REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Modif iers-GA MCD-PY-1353 04/01/2022 Policy Type REIMBU RSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan polici es and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part , or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services a lso include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Mo d ifiers-GAMCD-PY-1353Effective Dat e: 04/01/2022 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectModifiers B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claim s may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ic e staf f are encouraged to use self-service channels to verify a members eligibility. Reimbursement modif iers are a two-digit code that provide a way f or physicians andother qualif ied health care prof essionals to indicate that a service or procedure has been altered by some specif ic circumstance. Modifiers can be f ound in the appendices of both Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) manuals. Use of a modif ier does not change the code or the codes def ini tion. Examples of modif iers use includes: To dif f erentiate between the surgeon, assistant surgeon, and f acility f ee claims f or the same procedure; To indicate that a procedure was perf ormed on the left side, right side, or bilaterally; To report multipl e procedures performed during the same session by the same health care provider; To indicate multiple health care prof essionals participated in the procedure; To indicate a subsequent procedure is due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, use does not guaranteereimbursement. Some modif iers increase or decrease the reimbursement rate, while others do not af f ect the reimbursement rate. CareSource may verif y the use of any modif ier through post-paymen t audit. Using a modif ier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All inf ormation regarding the use of these modifiers must be made available upon CareSources request. C. Def initions Curr ent Procedural Terminology (CPT) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language f or coding and billing medical services and procedures. Healthcare Common Procedure Coding System (H CPCS) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language f or coding and billing of products, supplies, and services not included in the CPT codes. Modifier – two-character codes , used along with a CPT or HCPCS code , to provide additional inf ormation about the service or supply rendered. Mo d ifiers-GAMCD-PY-1353Effective Dat e: 04/01/2022 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is approved.D. Policy It is the responsibility of the submitting provider to submit accurate documentation of services perf ormed. Providers are expected to use the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided according to the f ollowing industry standard guidelines (may not be all-inclusive): National Correct Coding Initiative (NCCI) editing guidelines; American Medical Association (AMA) guidelines; American Hospital Association (AHA) billing rules; Current Procedural Terminology (CPT); Healthcare Common Procedure Coding System (HCPCS); ICD-10 CM and PCS; National Drug Codes (NDC); Diagnosis Related Group (DRG) guidelines; and CCI table edits. The inclusion of a code in a policy does not imply any right to reimbursement or guarantee claims payment. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved CPT/HCPCS codes along with appropriate modif iers, if applicable. Please ref er to the individual Georgia Medicaid f ee schedule f or appropriate codes. Providers must f ollow proper billing, industry standards, and state compliant codes on all cla im submissions. The use of modif iers must be f ully supported in the medical recordand/or of f ice notes. Unless otherwise noted within the policy, CareSource policies apply to both participating and nonparticipating providers and f acilities. Note: In the event of any conf lict between this policy and a providers contract withCareSource, the providers contract will be the governing document.F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 01/20/2022 New PolicyDate Revised Date Effective 04/01/2022 Date Archived H. Ref erences1. Billing 340B Modif iers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved November 1 9, 2021 f rom www.cms.gov. Mo d ifiers-GAMCD-PY-1353Effective Dat e: 04/01/2022 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is approved.2. CPT overview and code approval. (2019, March 22). Retrieved November 1 9, 2021f rom www.ama-assn.org. 3. Med icare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners. (2018, November 30). Retrieved November 1 9, 2021 f rom www.cms.gov. 4. Medicare Claims Processing Manual Chapter 14 – Ambulatory Surgical Centers. (2017, December 22). Retrieved November 1 9, 2021 f rom www.cms.gov. 5. Optum360 EncoderProForPayers.com – Login. (2019, February 18). Retrieved November 1 9, 2021 f rom www.encoderprofp.com. GA-MED-P-1058952 Issue Date 12/15/2021 Ap p ro ved DCH 01/12/2022
