2020 09/15/2021New title used to be Global Obstetrical Services policy broken into two policies. Updated def initions, reorganized topics, removed total care inf ormation, updated most content, included modifiers and updated codes. Added Section E. For antepartum care only (e.g. 59425, 59426) please bill only the f inal date of service ra ther than the f ull date span; f ailure to do so may result in a timely f iling Obstetrical Care-Un bun d led Co st-GA MCD-PY-0924 Effective Dat e: 04/01/2023 10/12/2022denial. Added reimbursement policy language. Removed duplicate modif iers. Update Ref erences. Approved at PGC. Added that E/M antepartum visit limitationsdo not apply to FQHC/RHCDate Effective 04/01/2023 Date Archived H. References1. American Academy of Prof essional Coders. (2011, December). Code Obstetrical Care with Conf idence. Retrieved on October 4, 2022 f rom www.aapc.com 2. American College of Obstetricians and Gynecologists. (n.d.). Coding for Postpartum Services (The 4 th Trimester ). Retrieved October 4, 2022 f rom www.acog.org 3. American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Care. Retrieved October 4, 2022 from www.acog.org 4. American College of Obstetricians and Gynecologists. (2011, December). Patient Saf ety Checklist: Scheduling Induction of Labor. Retrieved October 4, 2022 f rom www.acog.org 5. American College of Obstetricians and Gynecologists. (2011, December). Patient Saf ety Checklist: Scheduling Planned Cesarean Delivery. Retrieved October 4, 2022 f rom www.acog.org 6. American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redef ining the Postpartum Visit. Retrieved October 4, 2022 from www.acog.org 7. American College of Obstetricians and Gynecologists. (2019, Jan uary). Preterm Labor and Birth. Retrieved September 13, 2021from www.acog.org 8. American College of Obstetricians and Gynecologists. (n.d.). Reporting a Services with Modif ier 22. Retrieved October 4, 2022 f rom www.acog.org 9. American Medical Association. (1997, April). Global OB Codes: Reporting and Use. CPT Assistant . 10. American Medical Association (2015, January). Maternity Care and Delivery. CPT Assistant. 11. Georgia Department of Community Health Division of Medicaid. Prvider manual f or Physician Services. Retrieved October 4, 2022 f rom www.mmis.georgia.gov GA-MED-P-1643150 Issue Date 07/01/2017 Ap p ro ved DCH 11/26/2022

Modifiers

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Modif iers-GA MCD-PY-1353 04/01/2023 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or suppli es 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 functi on, dysfunction of a body organ or part, or si gnificant 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 inc lude those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Rei mbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan c ontract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may mo dify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the li mitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Mo d ifiers-GAMCD-PY-1353Effective Dat e: 04/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectModifiers B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encouraged to use self-service channels to verify a members eligibility. Reimbursement modif iers are a two-digit code that provide a way f or physicians andother qualif ied health care prof essionals to indicate that a service or procedure has been altered by some specif ic circumstance. Modifiers c an be f ound in the appendices of bothCurrent Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) manuals. Use of a modif ier does not change the code or the codes def inition. Examples of modif iers use includes: To dif f erent iate between the surgeon, assistant surgeon, and f acility f ee claims f or the same procedure; To indicate that a procedure was perf ormed on the left side, right side, or bilaterally; To report multiple procedures performed during the same session by the s ame health care provider; To indicate multiple health care prof essionals participated in the procedure; To indicate a subsequent procedure is due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, use does not guaranteereimbursement. Some modif iers increase or decrease the reimbursement rate, while others do not af f ect the reimbursement rate. CareSource may verif y the use of any modif ier through post-payment audit. Using a modif ier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All inf ormation regarding the use of these modifiers must be made available upon CareSources request. C. Def initions Current Procedural Terminology (CPT) – Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language f or coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) – Codes that are issued, updated and mainta ined by the American Medical Association (AMA) that provide a standard language f or coding and billing of products, supplies, and services not included in the CPT codes. Modifier – Two-character codes , used along with a CPT or HCPCS code , to provide addit ional inf ormation about the service or supply rendered. Mo d ifiers-GAMCD-PY-1353Effective Dat e: 04/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is approved.D. PolicyIt is the responsibility of the submitting provider to submit accurate documentation of services perf ormed. Providers are expected to use the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided according to the f ollowing industry standard guidelines (may not be all-inclusive): National Correct Coding Initiative (NCCI) editing guidelines; American Medical Association (AMA) guidelines; American Hos pital Association (AHA) billing rules; Current Procedural Terminology (CPT); Healthcare Common Procedure Coding System (HCPCS); ICD-10 CM and PCS; National Drug Codes (NDC); Diagnosis Related Group (DRG) guidelines; and CCI table edits. The inclusion of a code in a policy does not imply any right to reimbursement or guarantee claims payment. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved CPT/HCPCS codes along with appropriate mo dif iers, if applicable. Please ref er to the individual Georgia Medicaid f ee schedule f or appropriate codes. Providers must f ollow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modif iers must be f ully supported in the medical recordand/or of f ice notes. Unless otherwise noted within the policy, CareSource policies apply to both participating and nonparticipating providers and f acilities. In the event of any conf lict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/Rules NA G. Review/Revision HistoryDATE ACTIONDate Issued 01/20/2022 New PolicyDate Revised 10/12/2022 No changes. Update ref erences. Date Effective 04/01/2023 Date Archived H. Ref erences1. Billing 340B Modif iers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved 09/30/2022 f rom www.cms.gov. 2. CPT overview and code approval. (2022, September 30). Retrieved 09/30/2022 f rom www.ama-assn.org. Mo d ifiers-GAMCD-PY-1353Effective Dat e: 04/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is approved.3. Medicare Claims Processing Manual Chapter 12 – Physicians/NonphysicianPractitioners. (2022, March 4). Retrieved 09/30/2022 f rom www.cms.gov. 4. Medic are Claims Processing Manual Chapter 14 – Ambulatory Surgical Centers. (2017, December 22). Retrieved 09/30/2022 f rom www.cms.gov. 5. Optum360 EncoderProForPayers.com – Login. (2022, September 30) Retrieved 09/30/2022 from www.encoderprofp.com. GA-MED-P-1643150 Issue Date 01/20/2022 Ap p ro ved DCH 11/26/2022

