REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Dental Procedures i n Hospital Outpatient Facility or Ambulatory Surgery Center GA MCD PY-0847 08/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidel ines. 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 be nefits 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. M edically 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 prolonge d, 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 prov ided 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 Handb ooks, 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 discret ion 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 beha vioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medi cal conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 4 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Dental Proceduresin Hospital Outpatient Facility or Ambulatory Surgery Center GA MCD PY-0847Effective Dat e: 08/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectDental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center B. BackgroundReimbursement 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 wi ll 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 acc urate andappropriate 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.Most dental care can be provided in a traditional dental office setting with local anesthesia and if medically necessary, a continuum of behavior guidance strategies, ranging from simple communicative techniques to nitrous oxide, enteral or parenteral seda tion. Monitored anesthesia care or sedation ( minimal, moderate , or deep) may bea requirement of some patients including those with challenges related to age, behavior or developmental disabilities, medical status, intellectual limitations or other special needs. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require as a medical necessity, general anesthesia in a healthca re facility such as an ambulatory surg ery center or outpatient hospital facility.C. Definitions Ambulatory Surg ery Center (ASC) – Any freestanding institution, building, or facility or part thereof, devoted primarily to the provision of surgical treatment to patients not requiring hospitalization, as provided under provisions of Georgia Code Section 88-1901. Such facilities do not adm it patients for treatment, which normally requires overnight stay, nor provide accommodations for treatment of patients for period of twenty-four (24) hours or longer. It is not under the operation or control of a hospital. The term does not include indivi dual or group practice offices of private physicians or dentists, unless the offices have a distinct part used solely for outpatient surgical treatment on a regular and organized basis and has been regulated and certified by the state as such. Inpatient H ospital – A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions . Off Campus-Outpatient Hospital – A portion of an off-campus hospital provider – based department which provides diagnostic, therapeutic (both surgical and Dental Proceduresin Hospital Outpatient Facility or Ambulatory Surgery Center GA MCD PY-0847Effective Dat e: 08/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalizat ion or institutionalization. On Campus-Outpatient Hospital – A portion of a hospitals main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitali zation or institutionalization. Short Procedure Unit (S PU ) – A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic , or medical services. Minimal Sedation (Anxiolysis ) – A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. Moderate Sedation/Analgesia (Conscious Sedation ) – A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and sp ontaneous ventilation is adequate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. Monitored Anesthesia Care ( MAC ) – Does not describe the continuum of depth of sedation; rather it describes a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Deep Sedation/Analgesia – A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. General Anesthesia – A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and po sitive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Because sedation is a continuum, it is not always possible to predict h ow an individual patient will respond. Practitioners intending to produce a given level of sedation should be able to rescue*** patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation/ analgesia ( conscious sedation) should be able to rescue*** patients who enter a state of deep sedation/ analgesia, while those administering deep sedation/ analgesia should be able to rescue*** patients who enter a state of general anesthesia. *** Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life Dental Proceduresin Hospital Outpatient Facility or Ambulatory Surgery Center GA MCD PY-0847Effective Dat e: 08/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia , and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation. D. PolicyMost dental care and/or oral surgery is effectively provided in an office setting. However, some members may have a qualifying condition that requires the procedure be provided in a hospital setting or ambulatory surg ery center under general anesthesia. The purpose of this document is to provide reimbursement and billing guidance for facility related services when dental procedures are rendered in a hospital or ambulatory surg ery center (ASC) place of service (POS) under general anesthesia. Hospital inpatient or outpatient facility services and ASC facility services for the provision of dental care under general anesthesia are addressed in this policy, not dental care or oral surgery in an office set ting. Professional dental services are covered only to the extent that the member has dental benefits and guidelines for dental services are provided in the applicable dental policy manual. CareSource policy notes the intent of hospital, outpatient, an d ASC facility requests isthe medical necessity of general anesthesia services to perform dental procedures on a member. Requests with the goal of no, minimal, moderate , or deep sedation services,will only be considered in extenuating circumstances manda ted by systemic disease for which the patient is under current medical management , and which increases the probability of complications, such as respiratory illness, cardiac conditions , or bleeding disorders. Medical record and physician attested letter would be required with authorization requests. I. Prior authorizationA. A prior authorization is required for all hospital inpatient or outpatient facility or ambulatory surg ery center facility procedures that require general anesthesia or anesthesia monitoring with sedation . 1. No prior authorization is required for CPT 00170. B. The review for dental services in a hospital inpatient or outpatient facility or ambulatory surgery center facility under anesthesia is a two-step process. 1. STEP ONE is completed by the treating dentist . An authorization for the requested dental services is sent to the Dental Utilization Management (UM – DM) team who will determine the medical necessity of t he services being completed in a hospital or outpatient setting . a. For authorization requests for POS ( 19, 21, 22, or 24) medical necessity review, the treating dentist should submit at least one (1) unit of (D9420) hospital or ambulatory surg ery center call. b. The pre-determination letter (PDL) or authorization is sent to the treating/submitting dentist and to the member. c. The treating/submitting dentist must provide the facility with the PDL. 2. STEP TWO is completed only after the first step has been approved. Dental Proceduresin Hospital Outpatient Facility or Ambulatory Surgery Center GA MCD PY-0847Effective Dat e: 08/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.a. The facility will submit a precertification/authorization to the medical management team and must include a copy of the PDL. b. The Medical Utilization Management (UM-MM) team will complete ALL of the following: 01. Verify that facility is in or out of network ; 02. Review the pre-determination letter (PDL) or authorization ; 03. Determine medical necessity for any other non-dental CPT/HCPCS codes submitted ; 04. Fax a Facility Approval to the hospital/ASC which can also be viewed in CareSource Provider Portal . II. Additional guidelines on the benefit limits/frequencies of D9420 can be found in theDental Health Partner Provider Manual. NOTE: The provider who submits the authorization for the dental therapeutic services must be the provider that performs the services. If the autho rized provider does not perform the service, claims will deny. In the event the authorized provider is unable to perform the services or the location changes, CareSource must be notified to update the authorization prior to the services being performed. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifier s, 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 all inclusive and is subject to updates. Revenue codes and additional information ca n be found in theDepartment of Community Health and ASC Policy manuals as well as the Dental HealthPartner Provider Manual. Outpatient Hospital Facility (SPU) POS (19, 22) ; Ambulatory Surgical Center POS (24) o Use dental code D9420 for the technical component with appropriate billed charges OR time use for dental services performed. Time is calculated as 1 unit = 30 minutes, where the maximum units reimbursable per date of service is 6. o Use CPT 00170 for anesthesia for intraoral treatments, including biopsy. Time units for physician and CRNA services both personally performed and medically directed are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. Total minutes are listed as the units (i.e., 75 minutes) 75 = 6 units (of 15-minute increments). CMS Base units = 5. Maximum state allowances may be applicable. o Recovery room is intended for cases when a patient requires recovery from deep sedation or anesthesia. Recovery room use is reimbursable only when billed for Dental Proceduresin Hospital Outpatient Facility or Ambulatory Surgery Center GA MCD PY-0847Effective Dat e: 08/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.the same date of service as a surgery that is not considered a common office procedure. o Hospital add-on (HAO) services only applicable if state or contract required. Separate reimbursement may n ot be applicable. Maximum allowances may be applicable . Inpatient Hospital Facility POS (21) o All services as well as any additional room and board fees would have to be pre – certified and receive medical necessity review. Services are subject to benefit provisions . Dental/Oral Surgery Professional Services o The scope of this policy is limited to medical plan coverage of the facility and/or general anesthesia services provided in conjunction with dental treatment, and not the dental or oral surgery services. The professional dental procedure codes listed are for reference only and do not imply coverage of dental procedures. Information on dental benefits, please consult the Dental Health Partner manual for clinical guidelines, policies , and procedure s. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 10/ 01/2019 New PolicyDate Revised 08/1 9/2020 01/28/2022Removed PA for CPT 00170. Annual Review. Removed tables, simplified codinginformation.Date Effective 08/01/2022 Date Archived H. References1. American Academy of Pediatric Dentistry. Oral Health Policies and Recommendations (The Reference Manual of Pediatric Dentistry) . (20 21-2022 ). Retrieved J anuary 28, 2022 from www.aapd.org . 2. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. (201 9, October 23). Retrieved J anuary 28, 2022 from www.asahq.org . 3. Part II Policies and Procedures for Ambulatory Surgical and Birthing Center Services (202 2, January ). Retrieved January 28, 2022 from www.mmis.georgia.gov . 4. Part II Policies and Procedures for Dental Services (202 1, October ). Retrieved January 28, 2022 from www.mmis.georgia.gov . 5. Part II Policies and Procedure for Hospital Services (202 2, J anuary ). Retrieved January 28, 2022 from www.mmis.georgia.gov . GA-MED-P-1230387 Issue Date 10/01/2019 Approved DCH 04/25/2022
REIMBURSEMENT POLICY ST AT EMENT Georgia Medicaid Policy Name & Number Date Effective Smoking Cessation – GA MCD – PY-0378 08/01/2022-1 1/ 3 0/ 2022 Policy Type REIMBURSEMENT Table of ContentsA. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….3 D. Policy ………………………………………………………………………………………………………………..3 E. Conditions of Co ve r age…………………………………………………………………………………………4 F. Related Policies/Rules ………………………………………………………………………………………….4 G. Review/Revision History ………………………………………………………………………………………..4 H. Ref er en ce s …………………………………………………………………………………………………………4 Reimbursement Po licie s prepared by CareSource a nd its a ffilia te s a re intended to provide a general reference regarding b illin 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 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 limite d to, those health ca re services or supplies that are proper and necessary for the diagnosis or treatment of disease, illn e ss, 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, Ev id en c e 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 co n flict between th is 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 a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy 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 limita tio n s that a re le ss favorable t h an the limita tio n s that apply to medical conditions as covered under this policy. Smoking Ces s ati o n-GA MCD-PY-0378 Effec ti v e Date:08/01/2022 Th e REIMBURSEMENT Policy Statemen t d etai l ed abo v e h as rec ei ved due c o ns id eratio n as defi n ed in th e REIMBURSEMENT Policy Statemen t Po l i c y an d i s approved. A. Subjec tSmoking & Tobacco Ce ss at i on B. Bac k groundReimbursement policies are designed to assist providers when submitting claims to CareSource. These proprietary policies are routinely updated to promote accurate coding and policy clarif ication but 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 ac t u al services provided to a member an d will be determined when the claim is received f or processing. Health care providers and of fice staff are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply an y right to reimbursement or guarantee claims payment. The use of tobacco products generally leads to tobacco/nicotine dependence an d of ten results in serious health problems. Quitting smoking greatly reduces the risk of developing smoking-r elat e d diseases. Tobacco/nicotine dependence is a condition that of ten requires repeated treatments, as nicotine is strongly addictive. Because of this, quitting smoking and ending tobacco use may be a dif f icult process requiring several, staged attempts and may involve stress, irritability, and other withdrawal symptoms f or individuals addicted to nicotineHowever, continued tobacco use in any f orm i s f ar more harmf ul. Tobacco smoke contains seriously harmf ul chemicals and carcinogens and leads to lung and other cancers, chronic lung disease, heart disease, stroke, vascular disease, an d inf ertility. Additionally, smokeless tobacco is directly linked t o cancers of the mouth, tongue, cheek, gum, esophagus, and pancreas. Counseling and medication are both ef f ective means f or ending dependency on tobacco products an d ar e even mo r e ef fective together t h an either method alone. Counseling c an be ef f ective when delivered via individual, group, or telephone counseling, one-on-one brief help sessions with a provider, behavioral therapies, or even through mobile phone apps.Medications have been f ound to be effective, including prescription non-nicotine medications such as bupropion SR ( Zy b an ) an d varenicline tartrate (Chantix ), and nicotine replacement products, such as nicotine patches, inhalers, or nasal sprays available by prescription and over-the-counter nicotine patches, gums or lozenges. The United States government recognizes the health dangers and risks associated with the use of tobacco in its citizens and has set up a f ree telephone support service to help people stop smoking an d stop the use of tobacco, 1-80 0-QUIT-NOW. Callers ar e routed through this service to their states specific resource and may be able to obtain f ree support, advice, and counseling f rom experienced quit-line coaches, a personalized plan to quit, practical inf ormation on how to quit, including ways