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Coordination of Benefits PY-1344 01/01/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing logic, benefit s design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this P olicy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Cov erage ………………………….. ………………………….. ………………………….. ……. 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Coordination of BenefitsGEORGIA MEDICAIDPY-1344 Effective Date: 01/01/2022 2 A. SubjectCoordination of Benefits B. Background The purpose of this guideline is to define the order of coverage and how CareSource will coordinate benefit payments as the secondary payer. CareSource shall coordinate payment for Covered Services in accordance with the terms of a Members Benefit Plan, applicable state an d federal laws, and applicableCMS guidance. If CareSource is not the primary carrier, providers shall bill the primary carrier for all services they provide before they submit their claims to CareSource. Any balance due after receipt of payment from the p rimary carrier should be submitted toCareSource for consideration. The claim must include information verifying the services billed and the payment amount received from the primary carrier. C. Definitions CareSource Provider Agreement The contract between Provider and Plan for the provision of services by Provider to individuals enrolled with Plan, including but not limited to contracts titled Provider Agreement and Group Practice Services Agreement. Coordination of Benefits (COB) The process of deter mining which health plan or insurance policy will pay first and/or determining the payment obligations of each health plan, medical insurance policy, or third party resource when two or more health plans, insurance policies or third party resources cover t he same benefits for CareSource members. Explanation of Payment (EOP) A detailed explanation of payment or denial of a claim by an insurance carrier. Primary Carrier The insurance carrier that has been determined to be responsible for primary payment. D. Policy I. Submitted claims must include total amount billed, total amount paid by primary carrier, and balance due, along with a valid provider signature. Any balance due after receipt of payment from the primary carrier should be submitted to CareSource for consideration and the claim must include information verifying the payment amount received from the primary plan. II. COB GuidelinesA. When CareSource coordinates ben efits with the primary carrier, reimbursement will be made according to the Medicaid contracted maximum allowable minus any payment made by the primary carrier. Any items or services for which another carriers reimbursement amount is equal to or greater t han the Medicaid contracted maximum allowable amount will be paid at zero. Claims that pay at zero are considered to be paid claims, not denied claims. Coordination of BenefitsGEORGIA MEDICAIDPY-1344 Effective Date: 01/01/2022 3 B. When the payment from another insurance carrier is less than the Medicaid contracted amount, CareSo urce will pay up to the Medicaid contracted total allowed amount. The sum of the payments will not exceed the Medicaid contracted maximum allowable amount (as indicated in the CareSource Provider Agreement) . Example 1: Charged Amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $50.00 $10.00 $0 $0 $40.00 CareSource $35.00 $0.00 Summary : In this example, since the primary carrier paid amount of $40.00 is to the Medicaid contracted allowed amount of $35.00, then CareSource pays zero (as indicated in the CareSource Provider Agreement). Example 2: Charged Amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $80.00 $50.00 $0 $0 $30.00CareSource $40.00 $10.00 Summary : In this example, subtract the primary paid amount of $30.00 from theMedicaid contracted allowed amount of $40.00. Therefore, in this example, CareSource will pay $10.00 (as indicated in the CareSource Provider Agreement). Example 3: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $200.00 $0 $200.00 $0 $0.00 CareSource $125.00 $125.00 Summary : In this example, subtract the primary paid amount of $0 from theMedicaid contracted allowed amount of $125.00. Therefore, in this example,CareSource will pay $125.00 which is the total allowed amount (as indicated in the CareSource Provider Agreement ). Example 4: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance Paid Primary Insurance $150.00 $0 $100.00 $40.00 $10.00 CareSource $125.00 $115.00 Coordination of BenefitsGEORGIA MEDICAIDPY-1344 Effective Date: 01/01/2022 4 Summary : In this example, subtract the primary paid amount of $10.00 from theMedicaid contracted allowed amount of $125.00. Therefore, in this example, CareSource will pay $115.0 0 (as indicated in the CareSource Provider Agreement). Example 5: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $150.00 $30.00 $100.00 $0 $20.00CareSource $200.00 $180.00 Summary : In this example, subtract the primary paid amount of $20.00 from theMedicaid contracted allowed amount of $200.00. Therefore, in this example CareSource will pay $180.00 (as indicated in the CareSource Provider Agreement). C. Non-Contracted Providers1. When the payment from another insurance carrier is less than theCareSource Medicaid non-participating reimbursement rate , the sum of the payments will not exceed the Care Source Medicaid non-participating reimbursement rat e. III. COB Timely Filing GuidelinesA. If a provider is aware that a member has primary coverage, the provider should submit a copy of the primary payers EOP along with the claim to CareSource, within the claims timely filing period. 1. If CareSource receives a claim for a member that we have identified as having other coverage and a primary payer EOP was not submitted with the claim(s), CareSource will deny the claim(s) requesting the required COB information. 