Coordination of Benefits

REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Coordination of Benefits-GA MCD-PY-1344 04/01/2023 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or suppli es 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 functi on, dysfunction of a body organ or part, or si gnificant 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 inc lude those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Rei mbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan c ontract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may mo dify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the li mitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. … 2 B. Background ………………………….. ………………………….. ………………………….. ……………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. …….. 6 H. References ………………………….. ………………………….. ………………………….. ………………………. 6 Coordination of Benefits-GA MCD-PY-1344Effective Dat e: 04/01/2023The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectCoordination of Benefits B. BackgroundThe purpose of this guideline is to define the order of coverage and how CareSource will coordinate benefit payments as the secondary payer. CareSource shall coordinate payment for covered services in accordance with the termsof a members benefit plan, applicable state and federal laws, and applicable CMSguidance. If CareSource is not the primary carrier, providers shall bill the primary carrier for all services provide d before submi tting claims to CareSource. Any balance due after receipt of payment from the primary carrier should be submitted to Care Source for conside ration. The claim must include information verifying the services billed and the payment amount received from the primary carrier. C. Definitions CareSource Provider Agreement The contract between provider and plan for the provision of services by provider s to individuals enrolled with the plan, including but not limited to contracts titled Provider Agreement and Group Practice Services Agreement . Coordination of Benefits (COB) The process of determining which health plan or insurance policy will pay first and/or determining the payment obligations of each health plan, medical insurance policy, or third party resource when two or more health plans, insurance policies , or third party resources cover the same benefits for CareSource members. Explanation of Payment (EOP) A detailed explanation of payment or denial of a claim by an insurance carrier. Primary Carrier The insurance carrier that has been determined to be respon sible for primary payment. D. PolicyI. Submitted claims must include total amount billed, total amount paid by primary carrier, and balance due, along with a valid provider signature. Any balance due after receipt of payment from the primary carrier should be submitted to CareSource for consideration and the claim must include information verifying the payment amount received from the primary plan. II. COB GuidelinesA. When CareSource coordinates benefits with the primary carrier, reimbursement will be made according to the Medicaid contracted maximum allowable minus any payment made by the primary carrier. Any items or services for which another carriers reimbursement amount is equal to or greater than the Medicaid contracted maximum allowable amou nt will be paid at zero. Claims that pay at zero are considered to be paid claims, not denied claims. Coordination of Benefits-GA MCD-PY-1344Effective Dat e: 04/01/2023The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.B. When the payment from another insurance carrier is less than the Medicaid contracted amount, CareSource will pay up to the Medicaid contracted total allowed amount. The sum of the payments will not exceed the Medicaid contracted maximum allowable amount , as indicated in the CareSource ProviderAgreement . Example 1: Charged Amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $50.00 $10.00 $0 $0 $40.00 CareSource $35.00 $0.00 Summary : In this example, since the primary carrier paid amount of $40.00 is to the Medicaid contracted allowed amount of $35.00, then CareSource pays zero , as indicated in the CareSource Provider Agreement . Example 2: Charged Amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $80.00 $50.00 $0 $0 $30.00CareSource $40.00 $10.00 Summary : In this example, subtract the primary paid amount of $30.00 from theMedicaid contracted allowed amount of $40.00. CareSource will pay $10.00 , as indicated in the CareSource Provider Agreement . Example 3: Charged Amount $200. 00Carrier Allowed Co-pay Deductible Co-Insurance Paid Primary Insurance $200.00 $0 $200.00 $0 $0.00 CareSource $125.00 $125.00 Summary : In this example, subtract the primary paid amount of $0 from theMedicaid contracted allowed amount of $125.00. CareSource will pay $125.00 ,which is the total allowed amount as indicated in the CareSource Provider Agreement . Example 4: Charged Amo unt $200.00Carrier Allowed Co-pay Deductible Co-Insurance Paid Primary Insurance $150.00 $0 $100.00 $40.00 $10.00 CareSource $125.00 $115.00 Coordination of Benefits-GA MCD-PY-1344Effective Dat e: 04/01/2023The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.Summary : In this example, subtract the primary paid amount of $10.00 from theMedicaid contracted allowed amount of $125.00. CareSource will pay $115.00 , as indicated in the CareSource Provider Agreement . Example 5: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $150.00 $30.00 $100.00 $0 $20.00CareSource $200.00 $180.00 Summary : In this example, subtract the primary paid amount of $20.00 from theMedicaid contracted allowed amount of $200.00. CareSource will pay $180.00 , as indicated in the CareSource Provider Agreement . C. Non-Contracted ProvidersWhen the payment from another insurance carrier is less than the CareSource Medicaid non-participating reimbursement rate, the sum of the payments will not exceed the Care Source Medicaid n on-participating reimbursement rate. III. COB Timely Filing GuidelinesA. If a provider is aware that a member has primary coverage, the provider should submit a copy of the primary payers EOP along with the claim to CareSource, within the c laims timely filing period. 