to cope with nicotine withdrawal, the latest inf ormation about stop-smoking medications, f ree or dis c o un t edSmoking Ces s ati o n-GA MCD-PY-0378 Effec ti v e Date:08/01/2022 Th e REIMBURSEMENT Policy Statemen t d etai l ed abo v e h as rec ei ved due c o ns id eratio n as defi n ed in th e REIMBURSEMENT Policy Statemen t Po l i c y an d i s approved. medications ( av ailab le f or at le as t so me callers in mo st states), ref errals to other resources, and/or mailed self-h elp mat e r ials . CareSource encourages all members to r e f rain f r om the use of tobacco, and if using it in any f orm, to make concerted and ongoing attempts to quit use as soon as possible.C. Def initions Tobacco products Any product containing tobacco or nicotine, including but not limited to cigarettes, pipes, cigars, cigarillos, bi dis, hookahs, kreteks, e-cigarettes, vaporized an d other inhaled tobacco an d nicotine products, smokeless t o bac c o (e.g., dip, chew, snuf f , snus), dissolvable tobacco (e.g., strips, sticks, orbs, lozenges), or other ingestible tobacco products, and/or chewi ng tobacco. D.Polic y I. Prior authorizations are required f or participating (contracted) providers only when the services they ar e providing for tobacco cessation exceed the limits of this policy. II. Non-participating providers ( no t contracted with Car e So ur c e) should contact CareSource f or prior authorization f or these services.III. CareSource will reimburse participating providers for the following t o bac c o use intervention and cessation care methods: A. An encounter for evaluation an d management of the me mber on the s ame d ay as counseling to prevent or cease tobacco use; B. Screenings f or tobacco use as needed f or members 20 an d younger; C. One screening for t o bac c o use per calendar y e ar f or members 21 an d older; and, D. Two individual tobacco cessation counseling attempts per calendar y e ar in a f ac e to f ace setting: 1. Eac h attempt will not exceed 12 weeks of treatment. 2. Services mu st be documented every 30 d ay s in the members medical record during each 12-week treatment period. E. Nicotine replacement or non-nicotine medications p r es c r ibe d an d approved for use f or tobacco cessation. IV. CareSource will not reimburse claims f or counseling to prevent or cease tobacco use in excess of 12 sessions within a calendar year unless prior authorization has been obtained by the provider. V. The number of CPT, HCPCs, and diagnosis codes (ICD-10) potentially associated with the diagnosis an d treatment of tobacco use an d addiction is too great to list. As such, the specif ic tobacco cessation codes provided below are eligible to be reimbursed with any appropriate, associated code. VI. Ev alu at io n an d Management service f or the member, which is provided on the s ame d ay as counseling to prevent or cease tobacco use, should be reported with modifier-EP to indicate t h at the E&M service is separately identif iable from the c ou ns e ling . Smoking Ces s ati o n-GA MCD-PY-0378 Effec ti v e Date:08/01/2022 Th e REIMBURSEMENT Policy Statemen t d etai l ed abo v e h as rec ei ved due c o ns id eratio n as defi n ed in th e REIMBURSEMENT Policy Statemen t Po l i c y an d i s approved. E. Conditions of Cov erageReimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS an d CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual Georgia Medicaid f ee schedule f or appropriate codes. 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 Description 99406 Smo k ing and tobacco us e intermediate counseling; g reater than 3 minutes up to 10 minutes 99407 Smo k ing and tobacco us e intensive counseling; greater than 10 minutes F. Related Polic ies/RulesNA G. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 9/06/2017 New PolicyDate Revised 8/19/2019 03/16/2022Updated policy reimbursement methods, code modif ier and ref erence list.Date Effective 08/01/2022 Date Archived 11/30/2022 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 f ollow CMS/State/NCCI guidelines without a f ormal documented Policy. H. Ref erenc es1. Centers f or Disease Control an d Prevention. ( 20 2 1, June 2 ). Fas t Facts: Smoking & Tobacco Use. Of f ice on Smoking and Health, National Center f or Chronic Disease Prevention and Health Promotion. Retrieved February 21, 2022 f ro m www.cdc.gov. 2. Centers f or Disease Control and Prevention. Quitting Smoking Among Adults United States, 20002015. Morbidity an d Mor t alit y Weekly Report 2017:65(52):1457-64. Retrieved February 21, 2022 f r om www.cdc.gov. 3. Centers f or Disease Control and Prevention. Best practices f or comprehensive tobacco control programs. 2014. Atlanta: U.S. Department of Health and Human Services, centers for Disease Control an d Prevention, Nat io n al Center f or Chronic Disease Prevention and Health Promotion, Of f ice on Smoking and Health, 2014. Retrieved February 21, 2022 f rom www.cdc.gov. 4. Centers f or Medicare and Medicaid Services (CMS). National Coverage Determination: Counseling to Prevent To bac c o Use. 210.4.1.v2. Effective September 26, 2017. Retrieved February 21, 2022 f rom www.cms.gov. 5. Creamer MR, et al. Tobacco product use among high school students youth risk behavior survey, United States, 2019. Centers f or Disease Control and Prevention. Smoking Ces s ati o n-GA MCD-PY-0378 Effec ti v e Date:08/01/2022 Th e REIMBURSEMENT Policy Statemen t d etai l ed abo v e h as rec ei ved due c o ns id eratio n as defi n ed in th e REIMBURSEMENT Policy Statemen t Po l i c y an d i s approved. MMWR. 2020 August;69(1):56-563. Retrieved Fe br uar y 21, 2022 f ro m www.cdc.gov. 6. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Ref erence Guide f or Clinicians. Rockville, MD: U.S. Department of Health and Hu man Services. April 2009. Retrieved Feb r uar y 21, 2022 from www.ahrq.gov .7. Georgia Department of Community Health Division of Med ic aid . Par t II: Policies and Procedures f or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services Health Check Program (COS 600). (2022, January). Retrieved February 21, 2022 f rom www.mmis.georgia.gov. 8. Krist AH, et al. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(3):265-279. Retrieved February 21, 2022 from www.uspreventiveservicestaskforce.org. 9. National Institute on Drug Abuse. (2021, April 12). Tobacco, nicotine, and e-cigarettes research report: is nicotine addictive? Retrieved Fe br u ar y 21, 2022 f r om www.nida.nih.gov. 10. Physician Services Man u al, 903.19, "Tobacco cessation services for Medicaid eligible members." Ibid. Appendix D, "Health check and adult preventive visit. (2022, January 1). Retrieved February 21, 2022 f rom www.mmis.georgia.gov. 11. U.S. Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers f or Disease Control an d Prevention, Center for Chronic Disease Prevention an d Health Promotion, Of fice on Smoking an d Health, 2020. Retrieve d Feb ru ar y 21, 2022 f rom www.hhs.gov. 12. U.S. Departm ent of Health and Hum an Serv ic es. The Health Consequenc es of Sm ok ing50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Departm ent of Health and Hum an Serv ic es, Centers f or Disease Control and Prev ention, National Center f or Chronic Disease Prev ention and Health Prom otion, Of f ic e on Sm ok ing and Health, 2014. Retriev ed February 21, 2022 f rom www.nc bi.nlm .nih.gov .GA-MED-P-1230387 Issue Date 09/06/2017 Approved DCH 04/25/2022