2. If a claim is denied for COB information needed, the provi der must submit the primary payers EOP. If the initial timely filing period has elapsed, the EOP must be submitted to us within 90 days from the primary payers EOP date. B. If a provider has information that the primary payers policy has terminated or was not in effect during the date of service for the claim(s), the provider must notify CareSource of the dispute within the original timely filing period or within 90 days of the providers actual receipt of the primary payers EOP date, whichever is greate r. C. If the dispute is received within the original timely filing period: 1. CareSource will confirm whether or not the primary payer was in effect during the date of service. If the policy was NOT in effect, CareSource will process the claim(s) that ar e within the original timely filing period or 90 days of the providers actual receipt of the payers EOP date. 2. If the policy WAS in effect, the claim will remain denied for lack of primary payers EOP.D. If the provider does not notify CareSource of the dispute within the original timely filing period or if the provider does not submit the primary payers EOP within 90 Coordination of BenefitsGEORGIA MEDICAIDPY-1344 Effective Date: 01/01/2022 5 days of the providers actual receipt of the Primary Payers EOP date, the claim will re-deny as not being timely filed.IV. COB C laim Submission to CareSourceA. CareSource follows HIPAA guidelines and accepts industry standard codes. It is imperative that claims are filed with the same codes that the primary payer presented on the EOB to ensure that claims are processed correctly. Claim(s) will be denied if there is a mismatch between the codes on the received claim and the primary payers EOP. B. CareSource applies standard claim adjustment codes, which can be found at the following site: https://x12.org/codes/claim-adjustment-reason-codes C. Claim Adjustment G roup Codes are as follows: 1. CO Contractual Obligation 2. OA Other Adjustment 3. PI Payer Initiated Reductions 4. PR Patient Responsibility D. When filing claims with patients responsibility, the following Claim Adjustment Reason Codes should be used: 1. PR1 Deductible 2. PR2 Coinsurance 3. PR3 Copayment E. When filing claims with contractual obligation, please use Adjustment Group Code CO. Contractual obligation can be communicated on the Primary Payers EOB with several different codes . Please use the code reflected on the primary payers EOB. Some examples of these codes are: 24, 45, 222, P24, P25, 26. (This is not an all-inclusive list). The same process should be followed when using Adjustment Group Code OA Other Adjustment. V. Denied COB ClaimsA. Will be automatically adjusted when primary insurance has been updated retroactively to show coverage was terminated at the time of service AND the claim was denied for COB within 90 days of CareSource receiving the notification. B. Will NOT be automatically adjusted if the updated coverage information was received after 90 days from the denial for COB information. In this case, the provider must request claim adjustment within the original timely filing period or within 90 days fro m the date of the EOP denial, whichever is greater. 1. Although CareSource is implementing this COB Adjustment Policy, it is still the providers responsibility to review their accounts and submit COB claims in a timely manner for payment. VI. Disputes for Denied COB ClaimsA If a provider has information that the primary carriers policy has terminated or was not in effect during the date of service for the claim(s), the provider must notify CareSource of the dispute within the original timely filing pe riod or within 90 days of the original denial date or 90 days from the primary carriers EOP date, whichever is greater. Coordination of BenefitsGEORGIA MEDICAIDPY-1344 Effective Date: 01/01/2022 6 1. If the dispute is received within the original timely filing period or within 90 days of the original denial date:B. CareSource wi ll confirm whether or not the primary coverage was in effect during the date of service. If the policy was NOT in effect, CareSource will process the claim(s) that are within the original timely filing period. If the initial timely filing period has elapse d, then we will process the claims that are within 90 days of the original denial. If the policy WAS in effect, the claim will remain denied for needing primary carriers EOP. 1. If the provider does not notify CareSource of the dispute within the origina l timely filing period, within 90 days of the CareSource denial, or if the provider does not submit the primary carriers EOP within 90 days of the Primary Carriers EOP date, the claim will re-deny as not being filed timely. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 10/13/2021 New policy. Approved at PGCDate Revised Date Effective 01 /01/2022 Date Archived H. References 1. Georgia Department of Community Health. Policies and Procedures For Medicaid/PeachCare for Kids (July 1, 2021). Retrieved September 27, 2021 from www.mmis.georgia.gov . 2. CareSource Georgia Medicaid Provider Manual ( March 2020). Retrieved September 27, 20 21 from www.caresource.com . The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.GA-MED-P-964661 Issue Date 10/13/2021 Approved DCH 10/26/2021