1. If CareSource receives a claim for a member that we have identified as having other coverage and a primary payer EOP was not submitted with the claim(s), CareSource will deny the claim(s) requesting the required COB informat ion. 2. If a claim is denied for COB information needed, the provider must submit the primary payers EOP. If the initial timely filing period has elapsed, the EOP must be submitted to CareSource within 90 days from the primary payers EOP date. B. If a provider has information that the primary payers policy has terminated or was not in effect during the date of service for the claim(s), the provider must notify CareSource of the dispute within the original timely filing period or within 90 days of t he providers actual receipt of the primary payer s EOP date, whichever is greater. C. If the dispute is received within the original timely filing period: 1. CareSource will confirm whether or not the primary payer was in effect during the date of servi ce. If the policy was NOT in effect, CareSource will process the claim(s) that are within the original timely filing period or 90 days of the providers actual receipt of the payer s EOP date. 2. If the policy was in effect, the claim will remain denied for lack of primarypayer s EOP.D. If the provider does not notify CareSource of the dispute within the original timely filing period or if the provider does not submit the primary payer s EOP within 90 Coordination of Benefits-GA MCD-PY-1344Effective Dat e: 04/01/2023The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.days of the providers actual receipt of the primary pa yer s EOP date, the claim will re-deny as not being timely filed. IV. COB Claim Submission to CareSourceA. CareSource follows The Health Insurance Portability and Accountability Act (HIPAA ) guidelines and accepts industry standard codes. It is imperative that claims are filed with the same codes that the primary payer presented on the EOB to ensure that claims are processed correctly. Claim(s) will be denied if there is a mismatch be tween the codes on the received claim and the primary payers EOP. B. CareSource applies standard claim adjustment codes . C. Claim Adjustment Group Codes are as follows: 1. CO Contractual Obligation ; 2. OA Other Adjustment ; 3. PI Payer Initiated Re ductions ; or 4. PR Patient Responsibility . D. When filing claims with patients responsibility, the following Claim Adjustment Reason Codes should be used: 1. PR1 Deductible ; 2. PR2 Coinsurance ; or 3. PR3 Copayment . E. When filing claims with contr actual obligation, please use Adjustment Group Code CO. Contractual obligation can be communicated on the primary payers EOB with several different codes. Use the code reflected on the primary payers EOB. Some examples of these codes are: 24, 4 5, 222, P24, P25, and 26. The same process should be followed when using Adjustment Group Code OA Other Adjustment. V. Denied COB ClaimsA. Denied COB claims w ill be automatically adjusted when primary insurance has been updated retroactively to show coverage was terminated at the time of service AND the claim was denied for COB within 90 days of CareSource receiving the notification. B. Denied COB claims w ill NOT be automatically adjusted if the updated coverage information was received after 90 days from the denial for COB information. In this case, the provider must request claim adjustment within the original timely filing period or within 90 days from the d ate of the EOP denial, whichever is greater. Although CareSource is implementing this COB Adjustment Policy, it is still the providers responsibility to review their accounts and submit COB claims in a timely manner for payment. VI. Disputes for Denied COB ClaimsA If a provider has information that the primary carriers policy has terminated or was not in effect during the date of service for the claim(s), the provider must notify CareSource of the dispute within the original timely filing period or within 90 days o f the original denial date or 90 days from the primary carriers EOP date, Coordination of Benefits-GA MCD-PY-1344Effective Dat e: 04/01/2023The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.whichever is greater. If the dispute is received within the original timely filing period or within 90 days of the original denial date:B. CareSource will confirm whether or not the primary coverage was in effect during the date of service. If the policy was NOT in effect, CareSource will process the claim(s) that are within the original timely filing period. If the initial timely filing period has elapsed, then CareSource will proce ss the claims that are within 90 days of the original denial. If the policy was in effect, the claim will remain denied for needing primary carriers EOP. If the provider does not notify CareSource of the dispute within the original timely filing period, w ithin 90 days of the CareSource denial, or if the provider does not submit the primary carriers EOP within 90 days of the primary carrier s EOP date, the claim will re-deny as not being filed timely. E. Conditions of CoverageReimbursement is dependent on , but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 10/13/2021 New policy. Approved at PGCDate Revised 11/30/2022 Editorial and reference updates only. Date Effective 04/01/2023 Date Archived H. References1. Georgia Department of Community Health. Medicaid/PeachCare for Kids Provider Billing Manual (Version 1.29 ). Retrieved November 11, 2022 from www.mmis.georgia.gov . 2. CareSource Georgia Medicaid Provider Manual ( March 2020). Retrieved November 11, 2022 from www.caresource.com . GA-MED-P- 1748853 Issue Date 10/13/2021 Approved DCH 01/19/2023