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Robotic-Assisted Surgery GA MCD PY-0959 07/01/2022 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 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 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 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 Contents 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 ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3Robotic-Assisted Surgery GA MCD PY-0959 Effective Date:07/01/2022The REIMBURSEMENTPolic 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 REIMBURSEMENTPo lic y St ate m ent Po lic y a nd is a pp rove d.A. SubjectRobotic-Assisted Surgery 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. Reimbu rsement 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. Robot-assisted surgery involves the use of a robot and computer technology under the direction and guidance of a surgeon. These surgeries are minimally invasive procedures using robotic devices designed to acces s surgical locations through smaller incisions or ports. There surgeries are generally performed using a workstation console containing remote controls for the surgical instruments as well as a computer equipped with a three-dimensional magnified video monitor of the surgical site through use of miniature cameras. The primary difference between robotic and conventional laparoscopic procedures is that the surgical instruments are manipulated indirectly through computer controls rather than manually by the surgeon. The robotic controls allow the surgical tools to emulate the movement of the surgeon performing cuts, clamps and suturing in a similar fashion as would be done in an open procedure. Examples of robotic surgical systems include the da Vinci Surgical System (Intuitive Surgical, Inc.) and the ZEUS Robotic Surgical System (Computer Motion, Inc.) C. Definitions Robotic Assisted Surgery-is defined as the performance of operative procedures with the assistance of robotic technology. D. Policy I. Robotic-Assisted Surgery, HCPCS S2900, is included in the primary surgical procedure and not separately reimbursable. II. Modifier 22 (increased procedural services) : 1. Should be used only to report complications or complexities during the surgical procedure that are unrelated to the use of the robotic system, such as increased intensity, increased time, increased difficulty of procedures, or severity of patients conditi on Robotic-Assisted Surgery GA MCD PY-0959 Effective Date:07/01/2022The REIMBURSEMENTPolic 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 REIMBURSEMENTPo lic y St ate m ent Po lic y a nd is a pp rove d.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the Georgia Medicaid fee schedule for appropriate codes. F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 10/17/2019 New PolicyDate Revised 01/19/2022 No changes; updated references Date Effective 07/01/2022 Date Archived H. References 1. Robotic surgery. Medline Plus Web site.(May 2013). Retrieved December 28, 2021 from www.nlm.nih.gov. 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services; Retrieved December 28, 2021 from www.cms.gov. 3. Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets. Retrieved December 28, 2021 from www.cms.gov. 4. Daniel M. Herron, MD. A consensus Document on Robotic Surgery. Prepared by the SAGES-MIRA Robotic Surgery Consensus gr oup. Position Papers/ Statement published on 11/2007. Retrieved December 28, 2021 from www.sages.org.5. Estes, Stephanie Jet al. Best Practices for Robotic Surgery Programs. JSLS : Journal of the Society of Laparoendoscopic Surgeons vol. 21,2 (2017): e2016.00102. Retrieved December 28, 2021 from www.nlm.nih.gov. 6. U.S. Food and Drug Administration. Computer-Assisted Surgical Systems (Aug. 20, 2021). Retrieved December 28, 2021 from www.fda.gov GA-MED-P-1157650 Issue Date 10/17/2019 Approved DCH 03/23/2022
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date 340B Drug Pricing PY-PHARM-0086 11-1-2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reim bursement 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-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 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. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Archived 340B Drug Pricing GEORGIA MEDICAID PY-PHARM-0086 Effective Date: 11-1-2021 2A. Subject 340B Drug Pricing 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/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 payment. The 340B Drug Pricing Program is a federal program, which limits the cost of covered outpatient drugs to eligible health care organizations and covered entities. The purpose of the program was to enable covered entities to stretch scarce federal resources as far as possible, reach more eligible patients and provide more comprehensive services. This policy describes the claim submission requirements for outpatient pharmacy and provider administered drugs. C. Definitions 340B Covered Entity (CE) A facility that is eligible to purchase drugs through the 340B Program and appears on the HRSA Office of Pharmacy Affairs Information System (OPAIS). 340B Drug Discount Program (340B) Section 340B of the Public Health Service (PHS) Act (1992) that requires drug manufactures participating in the Medicaid Drug Rebate Program to sign a pharmaceutical pricing agreement (PPA) with the Secretary of Health and Human Services. 340B Medicaid Exclusion File (MEF) A file established by HRSA to assist 340B covered entities and States in the prevention of duplicate discounts for drugs subject to Medicaid rebates. Actual Acquisition Cost The actual prices paid to acquire drug products sold by a specific manufacturer. Care Management Organization (CMO) Organizations, such as CareSource, contracted by the Georgia Department of Community Health to coordinate services for Medicaid members. Contract Pharmacy A pharmacy under contract with a Covered Entity. Current Procedural Terminology (CPT) A medical code set maintained by the American Medical Association to describe and bill for medical, surgical, and diagnostic services. Archived340B Drug Pricing GEORGIA MEDICAID PY-PHARM-0086 Effective Date: 11-1-2021 3Fee-for-Service (FFS) Claims billed directly to Georgia Medicaid for prescriptions and physician administered drugs provided to FFS members. Healthcare Common Procedure Coding System (HCPCS) A set of health care procedure codes based on CPT. Health Resources and Services Administration (HRSA) The primary federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable. National Drug Code (NDC) A drug product that is identified and reported using a unique, three-segment number, which serves as a universal product identifier for the specific drug. Provider Administered Drugs Drugs administered directly by a health care provider to a patient. D. Policy I. Outpatient Pharmacy (Point-of-Sale) 340B Claims A. Effective April 1, 2017, all 340B Covered Entities are required to use a submission clarification code when billing the Georgia Medicaid Division on Fee-for-Service (FFS) and Care Management Organization (CMO) outpatient pharmacy claims per Part II Policies and Procedures for Pharmacy Services Manual as published by the Georgia Department of Community Health. B. The Covered Entity should submit claims through their pharmacy claims platform through our pharmacy benefits manager, Express Scripts, and the claim should include: 1. A 20 in the submission clarification code field 420-DK 2. NDC of the drug dispensed 3. Actual Acquisition Cost C. Express Scripts will indicate on the encounter file any 340B submitted claims to Georgia Medicaid in order to ensure rebates are not collected on these drugs. It is the responsibility of Express Scripts to review the updated Health Resource and Service Administration (HRSA) 340B discount drug program file quarterly. The pharmacy should bill appropriately and their transactions are subject to audit. Please visit the Express Scripts Pharmacist Resource Center for additional information. D. If the product is not purchased at 340B pricing, do not include the basis of cost determination or the submission clarification code values and bill at the regular Medicaid (FFS or managed care) rate. E. Contract pharmacies are not allowed to bill for 340B purchased drugs. All 340B acquired drugs identified and discounted at the claim level must be carved-out for Medicaid (FFS or managed care). II. Provider Administered 340B Drug Claims A. For Provider Administered Drugs, the 340B Covered Entity should submit the claim on a CMS 1500 or UB-40 and the claim should include: 1. A UD modifier 2. The HCPCS/CPT code 3. NDC Archived 340B Drug Pricing GEORGIA MEDICAID PY-PHARM-0086 Effective Date: 11-1-2021 44. Actual Acquisition Cost B. CareSource will capture and include the UD modifier on the encounter file submission to Georgia Medicaid. E. Conditions 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 fee schedule for appropriate codes. F. Related Policies/Rules None applicable G. Review/Revision History DATE ACTIONDate Issued 05/13/2021 Date Revised Date Effective TBD Date Archived H. References 1. Georgia Department of Community Health Division of Medicaid. Part II Policies and Procedures for Pharmacy Services. Revised July 1, 2021. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Archived
