Coordination of Benefits

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

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

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

Modifier 59 XE XP XS XU

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

Modifier 25

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

Standard Medical Billing Guidance

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

Interest Payments

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Interest Payments-GA MCD-PY-1326 10/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of serv ice, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the mem ber or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures . This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Poli cy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments-GA MCD-PY-1326 Effective Date: 10/01/2022 The REIMBURSEMENT Polic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.A. SubjectInterest Pay ments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any ri ght to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and additional elements, or revisions to data elements, of which the provider has knowledge. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by State and/or Federal regulation defining timeliness and interest requirements. D. Policy I. CareSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations. ( O.C.G.A. 33-24-59.5, O.C.G.A. 33-21A-7 (Second Pass)) II. Payment of interest on original claims is made when CareSource fails to adjudicate original claims within the applicable state and federal prompt pay timeframes on clean claims. III. Payment of interest on adjusted claims st arts on the date the provider disputes the original payment with CareSource. IV. CareSource considers interest payment on claims that were not paid accurately on prior processing attempts. If CareSource had the information to pay the claim correctly on a prev ious payment but failed to do so, CareSource will pay the claim Interest Payments-GA MCD-PY-1326 Effective Date: 10/01/2022 The REIMBURSEMENT Polic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.within the allotted timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe. V. CareSource only pays interest on claim payment that is occurring under prompt pay regulations. A contractual adjustment of a claim is not subject to state and federal regulations for interest payment. VI. CareSource performs regular reviews of our paid claims to correct claim payment. A. Reviews can include items , such as retroactive eligibility updates, authorization updates, coordination of benefits (COB) updates, and fee schedule updates. B. Reviews include proactive measures to correct claim payment when it has been determined that a systemic issue has paid claims incorrectly. C. Claims are not subject to interest payment when CareSource takes proactive measures to pay claims correctly.E. Condit ions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. F. Related Policies/Rules NA G. Revie w/Revision History DATE ACTIONDate Issued 03/31/2021 New PolicyDate Revised 04/27/2022 No changes; Updated references Date Effective 10/01/2022 Date Archived H. References1. Bureau of the Fiscal Service. (2013, January-2021, June). Interest Rates. Retrieved April 5, 2022 from www.fiscal.treasury.gov . 2 . Centers for Medicare & Medicaid Services. (2019, January). Notice of New Interest Rate for Medicare Overpayments and Underpayments-2nd Qtr. Retrieved April 5, 2022 from www.cms.gov . 3. Federal Register. Prompt Payment Interest Rate; Contract Disputes Act. Retrieved April 5, 2022 from www.fiscal.treasury.gov . 4 . Justia US Law. (2020). 2020 Georgia Code Title 33 Insurance Chapter 21A-Medicaid Care Management Organization 33-21A-7 – Bundling of provider complaints and appeals. Retrieved Apri l 5, 2022 from www.justia.com/codes/georgia.Interest Payments-GA MCD-PY-1326 Effective Date: 10/01/2022 The REIMBURSEMENT Polic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.5. Legal Information Institute. 42 CFR 422.520-Prompt payment by MA organization. Retrieved April 5, 2022 from www.law.cornell.edu . 6 . Social Security Association. Sec 1816(c)(2)(B). Retrieved April 5, 2022 from www.ssa.gov . 7 . Social Security Association . Sec 1842(c)(2)(B). Retrieved April 5, 2022 from www.ssa.gov . 8 . United States Government Publishing Office. Title 31, Section 3902. Retrieved April 5, 2022 from www.govinfo.gov . 9 . United States Government Publishing Office. Title 42, Section 7109. Retrieved April 5, 2022 from www.govinfo.gov .The Reimbursement Po lic y Sta te m ent d etai le d a bo ve h as r ecei ved due c on sidera tio n a s d efi ned i n the ReimbursementPolic y St ate m ent Polic y a nd i s a pp ro ved. GA-MED-P-135053 Issue Date 03/31/2021 Approved DCH 06/29/2022

Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center

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

Smoking Cessation

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

Robotic-Assisted Surgery

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

340B Drug Pricing – Archive on July 6, 2023

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

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