JW Modifier – Drug Waste – Archived on 01/01/2024

REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date JW Modifier Drug Waste PY-PHARM-0092 01-22-2022Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing lo gic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management 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 patien t 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 lowes t 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 federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy 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. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify thi s Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitatio ns that apply to medical conditions as covered under this policy. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. 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 ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Modifier JW Reimbursement Statement GEORGIA MEDICAID PY-PHARM-0092 Effective Date: 01-22-2022 2 A. Subject This policy provides guidelines for the documentation and reimbursement of discarded drug wastage from single dose injectable vials. B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routine ly updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims paymen t. This policy describes documentation requirements and reimbursement guidelines for billing of the discarded portion of drugs and biologicals . Providers shall bill and receive reimbursement for both the dose administered and the unused portion of weigh t-based or variable dosing injectable drugs that are manufactured and supplied only in single dose or single use format. The discarded portion of single use or single dose vials must be identified with the JW Modifier as a separate line item from the dose or administered portion. Providers may be reimbursed for the discarded portion s of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropria tely reported based on the policy reimbursement guidelines. C. Definitions Modifie r JW refers to the drug amount discarded (wasted) /not administered to any patient. Discarded Wastage or Unused Portion is defined as the amount of a single use/dose vial or other single use/dose package that remains after administering a dose/quantity of a drug or biological. Single Dose Vial is defined as a vial of medication intended for administration by injection or i nfusion that is meant for use in a single patient for a single procedure. These vials are labeled as single-dose or single-vial by the manufacturer and typically, do not contain a preservative. Multi-Dose Vial is defined as a vial of medication intended fo r administration by injection or infusion that contains more than one dose of medication. These vials are labeled as multi-dose by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. Archived Modifier JW Reimbursement Statement GEORGIA MEDICAID PY-PHARM-0092 Effective Date: 01-22-2022 3 D. Policy Modifier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modifier JW. Both details are reimbursable. CareSource w ill consider reimbursement for: I. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not adminis tered to another patient. CareSource will NOT consider reimbursement for: I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed without using th e most appropriate size vial, or combination of vials, to deliver the administered dose. E. Conditions of Coverage Providers must not use the JW modifier for medications manufactured in a multi-dose vial format. Providers must choose the most appropriate vial size(s) required to prepare a dose to minimize waste of the discarded portion of the injectable vials. Claims considered for reimbursement must not exceed the package size of the vial used for preparation of the dose. Providers must not bill for vial contents overfill. Providers must not use the JW modifier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modifer is only applied to the amount of drug or biologi cal that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modifier. I. Claim Line #1 HCPCS code for drug administered and the amount admistered to the patient. II. Claim Line #2 HCPCS code for drug discarded (wasted) with JW modifier appended to indicate waste and the amount discarded (wasted). Note: In the event of any conflict between this policy and a providers contract with CareSource, the providers contrac t will be the governing document. F. Related Policies/Rules Chapter 17, Section 40.1 of CMS Medicare Claims Processing Manual ArchivedModifier JW Reimbursement Statement GEORGIA MEDICAID PY-PHARM-0092 Effective Date: 01-22-2022 4 G. Review/Revision History DATE ACTION Date Issued Date Revised Date Effective 01-22-2022 Date Archived H. References 1. https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/downloads/jw-modifier-faqs.pdf 2. https://www.k map-state-ks.us/Documents/Content/Bulletins/16226%20 – %20General%20 -%20Modifier%20JW.pdf 3. https://www.mmis.georgia.gov/portal/portals/0/staticcontent/public/all/handbooks/padl%20man ual%20 – %20%20published%20copy%20 – %2010-2021%2020211001142053.pdf The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived