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Modif iers-GA MCD-PY-1353 04/01/2022 Policy Type REIMBU RSEMENT 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 service, m edical necessity, adherence to plan polici es 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 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 a lso 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.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: 04/01/2022 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 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 their of f ic e 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 can be f ound in the appendices of both Current 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 ini tion. Examples of modif iers use includes: To dif f erentiate 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 multipl e procedures performed during the same session by the same 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-paymen t 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 Curr ent 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 (H CPCS) – codes that are issued, updated and maintained 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 additional inf ormation about the service or supply rendered. Mo d ifiers-GAMCD-PY-1353Effective Dat e: 04/01/2022 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. Policy It 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 Hospital 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 modif 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 cla im 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. Note: In the event of any conf lict between this policy and a providers contract withCareSource, the providers contract will be the governing document.F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 01/20/2022 New PolicyDate Revised Date Effective 04/01/2022 Date Archived H. Ref erences1. Billing 340B Modif iers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved November 1 9, 2021 f rom www.cms.gov. Mo d ifiers-GAMCD-PY-1353Effective Dat e: 04/01/2022 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is approved.2. CPT overview and code approval. (2019, March 22). Retrieved November 1 9, 2021f rom www.ama-assn.org. 3. Med icare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners. (2018, November 30). Retrieved November 1 9, 2021 f rom www.cms.gov. 4. Medicare Claims Processing Manual Chapter 14 – Ambulatory Surgical Centers. (2017, December 22). Retrieved November 1 9, 2021 f rom www.cms.gov. 5. Optum360 EncoderProForPayers.com – Login. (2019, February 18). Retrieved November 1 9, 2021 f rom www.encoderprofp.com. GA-MED-P-1058952 Issue Date 12/15/2021 Ap p ro ved DCH 01/12/2022
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Coordination of Benefits PY-1344 01/01/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement 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 logic, benefit s 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 this P olicy 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 ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Cov erage ………………………….. ………………………….. ………………………….. ……. 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Coordination of BenefitsGEORGIA MEDICAIDPY-1344 Effective Date: 01/01/2022 2 A. SubjectCoordination of Benefits B. Background The 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 terms of a Members Benefit Plan, applicable state an d federal laws, and applicableCMS guidance. If CareSource is not the primary carrier, providers shall bill the primary carrier for all services they provide before they submit their claims to CareSource. Any balance due after receipt of payment from the p rimary carrier should be submitted toCareSource for consideration. 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 to individuals enrolled with Plan, including but not limited to contracts titled Provider Agreement and Group Practice Services Agreement. Coordination of Benefits (COB) The process of deter mining 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 t he 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 responsible for primary payment. D. Policy I. 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 ben efits 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 t han the Medicaid contracted maximum allowable amount will be paid at zero. Claims that pay at zero are considered to be paid claims, not denied claims. Coordination of BenefitsGEORGIA MEDICAIDPY-1344 Effective Date: 01/01/2022 3 B. When the payment from another insurance carrier is less than the Medicaid contracted amount, CareSo urce 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 Provider Agreement) . 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. Therefore, in this example, CareSource will pay $10.00 (as indicated in the CareSource Provider Agreement). Example 3: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary 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. Therefore, in this example,CareSource will pay $125.00 which is the total allowed amount (as indicated in the CareSource Provider Agreement ). Example 4: Charged Amount $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 BenefitsGEORGIA MEDICAIDPY-1344 Effective Date: 01/01/2022 4 Summary : In this example, subtract the primary paid amount of $10.00 from theMedicaid contracted allowed amount of $125.00. Therefore, in this example, CareSource will pay $115.0 0 (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. Therefore, in this example CareSource will pay $180.00 (as indicated in the CareSource Provider Agreement). C. Non-Contracted Providers1. When the payment from another insurance carrier is less than theCareSource Medicaid non-participating reimbursement rate , the sum of the payments will not exceed the Care Source Medicaid non-participating reimbursement rat e. 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 claims 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 information. 2. If a claim is denied for COB information needed, the provi der must submit the primary payers EOP. If the initial timely filing period has elapsed, the EOP must be submitted to us 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 the providers actual receipt of the primary payers EOP date, whichever is greate r. 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 service. If the policy was NOT in effect, CareSource will process the claim(s) that ar e within the original timely filing period or 90 days of the providers actual receipt of the payers EOP date. 2. If the policy WAS in effect, the claim will remain denied for lack of primary payers 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 payers EOP within 90 Coordination of BenefitsGEORGIA MEDICAIDPY-1344 Effective Date: 01/01/2022 5 days of the providers actual receipt of the Primary Payers EOP date, the claim will re-deny as not being timely filed.IV. COB C laim Submission to CareSourceA. CareSource follows 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 between the codes on the received claim and the primary payers EOP. B. CareSource applies standard claim adjustment codes, which can be found at the following site: https://x12.org/codes/claim-adjustment-reason-codes C. Claim Adjustment G roup Codes are as follows: 1. CO Contractual Obligation 2. OA Other Adjustment 3. PI Payer Initiated Reductions 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 3. PR3 Copayment E. When filing claims with contractual obligation, please use Adjustment Group Code CO. Contractual obligation can be communicated on the Primary Payers EOB with several different codes . Please use the code reflected on the primary payers EOB. Some examples of these codes are: 24, 45, 222, P24, P25, 26. (This is not an all-inclusive list). The same process should be followed when using Adjustment Group Code OA Other Adjustment. V. Denied COB ClaimsA. Will 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. Will 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 fro m the date of the EOP denial, whichever is greater. 