Modifier 59 XE XP XS XU

REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 01/01/2023-11/30/2023 Policy Type REIMBURSEMENT Table of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 4 F. Related Policies/Rules ……………………………………………………………………………………………. 5 G. Review/Revision History …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 5 Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management 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 an y federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy 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. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A.Subject Modifier 59, XE, XP, XS, XU B. Background Reimbursement policies are designed to assist physicians when submitting claims t o C areSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will bees tablished based upon a review of the actual services provided to a member and will be det ermined when the claim is received for processing.Reimbursement modifiers are two-digit codes that provide a way for physicians and ot her qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate.CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifi ers must be made available upon CareSources request.The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when two Healthcare Common Procedure Coding System(HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together, but are appropriate under the patients specific circumstance.National Correct Coding Initiative (NCCI) guidelines state that providers should not us e m odifier 59 solely because two different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the tw o pr ocedures/s urgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance.The Centers for Medicare and Medicaid Services (CMS) established four HCPCSmodifiers to define specific subsets of modifier 59:XE Separate Encounter, a service that is distinct because it occurred during a s eparate encounterXP Separate Practitioner, a service that is distinct because it was performed by a di fferent practitionerXS Separate Structure, a service that is distinct because it was performed on a s eparate organ/structureXU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standar d l anguage for coding and billing medical services and procedures.Healthcare Common Procedure Coding System (HCPCS) Codes that ar e i ssued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes.Modifier Two-character code used along with a CPT or HCPCS code to provi de addi tional information about the service or procedure rendered. D.Policy I. CareSource reserves the right to audit any submission at any time to ensure correct coding standards and guidelines are met.II. It is the responsibility of the submitting provider to submit accurate documentation of services performed when requested from CareSource. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial.III. Provid er claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding audit. Once the claim has been clinically validated , it is either released for payment or denied fo r i ncorrect use of the modifier. IV. Modifiers X {EPSU} should be used prior to using modifier 59. V. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available.Documentation should support a different session, different procedure or surgery,different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty.A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgica l t herapeutic procedures, or diagnostic procedures that:1. Are performed at different anatomic sites; and2. Are not ordinarily performed or encountered on the same day; and3. C annot be described by one of the more specific anatomic NCCI Procedur e to P rocedure (PTP) -associated modifiers (i.e., RT, LT, E1-E4, FA, F1-F9, TA,T1-T9, LC, LD, RC, LM, RI). Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. B.Modifier XE (or 59, when applicable) is for surgical procedures, non-surgica l t herapeutic procedures, or diagnostic procedures that:1. Are performed during different patient encounters; and2. Cannot be described by one of the more specific NCCI PTP-associated modifiers (i.e., 24, 25, 27, 57, 58, 78, 79, 91).C. Modifier XE (or 59, when applicable) may also be used when two tim ed pr ocedures are performed during the same encounter but occur one after another (the first service must be completed before the next service begins).D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgica l t herapeutic procedures, or diagnostic procedures that:1. Are performed at separate anatomic sites; or2. Are performed at separate patient encounters on the same date of service.E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedur e i s performed before a therapeutic procedure only when:1. The diagnostic procedure is the basis for performing the therapeutic procedure; and2. It occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires; and3. Provides clearly the information needed to decide whether to proceed with the therapeutic procedure; and4. Does not constitute a service that would have otherwise been required duri ng t he therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately.F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedur e i s performed after a therap eutic procedure only when:1. The diagnostic procedure is not a common, expected, or necessary follow – up t o the therapeutic procedure; and2. It occurs after the completion of the therapeutic procedure and is not mingl ed w ith or otherwise mixed with services that the therapeutic interventi on r equires; and3. D oes not constitute a service that would have otherwise been required duri ng t he therapeutic intervention. If the post-procedure diagnostic procedure is an i nherent component or otherwise included (e.g., not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately. E. Conditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual f ee s chedule for appropriate codes.Providers must follow proper billing, industry standards, and state compliant codes on a ll c laims submissions. The use of modifiers must be fully supported in the medical recor d and/ or office notes. Unless otherwise noted within the policy, this policy applies to both participating and nonparticipating providers and facilities. Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. F.Related Policies/Rules Modifier 2 5 M odifiers G. Review/Revision History DATE ACTION Date Issued 08/17/2022 Date Revised Date Effective 01/01/2023 Date Archived 11/30/2023 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H.References 1. Centers for Medicare & Medicaid Services. General Correct Coding Policies forNational Correct Coding Initiative Policy Manual for Medicare Services. RevisedJanuary 1, 2022. Retrieved June 24, 2022 from www.cms.gov.2. C enters for Medicare & Medicaid Services. (2022 March). Medicare ClaimsProcessing Manual Chapter 12 Physicians/No nphysician Practitioners. Rev.11288. Retrieved June 24, 2022 from www.cms.gov.3. C enters for Medicare & Medicaid Services (2022 March). MLN1783722-Proper Use of Modifiers 59 & – X{EPSU}. Retrieved July 12, 2022 from www.cms.gov.4. C enters for Medicare & Medicaid Services. (2022). National Correct Coding Initiativ e ( NCCI) Tool.5. Centers for Medicare & Medicaid Services (2014 August). Transmittal R1422OTN-Publication 100-20-MM8863-Specific Modifiers for Distinct Procedural Services.Retrieved July 12, 2022 from www.cms.gov. GA-MED-P-1531850 Issue Date 8/17/2022 Approved DCH 9/30/2022