1. 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 pe riod or within 90 days of the original denial date or 90 days from the primary carriers EOP date, whichever is greater. Coordination of BenefitsGEORGIA MEDICAIDPY-1344 Effective Date: 01/01/2022 6 1. If the dispute is received within the original timely filing period or within 90 days of the original denial date:B. CareSource wi ll 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 elapse d, then we will process 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. 1. If the provider does not notify CareSource of the dispute within the origina l timely filing period, within 90 days of the CareSource denial, or if the provider does not submit the primary carriers EOP within 90 days of the Primary Carriers EOP date, the claim will re-deny as not being filed timely. E. Conditions 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 fee schedule for appropriate codes. F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 10/13/2021 New policy. Approved at PGCDate Revised Date Effective 01 /01/2022 Date Archived H. References 1. Georgia Department of Community Health. Policies and Procedures For Medicaid/PeachCare for Kids (July 1, 2021). Retrieved September 27, 2021 from www.mmis.georgia.gov . 2. CareSource Georgia Medicaid Provider Manual ( March 2020). Retrieved September 27, 20 21 from www.caresource.com . The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.GA-MED-P-964661 Issue Date 10/13/2021 Approved DCH 10/26/2021
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Overpayment Recovery PY-1112 01/ 01/202 2 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims e diting 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 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. CSMG Co. 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.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 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 RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 01/01/2022 2 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 a re not a guarantee of paymen t. 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 s ervice that is being provided. Theinclusion 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 ac curacy in the payment process. CareSourc e will request voluntary repayment fromproviders when an overpayment is identified .Fraud, waste and abuse investigations ar e an exception to this policy. In theseinvestigations, 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, a partial payment, a reduced payment, a penalty applied, an additional payment or a supplemental paymen t. 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. EOP The EOP or Explanation of Payment contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Coordination of Benefi ts (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. 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; Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 01/01/2022 3 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. PLB (Provider Level Balancing) 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 pa yment (BPR, which means total payment within the EOP). Forwarding Balance (FB) An 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 remi ttance 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 provid er: 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 a ppeal rights . II. Overpayment RecoveriesA. 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 timef rame 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. III. Coordination of Benefit RecoveriesA. Lookback period is 12 months from the last date of serv ice 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 filin g limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Retro Active Eligibility RecoveriesA. Lookback period is 12 months from date CareSource is notified by Medicaid of the updated eligibility status. B. Advanced no tification will occur 30 days in advance of recovery. Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 01/01/2022 4 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 c laims being submitted within original claim timely filing guidelines. V. Management of Claim Credit Balances.A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim cr edit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. 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 overpaymen t 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 when adjusted, 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 p ayment is subject to the guidelines outlines in section D.I D. IV. b. The reduced payment will trigger a 30-day advanced notification with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through clai ms 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 their Accounts Receivable (AR) to account for the reconciliation of negative balances. E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. 1. Providers are expected to maintain their Accounts Re ceivable (AR) to account for the reconciliation of negative balances when they occur. VI. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document.Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 01/01/2022 5 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/Rules CareSource Provider Agreement , ARTICLE V. CLAIMS AND PAYMENTS G. Review/Revision History DATE ACTIONDate Issued 05/05/2020 New policyDate Revised 10/13/2021 Updated definitions. Added D. V. and D. VI. Updated references. Approved at PGC. Date Effective 01/01/2022 Date Archived H. References 1. Georgia Code (201 9). Title 33 Insurance Chapter 20A – Managed Health Care Plans Article 3 – Managed Health Care Plans 33-20A-62. Payment. Retrieved October 4, 2021 from www.law.justia.com The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved. GA-MED-P-964661 Issue Date 05/05/202 0 Approved DCH 10/26/2021
R EIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Obstetrical Care Unbundled cost PY-0924 12/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) 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, m edical necessity, adherence to plan policies and procedures, cl aims 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 pr oper 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, dysfunctio n 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 ser vices 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. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may m odify this Policy at any time.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 8 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 2A. Subject Obstetrical Care Unbundled cost 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/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Obstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members r e c e iv e in a h o s p it a l o r b ir t h in g c e n t e r a s we l l 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 providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedu re 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 prov iders and facilities. C. Definitions Prenatal profile – Initial laboratory services . Initial and prenatal visit – Practitioner visit to determine member is pregnant . Unbundled (partial) obstetrical c are – The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. o Antepartum care (prenatal) – T he initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery. o Delivery services – A dmission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery. Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 3o Postpartum care – Hospital and office visits following vaginal or cesarean section delivery . The American College of Obstetricians and Gynecologists (ACOG ) recommends contact within the first 3 weeks postpartum , ongoing care are needed concluding with a postpartum visit no later than 12 weeks after birth. High risk delivery – Labor management and delivery for an unstable or critically ill pregnant patient. Premature birth – Delivery before 39 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 or 40 weeks. 