Modifier 25

REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Modifier 25-GA MCD-PY-1361 01/01/2023-11/30/2023 Policy Type REIMBURSEMENT Table of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 4 F. Related Policies/Rules ……………………………………………………………………………………………. 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 4 Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In additi on to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management 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 federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan cont ract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy 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. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Modifier 25-GA MCD-PY-1361 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A.Subject Modifier 25 B. Background Reimbursement policies are designed to assist physicians when submitting claims t o C areSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will bees tablished based upon a review of the actual services provided to a member and will be det ermined when the claim is received for processing. CareSource may verify the us e of any modifier through prepayment and post-payment edit or audit.Reimbursement modifiers are a two-digit code that provide a way for physicians and ot her qualified health care professionals to indicate that a service or procedure has been altered by s ome specific circumstance. Modifier-25 is used to report an Evaluati on and M anagement (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American MedicalAssociati on (AMA) Current Procedural Terminology (CPT) book defines modifier-25 as a significant, separately identifiable evaluation and management service by the sam e phy sician or other qualified health care professional on the same day of the procedure o r ot her service. There must be documentation that substantiates the use of modifier-2 5 pr ovided in the medical record.It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to b e r eported (see Evaluation and Management Services Guidelines for instructions ondet ermining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier-25 to the appropriate level of E/Mservice. Note: This modifier is not used to report an E/M service that resulted i n a dec ision to perform surgery. See modifier-57. For significant, separately identifiabl e non -E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbur sement rate, whil e ot hers do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursem ent for apr oduct or service. All information regarding the use of these modifiers must be made available upon CareSources request. CareSource uses published guidelines from CPT Modifier 25-GA MCD-PY-1361 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly. C.Definitions C urrent Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standar d l anguage for coding and billing medical services and procedures. H ealthcare Common Procedure Coding System (HCPCS) Codes that issued,updated, and maintained by the American Medical Association (AMA) that provides a s tandard language for coding and billing products, supplies, and services not included in the CPT codes. M odifier Two-character code used along with a CPT or HCPCS code to provi de addi tional information about the service or procedure rendered. D.Policy I. It is the responsibility of the submitting provider to submit accurate documentation o f s ervices performed. Failure may result in prepayment and post-payment audit and unpai d claims.II.Provider claims billed with modifier-25 may be flagged for either a prepayment clinical validation or prepayment medical record coding audit and also be selected fo r a pos t payment medical record review. Once the claim has been clinically validated,it is either released for payment or denied for incorrect use of the modifier.III. Modifier-25 may only be used to indicate that a significant, separately identifiabl e ev aluation and management service [was provided] by the same physician on t he s ame day of the procedure or other service. If documentation does not support th e us e of modifier-25, the code may be denied.IV. Appending modifier-25 to an E/M service is considered inappropriate in the following circumstances:A. The initial decision to perform a major procedure is made during an E/M servic e t hat occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period.B. The E/M service is reported by a qualified professional provider other than th e qual ified professional provider who performed the procedure.C. The E/M service is performed on a different day than the procedure.D. The modifier is reported with an E/M service that is within the usual pre-operative or pos t-operative care associated with the procedure.E. The modifier is reported with a non-E/M service.F. The reason for the office visit was strictly for the minor procedure sinc e r eimbursement for the procedure includes the related pre-operative and post-operative service.G. The professional provider performs ventilation management in addition to an E/ M se rvice. Modifier 25-GA MCD-PY-1361 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. H.The preventative E/M service is performed at the same time as a preventativ e c are visit (e.g., a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Sinc e bot h services are preventative, only one should be reported.I. The routine use of the modifier is reported without supporting clinica l doc umentation. E.Conditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual f ee s chedule for appropriate codes.Providers must follow proper billing, industry standards, and state compliant codes on a ll c laims submissions. The use of modifiers must be fully supported in the medical recor d and/ or office notes. Unless otherwise noted within the policy, this policy applies to bot h par ticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document. F. Related Policies/Rules Modifiers G. Review/Revision History DATE ACTION Date Issued 08/17/2022 New Policy Date Revised Date Effective 01/01/2023 Date Archived 11/30/2023 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H.References 1. American College of Cardiology Foundation. (2022). Appropriate Use of Modifier 25. Retrieved June 17, 2022 from www.acc.org.2. C enters for Medicare and Medicaid Services. Chapter 1 General Correct Codi ng P olicies for National Correct Coding Initiative Policy Manual for Medicare Services.Revised January 1, 2022. Retrieved June 17, 2022 from www.cms.gov.3. C enters for Medicare & Medicaid Services. (2022). National Correct Coding Initiative(NCCI) Tool. CPT Modi fier 25. Retrieved June 17, 2022 from www.palmettogba.com.4. C enters for Medicare and Medicaid Services. (Rev. 11288, 2022, March 4). MedicareClaims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners.Retrieved June 17, 2022 from www.cms.gov. Modifier 25-GA MCD-PY-1361 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5. Felger TA, Felger M. Understanding when to use modifier-25. Fam Pract Manag. 2004;11(9):21-22. Retrieved June 17, 2022 from www.aafp.org.GA-MED-P -1531850 Issue Date 8/17/2022 Approved DCH 9/30/2022