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 were provided to diagnose 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 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 fo llowing 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. from another group practice c. The member leaves your group practice before the global obstetrical care is complete d. The member must be referred to a provider from another group practice or a different licensure (e.g. midwife to MD) for a cesarean delivery e. The member has an unattended precipitous delivery f. Termination of preg nancy 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 for 1-3 visits 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits b. For E/M codes, bill with a diagnosis code O09.00 O09.93 , Z33.3;Z34.00-Z34.93 . Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 4c. E/M codes for antepartum care are limited to 3. d. Use the appropriate modifier (This list may not be all inclusive): 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 following (This list may not be all inclusive ): 01. Monthly visits up to 28 weeks gestation 02. Biweekly visits to 36 weeks gestation 03. Weekly from 36 weeks until delivery 04. Fetal heart tones 05. Initial/subsequent hist ory 06. Physical exams 07. Recording of weight/blood pressures 08. Physician/other qualified 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. Referral to another physician for delivery 3. Delivery only Use i f only a delivery was performed 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 forceps)59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps)59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery c. Services (This list may not be all inclusive)Services included that may NOTbe billed separatelyServices excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 5Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or forceps Vaginal delivery after prior cesarean section Previous cesarean delivery who present with expectation of vaginal deliverySuccessful vaginal delivery after previous cesarean deliveryCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean delivery Cesarean deliveryClassic cesarean section Low cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesiaArtificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as delivery Delivery of placenta unless it occurs at a separate encounter from the deliveryMinor laceration repairsInpatient management after delivery/discharge services E/M services provided within 24hours of delivery d. Modifiers 01. A modifier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 02. Deliveries with modifiers UB or UD must show medical necessity and medical documentation may be request ed . Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 6e. Use the appropriate modifier (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 forceps);including postpartum care59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care b. Modifiers01. A modifier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 02. Deliveries with modifiers 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 therefore are NOT allowed to be billed separately (This list may not be all inclusive): 01. Admission history 02. Admission to hospital 03. Artificial rupture of membranes 04. Care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 05. Hospital/office visits following cesarean section or vaginal delivery 06. Management of uncomplicated labor 07. Physical exam 08. Vaginal delivery with or without episiotomy or forceps 09. Caesarean delivery 10. Classic cesarean sec tion 11. Low cesarean section 12. Successful vaginal delivery after previous cesarean delivery Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 713. Previous cesarean delivery who present with the expectation of a vaginal delivery 14. Caesarean delivery following unsuccessful vaginal delivery attempt after previous cesar ean delivery 5. Postpartum care only – If postpartum care only was provided: a. Use code 59430 postpartum care only. b. Only one 59430 can be billed per pregnancy as this includes all E/M pregnancy related visits provided for postpartum care. c. There is no specified number of visits included in the postpartum code . This includes h ospital and office visits following vaginal or cesarean section delivery. ACOG recommends contact within the first 3 weeks postpartum. d. Postpartum care may include; and therefore are NOT allowed to be billed separately (This list may not be all inclusive) : 01. Hospital, o ffice and outpatient visits following cesarean section or vaginal delivery 02. Qualified health care professional providing all or portion of antepartum/postpartum care, but no delivery due to referral to another physician for delivery or termination of pregnancy by abortion e. The following are billable separately during the postpartum period (This list may not be all inclusive): 01. Conditions unrelated t o pregnancy i.e. respi ratory tract infection 02. Treatment and management of complications during the postpartum period that require additional services II. Member eligibilityA. If a member was not eligible for Medicaid for the 9 months before delivery, the practitioner MUST use the appropriate delivery only or delivery and postpartum code to be reimbursed. Charges for hospital admission, history and physical or normal hospital evaluation and management services are not reimbursable. B. If a member becomes eligible for Medicaid due to a live birth, no prenatal services including laboratory services are reimbursable . III. Multiple gestations.A. Include diagnosis code for multiple gestations . B. Modifier 51 should be added to the second and any subsequent vaginal births identifying multiple p rocedures were performed . C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 should be added to support substantial additional work. Docume ntation must be submitted with the claim demonstrating the reason and the additional work provided . IV . High risk deliveriesA. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 Supervision of high-risk pregnancy. Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 8B. Modifier 22 may be added to the delivery code to support substantial additional work. Documentation must be submitted 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 modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. For antepartum care only (e.g. 59425, 59426) pl ease bill only the final date of service rather than the full date span; failure to do so may result in a timely filing denial . The following list(s) of c odes is provided as a reference. This list may not beall inclusive and is subject to updates.CPT Code Description E/M For antepartum care for 1-3 visits 59425 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, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59410 Vaginal delivery only (with or without episiotomy and/or forceps);including postpartum care 59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care 59430 Postpartum care only. F. Related Policies/RulesObs tetrical Care Hospital Admissions MM-0850Obstetrical Care Total Cost PY-0231 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 definitions, reorganized topics, removed total care information, updated most content, included modifiers and updated codes. Added Section E. For antepartum care only Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 9(e.g. 59425, 59426) please bill only the final date of service rather than the full date span; failure to do so may result in a timely filing denial . Added reimbursement policy language. Removed duplicate modifiers. Update References. Approved at PGC. Date Effective 12/ 01/2021 Date Archived H. References1. The American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redefining the Postpartum Visit. Retrieved September 13, 2021, from www.acog.org 2. American Medical Association. (1997, April). Global OB Codes: Reporting and Use. CPT Assistant . 3. American Medical Association (2015, Jan uary). Maternity Care and Delivery. CPT Assistant. 4. Georgia Department of Community Health Division of Medicaid. (20 21, July 1). PART II Policies and Procedures for Physician Services. Retrieved September 13, 20 21 from www.mmis.georgia.gov 5. American Academy of Professional Coders. (2013, August 1). From Antepartum to Postpartum, Get the CPT OB Basics. Retrieved September 13, 20 21 from www.aapc.com 6. American Academy of Professional Coders. (2011, December). Code Obstetrical Care with Confidence. Retrieved on September 13, 2021 from www.aapc.com 7. EncoderPro.com for Payers Professional. (2019) Retrieved September 13, 2021, from www .encoderprofp.com 8. The American College of Obstetricians and Gynecologists. (n.d.). Coding for Postpartum Services (The 4 th Trimester). Retrieved September 13, 2021, from www.acog.org 9. The American College of Obstetricians and Gynecologists. (n.d.). Reportin g a Services with Modifier 22. Retrieved September 13, 2021, from www.acog.org 10. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Induction of Labor. Retrieved September 13, 2021, www.acog.org 11. Ameri can College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Planned Cesarean Delivery. Retrieved September 13, 2021 from www.acog.org 12. American College of Obstetricians and Gynecologists. (2019), April Correct Coding Initiative Version 25.1. Retrieved September 13, 2021 from www.acog.org 13. American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Care. Retrieve d September 13, 2021, from www.acog.org 14. American College of Obstetricians and Gynecologists. (2019, January). Preterm Labor and Birth. Retrieved September 13, 2021from www.acog.org The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.GA-MED-P-904550 Issue Date 07/01/2017 Approved DCH 09/27/2021
REIMBURSEMENT POLICY STATEMENTGEORGIA M EDICAID Policy Name Policy Number Effective Date Payment to Out of Network Providers PY-1171 12/01/2021 Policy Type Medical Administrative Medicaid REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-stand ard 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 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. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Pol icy at any time.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Cov erage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Payment to Out of Network ProvidersGEORGIA MEDICAIDPY-1171 Effective Date: 12/01/2021 2 A. SubjectPayment to Out of Network Providers 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 a re 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. Heal th 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 s ervi ce that is being provided. Theinclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.This policy is intended to define the reimbursement rate for claims received from providers who are not contracted ( out of network) providers with CareSource.C. Definitions Emergency Services Emergency health care services are used to treat an emergency medical condition. Emergency Medical Condition A medical condition that manifests itself by signs and symptoms of sufficient severity or acuity, including severe pain, such that a prudent layperson would reasonably have cause to believe constitutes a condition that the absence of immediate medical attention could reasonably be expected to result in: o Placin g the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; o Serious impairment to bodily functions; or o Serious dysfunction of any bodily organ or part. Out of Network Providers th at are not part of CareSources network or do not have a signed contract. D. Policy CareSources standard reimbursement approach to out of network providers is as follows: I. Preauthorized, medically necessary services rendered to CareSource members by ou t-of-network providers will be reimbursed at A. 90 % of the Medicaid Fee schedule; and B. 60% of the Medicaid Fee schedule for labs. C. In the case where billed rate for any service provided is lower than the calculated allowed amount , CareSource will reimburse claim line s with the lesser of billed charges and the calculated allowed amount as shown in A or Babove. Payment to Out of Network ProvidersGEORGIA MEDICAIDPY-1171 Effective Date: 12/01/2021 3 II. In the event of any conflict between this policy and any written agreement between the provider and CareSource, tha t written agreement will be the governing document. III. Exclusions:A. Emergency Health Care Services will be reimbursed based on state regulations.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes alo ng with appropriate modifiers. Please refer to the individua l fee schedule s for appropriate codes . F. Related Policies/Rules N/A G. Review/Revision History DATE ACTIONDate Issued 09/15/2021 New policyDate Revised Date Effective 12/01/2021 Date Archived H. References N/A The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved. GA-MED-P-904550 Issue Date 09/1 5/2021 Approved DCH 09/27/2021
REIMBURSEMENT POL ICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Interest Payments PY-1326 09/01/2021-0 0/ 0 0/ 2022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..2 E. Conditions of Co v er ag e ………………………………………………………………………………………..3 F. Related Policies/Rules …………………………………………………………………………………………. 3 G. Review/Revision His t or y ……………………………………………………………………………………….3 H. Ref er en ce s …………………………………………………………………………………………………………3 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding b illin g , coding a nd documentation guidelines. Coding methodology, regulatory requirements, indust ry-sta ndard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Po licy, Reimbursement of services is subject to member benefits a n d e lig ib ility on the date of service, me d ical necessity, adherence to pla n po licie s and procedures, cla ims editing lo gic, provider contractual agreement, an d applicable re f e rral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d 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, dysfunc t ion 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. Me d ica lly 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. Th is Po licy does n ot 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 th is Po licy 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 a ffilia te s ma y use reasonable discretion in interpreting and applying th is Policy to serv ice s 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 t rea t me nt of a behavioral health disorder will not be subject to any limita tio n s that are less favorable than the limita tio ns that apply to medical conditions as covered under this policy. 2 A. Subjec tInterest Payments In teres t Pay men ts GEORGIA MEDICAID PY-1326 Effec ti v e Date: 09/01/2021B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote ac c u r at e coding an d policy clarif ication. These proprietary policies ar e 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 ac t u al services provided to a member an d will be determined when the claim is received f or processing. Health care providers and their office s t af f ar e encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the mo st ac c u r at e and appropriate CPT/HCPCS/ICD-10 code(s) f or 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.C. Def initions0078 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. 0078 Clean Claim A clean claim has no def ect, impropriety, or special circumstance, including incomplete documentation t h at delays timely payment. A provider submits a clean claim by providing the required d at a elements on the s t an d ar d claims f o r ms t h at ar e ac c u r at e at t h e time of payment, along with any attachments and additional elements, or revisions to data elements, attachments and addi tional elements, of which the provider has knowledge. 0078 Original Claim The initial complete claim f or one or more benefits on an application f orm. 0078 Pro mp t Paymen t Prompt payment is def ined by State and/or Federal regulation def ining timeliness and interest requirements. D. Polic yI. We strictly adhere to all regulatory guidelines r elat in g to interest. We f ollow 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 f ails to adjudicate original claims within the applicable state and f ederal prompt pay timef rames on clean claims. III. Payment of interest on adjusted claims starts on the d at e the provider disputes the original payment with CareSource. IV. CareSource considers interest pa yment on claims that were not p aid accurately on prior processing attempts. If CareSource had the inf ormation to pay the claim correctly on a previous payment but f ailed to do so, CareSource will pay the claim
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