Standard Medical Billing Guidance

REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Standard Medical Billing Guidance PY-PHARM-0123 – GA-MCD 07-22-2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. . 2 B. Background ………………………….. ………………………….. ………………………….. …………………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……………….. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ………. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ……. 4 H. References ………………………….. ………………………….. ………………………….. ……………………… 5 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry – stan dard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity , adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management 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, dysfun ction 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. Med ically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy 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. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. 2 A. SubjectStandard Medical Billing Guidance Standard Billing Reimbursement Statement GEORGIA MEDICAID PY-PHARM-0123-GA MCD Effective Date: 07-22-2022 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligib ility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimburse ment or guarantee claims payment. This reimbursement policy applies to all health care services reported using the CMS1500 Health Insurance Professional Claim Form (a/k/a HCFA), the CMS 1450 Health Insurance Institutional Claim Form (a/k/a UB04) or its electronic equivalent or any successor form. This policy applies to all products, all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract phy sicians and other qualified health care professionals. Additionally, this policy applies to drugs and biologicals being used for FDA-approved indications or labels. Drugs and biologicals used for indications other than those in the approved labeling may be covered if it is determined that the use is medically accepted, taking into consideration the major drug compendia, authoritative medical literatures and/or accepted standards of medical practice. C. Definitions Indication is defined as a diagnosis, illness , injury, syndrome, condition, or other clinical parameter for which a drug may be given. is defined as birth before 37 weeks of gestation. FDA approved Indication/Label is the official description of a drug product which includes indication (what the drug is used for); who should take it; adverse events (side effects); instructions for uses in pregnancy, children, and other populations; and safety information for the patient. Labels are often found inside drug product packaging. Off-label/Unlabeled use of a drug is defined as a use for a non-FDA approved indication, that is, one that is not listed on the drugs official label/prescribing information. Off-label use is further defined as giving the drug in a way that deviates significantly from the labeled prescribing information for a particular indication. This includes but is not necessarily limited to, dosage, route of administration, duration and frequency 3 of administration, and population to whom the drug would be administered.4 Standard Billing Reimbursement StatementGEORGIA MEDICAID PY-PHARM-0123-GA MCD Effective Date: 07-22-2022 Unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label. Drug compendia , defined as summaries of drug information that are compiled by experts who have reviewed clinical data on drugs. CMS (Center for Medicare and Medicaid Services) recognizes the following compendia: American Medical Association Drug Evaluations (AMA-DE), United States Pharmacopoeia-Drug Information (USP-DI) or its successor publication and American Hospital Formulary Service-Drug Information (AHFS-DI) as authoritative sources for use in the determination of a “medically-accepted indication” of drugs and biologicals used off – label in an anticancer chemotherapeutic regimen. The USP DI is a database of drug information developed by the U.S. Pharmacopoeia but maintained by Micromedex, which contains medically accepted uses for generic and brand name drug products D. PolicyCareSource requires t hat the use of a drug or biological must be safe and effective and otherwise reasonable and necessary. Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for indications specified on the labeling. Therefore, reimbursement may be provided for the use of an FDA approved drug or biological, if: It was administered on or after the date of the FDAs approval; It is reasonable and necessary for the individual patient; and All other applicable coverage requirements are met. An unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is ind icated on the official label may be covered if it is determined that the use is medically necessary, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. The following guideline s identify three categories in which medications would not be reasonable and necessary according to accepted standards of medical practice. Not for Particular Illness Medications given for a purpose other than the treatment of a particular condition, illness, or injury are not covered (except for certain immunizations.) Route of Administration Not Indicated Medication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medi cation by mouth (orally) is effective and is an accepted or preferred method of administration. Excessive Medications Medications administered for treatment of a disease which exceed the frequency or duration of dosing indicated by accepted standards of medical practice are not covered. Effective January 1, 1994, off-label, medically accepted indications of Food and Drug Administration -(FDA) approved drugs and biologicals used in an anti-neoplastic chemotherapeutic regimen are identified under the indicat ions described below. A 5 Standard Billing Reimbursement StatementGEORGIA MEDICAID PY-PHARM-0123-GA MCD Effective Date: 07-22-2022 regimen is a combination of anti-neoplastic agents clinically recognized for the treatment of a specific type of cancer. Off-label, medically accepted indications are supported in either one or more of the compendia or in peer-reviewed medical literature. E. Conditions of CoverageA medically accepted indication is one of the following: An FDA approved , labeled indication or a use supported in the American Hospital Formulary Service Drug Information (AHFS-DI), NCCN Drugs and Biologics Compendium, Truven Health Analytics Micromedex Drug Dex , Elsevier/Gold Standard Clinical Pharmacology and Wolters Kluw er Lexi – Drugs as the acceptable compendia based on CMS’ Change Request 6191 (Compendia as Authoritative Sources for Use in the Determination of a “Medically Accepted Indication” of Drugs and Biologicals Used Off-Label in an Anti-Cancer Chemotherapeutic Regimen); or Articles of Local Coverage Determinations (LCDs) published by CMS. In general, a use is identified by a compendium as medically accepted if the: Indication is a Category 1 or 2A in NCCN, or Class I, Class IIa, or Class IIb in DrugDex; or, Narrative text in AHFS-DI or Clinical Pharmacology is supportive, or Indication is listed in Lexi-Drugs as Use: Off-Label and rated as Evidence Level A A use is not medically accepted by a compendium if the: Indication is a Category 3 in NCCN or a Class III in DrugDex; or, Narrative text in AHFS or Clinical Pharmacology is not supportive, or Indication is listed in Lexi-Drugs as Use: Unsupported If a use is identified as not indicated by CMS or the FDA, or if a use is specifically identified as not indicated in one or more of the compendia listed, or if it is determined, based on peer-reviewed medical literature, that a particular use of a drug is not safe and effective, the off-label use is not supported and the drug w ill not be covered. F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate IssuedDate Revised Date Effective TBD Date Archived 6 Standard Billing Reimbursement StatementGEORGIA MEDICAID PY-PHARM-0123-GA MCD Effective Date: 07-22-2022 1. Drugs@FDA Glossary of Terms https://www.fda.gov/drugs/drug-approvals-and-databases/drugsfda-glossary-terms 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals 3. United States Federal Food, Drug and Cosmetic Act https:/ /www.f da.gov/regulatory-information/laws – enforced-fda/federal-food-drug-and-cosmetic-act-fdc-act The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. H. References

Interest Payments

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Interest Payments-GA MCD-PY-1326 10/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of serv ice, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management 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, i llness, 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 mem ber or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures . This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy 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 ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Poli cy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 Interest Payments-GA MCD-PY-1326 Effective Date: 10/01/2022 The REIMBURSEMENT Polic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.A. SubjectInterest Pay ments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any ri ght to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and additional elements, or revisions to data elements, of which the provider has knowledge. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by State and/or Federal regulation defining timeliness and interest requirements. D. Policy I. CareSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations. ( O.C.G.A. 33-24-59.5, O.C.G.A. 33-21A-7 (Second Pass)) II. Payment of interest on original claims is made when CareSource fails to adjudicate original claims within the applicable state and federal prompt pay timeframes on clean claims. III. Payment of interest on adjusted claims st arts on the date the provider disputes the original payment with CareSource. IV. CareSource considers interest payment on claims that were not paid accurately on prior processing attempts. If CareSource had the information to pay the claim correctly on a prev ious payment but failed to do so, CareSource will pay the claim Interest Payments-GA MCD-PY-1326 Effective Date: 10/01/2022 The REIMBURSEMENT Polic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.within the allotted timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe. V. CareSource only pays interest on claim payment that is occurring under prompt pay regulations. A contractual adjustment of a claim is not subject to state and federal regulations for interest payment. VI. CareSource performs regular reviews of our paid claims to correct claim payment. A. Reviews can include items , such as retroactive eligibility updates, authorization updates, coordination of benefits (COB) updates, and fee schedule updates. B. Reviews include proactive measures to correct claim payment when it has been determined that a systemic issue has paid claims incorrectly. C. Claims are not subject to interest payment when CareSource takes proactive measures to pay claims correctly.E. Condit ions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. F. Related Policies/Rules NA G. Revie w/Revision History DATE ACTIONDate Issued 03/31/2021 New PolicyDate Revised 04/27/2022 No changes; Updated references Date Effective 10/01/2022 Date Archived H. References1. Bureau of the Fiscal Service. (2013, January-2021, June). Interest Rates. Retrieved April 5, 2022 from www.fiscal.treasury.gov . 2 . Centers for Medicare & Medicaid Services. (2019, January). Notice of New Interest Rate for Medicare Overpayments and Underpayments-2nd Qtr. Retrieved April 5, 2022 from www.cms.gov . 3. Federal Register. Prompt Payment Interest Rate; Contract Disputes Act. Retrieved April 5, 2022 from www.fiscal.treasury.gov . 4 . Justia US Law. (2020). 2020 Georgia Code Title 33 Insurance Chapter 21A-Medicaid Care Management Organization 33-21A-7 – Bundling of provider complaints and appeals. Retrieved Apri l 5, 2022 from www.justia.com/codes/georgia.Interest Payments-GA MCD-PY-1326 Effective Date: 10/01/2022 The REIMBURSEMENT Polic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.5. Legal Information Institute. 42 CFR 422.520-Prompt payment by MA organization. Retrieved April 5, 2022 from www.law.cornell.edu . 6 . Social Security Association. Sec 1816(c)(2)(B). Retrieved April 5, 2022 from www.ssa.gov . 7 . Social Security Association . Sec 1842(c)(2)(B). Retrieved April 5, 2022 from www.ssa.gov . 8 . United States Government Publishing Office. Title 31, Section 3902. Retrieved April 5, 2022 from www.govinfo.gov . 9 . United States Government Publishing Office. Title 42, Section 7109. Retrieved April 5, 2022 from www.govinfo.gov .The Reimbursement Po lic y Sta te m ent d etai le d a bo ve h as r ecei ved due c on sidera tio n a s d efi ned i n the ReimbursementPolic y St ate m ent Polic y a nd i s a pp ro ved. GA-MED-P-135053 Issue Date 03/31/2021 Approved DCH 06/29/2022

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