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Overpayment Recovery PY-1112 01/ 01/202 2 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims e diting logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 01/01/2022 2 A. SubjectOverpayment Recovery B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies a re not a guarantee of paymen t. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or s ervice that is being provided. Theinclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Retrospective review of claims paid to providers assist CareSource with ensuring ac curacy in the payment process. CareSourc e will request voluntary repayment fromproviders when an overpayment is identified .Fraud, waste and abuse investigations ar e an exception to this policy. In theseinvestigations, the look back period may go beyond 2 years.C. Definitions Claims Adjustment Adjustment is defined as a claim that was previously paid and is being updated for one of the following reasons: o Denied as a zero payment, a partial payment, a reduced payment, a penalty applied, an additional payment or a supplemental paymen t. Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 CFR. o A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. EOP The EOP or Explanation of Payment contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Coordination of Benefi ts (COB) A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the member. Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. Improper Payment A payment that should not have been made or an overpayment was made. Examples include, but are not limited to: o Payments made for an ineligible member; o Ineligible service payments; Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 01/01/2022 3 o Payments made for a service not received; and o Duplicate payments. Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. PLB (Provider Level Balancing) Adjustments to the total check / remit amount occur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total pa yment (BPR, which means total payment within the EOP). Forwarding Balance (FB) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remi ttance advice. It only indicates that a past claim has been adjusted to a different dollar amount and that funds are owed to CareSource. D. Policy I. CareSource will provide all the following information when seeking recovery of an overpayment made to a provid er: A. The name and patient account number of the member to whom the service (s) were provided ; B. The date(s) of services provided ; C. The amount of overpayment; D. The reason for the recoupment ; and E. That the provider has a ppeal rights . II. Overpayment RecoveriesA. Lookback period is 12 months from the last date of service or discharge . B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timef rame is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. III. Coordination of Benefit RecoveriesA. Lookback period is 12 months from the last date of serv ice or discharge . B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filin g limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Retro Active Eligibility RecoveriesA. Lookback period is 12 months from date CareSource is notified by Medicaid of the updated eligibility status. B. Advanced no tification will occur 30 days in advance of recovery. Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 01/01/2022 4 C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected c laims being submitted within original claim timely filing guidelines. V. Management of Claim Credit Balances.A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim cr edit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. 1. This information will be displayed on the EOP in the PLB section. B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpaymen t recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $2 difference. b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D. IV. 2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced p ayment is subject to the guidelines outlines in section D.I D. IV. b. The reduced payment will trigger a 30-day advanced notification with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through clai ms payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. D. Providers are notified of negative balances through (EOPs) and 835s. 1. Providers are expected to use this information to reconcile and maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances. E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. 1. Providers are expected to maintain their Accounts Re ceivable (AR) to account for the reconciliation of negative balances when they occur. VI. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document.Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 01/01/2022 5 E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules CareSource Provider Agreement , ARTICLE V. CLAIMS AND PAYMENTS G. Review/Revision History DATE ACTIONDate Issued 05/05/2020 New policyDate Revised 10/13/2021 Updated definitions. Added D. V. and D. VI. Updated references. Approved at PGC. Date Effective 01/01/2022 Date Archived H. References 1. Georgia Code (201 9). Title 33 Insurance Chapter 20A – Managed Health Care Plans Article 3 – Managed Health Care Plans 33-20A-62. Payment. Retrieved October 4, 2021 from www.law.justia.com The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved. GA-MED-P-964661 Issue Date 05/05/202 0 Approved DCH 10/26/2021
R EIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Obstetrical Care Unbundled cost PY-0924 12/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, cl aims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are pr oper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those ser vices defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may m odify this Policy at any time.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 8 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 2A. Subject Obstetrical Care Unbundled cost B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Obstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members r e c e iv e in a h o s p it a l o r b ir t h in g c e n t e r a s we l l all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedu re Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating prov iders and facilities. C. Definitions Prenatal profile – Initial laboratory services . Initial and prenatal visit – Practitioner visit to determine member is pregnant . Unbundled (partial) obstetrical c are – The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. o Antepartum care (prenatal) – T he initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery. o Delivery services – A dmission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery. Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 3o Postpartum care – Hospital and office visits following vaginal or cesarean section delivery . The American College of Obstetricians and Gynecologists (ACOG ) recommends contact within the first 3 weeks postpartum , ongoing care are needed concluding with a postpartum visit no later than 12 weeks after birth. High risk delivery – Labor management and delivery for an unstable or critically ill pregnant patient. Premature birth – Delivery before 39 weeks of pregnancy . Pregnancy – For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days or 40 weeks. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and management (E/M) codes are utilized when services were provided to diagnose the pregnancy. These are not part of antepartum care . B. Unbundled Obstetric Care – Report the services performed using the most accurate, most comprehensive procedure code available based on what services the practitioner performed. The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. 1. Unbundled o bstetric care s hould be billed when any of the fo llowing occur : a. The member has a change of insurer during pregnancy b. The member has received part of the obstetrical care ( antenatal care , deliver, or postpartum care) elsewhere, e.g. from another group practice c. The member leaves your group practice before the global obstetrical care is complete d. The member must be referred to a provider from another group practice or a different licensure (e.g. midwife to MD) for a cesarean delivery e. The member has an unattended precipitous delivery f. Termination of preg nancy without delivery (e.g. miscarriage, ectopic pregnancy) 2. Antepartum care only Antepartum care only does not include delivery or postpartum care : a. Use the appropriate CPT and trimester code (s): CPT Code DescriptionE/M For antepartum care for 1-3 visits 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits b. For E/M codes, bill with a diagnosis code O09.00 O09.93 , Z33.3;Z34.00-Z34.93 . Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 4c. E/M codes for antepartum care are limited to 3. d. Use the appropriate modifier (This list may not be all inclusive): Modifier Description24 To indicate that the E/M visit was not related to typical postpartum care during the global period e. Only one code, either 59425 or 59426 can be billed per pregnancy.f. Antepartum care only code includes the following (This list may not be all inclusive ): 01. Monthly visits up to 28 weeks gestation 02. Biweekly visits to 36 weeks gestation 03. Weekly from 36 weeks until delivery 04. Fetal heart tones 05. Initial/subsequent hist ory 06. Physical exams 07. Recording of weight/blood pressures 08. Physician/other qualified health care professional providing all or a portion of antepartum/postpartum care, but no delivery 09. Routine chemical urinalysis 10. Termination of pregnancy by abortion 11. Referral to another physician for delivery 3. Delivery only Use i f only a delivery was performed a. Deliveries must be greater or equal to 20 weeks gestation to be billed as a delivery. b. Use the appropriate CPT and delivery outcome code (s): CPT Code Description59409 Vaginal delivery only (with or without episiotomy and/or forceps)59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps)59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery c. Services (This list may not be all inclusive)Services included that may NOTbe billed separatelyServices excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 5Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or forceps Vaginal delivery after prior cesarean section Previous cesarean delivery who present with expectation of vaginal deliverySuccessful vaginal delivery after previous cesarean deliveryCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean delivery Cesarean deliveryClassic cesarean section Low cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesiaArtificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as delivery Delivery of placenta unless it occurs at a separate encounter from the deliveryMinor laceration repairsInpatient management after delivery/discharge services E/M services provided within 24hours of delivery d. Modifiers 01. A modifier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 02. Deliveries with modifiers UB or UD must show medical necessity and medical documentation may be request ed . Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 6e. Use the appropriate modifier (This list may not be all inclusive ): CPT Code DescriptionUB Medically-necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) 4. Delivery and postpartum care only If only delivery and postpartum care were provided a. Use the appropriate CPT and outcome code: CPT Code Description59410 Vaginal delivery only (with or without episiotomy and/or forceps);including postpartum care59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care b. Modifiers01. A modifier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 02. Deliveries with modifiers UB or UD must show medical necessity and medical documentation may be requested. c. Services included in the delivery only and postpartum care codes; and therefore are NOT allowed to be billed separately (This list may not be all inclusive): 01. Admission history 02. Admission to hospital 03. Artificial rupture of membranes 04. Care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 05. Hospital/office visits following cesarean section or vaginal delivery 06. Management of uncomplicated labor 07. Physical exam 08. Vaginal delivery with or without episiotomy or forceps 09. Caesarean delivery 10. Classic cesarean sec tion 11. Low cesarean section 12. Successful vaginal delivery after previous cesarean delivery Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 713. Previous cesarean delivery who present with the expectation of a vaginal delivery 14. Caesarean delivery following unsuccessful vaginal delivery attempt after previous cesar ean delivery 5. Postpartum care only – If postpartum care only was provided: a. Use code 59430 postpartum care only. b. Only one 59430 can be billed per pregnancy as this includes all E/M pregnancy related visits provided for postpartum care. c. There is no specified number of visits included in the postpartum code . This includes h ospital and office visits following vaginal or cesarean section delivery. ACOG recommends contact within the first 3 weeks postpartum. d. Postpartum care may include; and therefore are NOT allowed to be billed separately (This list may not be all inclusive) : 01. Hospital, o ffice and outpatient visits following cesarean section or vaginal delivery 02. Qualified health care professional providing all or portion of antepartum/postpartum care, but no delivery due to referral to another physician for delivery or termination of pregnancy by abortion e. The following are billable separately during the postpartum period (This list may not be all inclusive): 01. Conditions unrelated t o pregnancy i.e. respi ratory tract infection 02. Treatment and management of complications during the postpartum period that require additional services II. Member eligibilityA. If a member was not eligible for Medicaid for the 9 months before delivery, the practitioner MUST use the appropriate delivery only or delivery and postpartum code to be reimbursed. Charges for hospital admission, history and physical or normal hospital evaluation and management services are not reimbursable. B. If a member becomes eligible for Medicaid due to a live birth, no prenatal services including laboratory services are reimbursable . III. Multiple gestations.A. Include diagnosis code for multiple gestations . B. Modifier 51 should be added to the second and any subsequent vaginal births identifying multiple p rocedures were performed . C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 should be added to support substantial additional work. Docume ntation must be submitted with the claim demonstrating the reason and the additional work provided . IV . High risk deliveriesA. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 Supervision of high-risk pregnancy. Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 8B. Modifier 22 may be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided . E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. For antepartum care only (e.g. 59425, 59426) pl ease bill only the final date of service rather than the full date span; failure to do so may result in a timely filing denial . The following list(s) of c odes is provided as a reference. This list may not beall inclusive and is subject to updates.CPT Code Description E/M For antepartum care for 1-3 visits 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59410 Vaginal delivery only (with or without episiotomy and/or forceps);including postpartum care 59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care 59430 Postpartum care only. F. Related Policies/RulesObs tetrical Care Hospital Admissions MM-0850Obstetrical Care Total Cost PY-0231 G. Review/Revision HistoryDATE ACTIONDate Issued 07/01/2017 New Policy. Date Revised 04/01/2020 09/15/2021New title used to be Global Obstetrical Services policy broken into two policies. Updated definitions, reorganized topics, removed total care information, updated most content, included modifiers and updated codes. Added Section E. For antepartum care only Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 12/01/2021 9(e.g. 59425, 59426) please bill only the final date of service rather than the full date span; failure to do so may result in a timely filing denial . Added reimbursement policy language. Removed duplicate modifiers. Update References. Approved at PGC. Date Effective 12/ 01/2021 Date Archived H. References1. The American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redefining the Postpartum Visit. Retrieved September 13, 2021, from www.acog.org 2. American Medical Association. (1997, April). Global OB Codes: Reporting and Use. CPT Assistant . 3. American Medical Association (2015, Jan uary). Maternity Care and Delivery. CPT Assistant. 4. Georgia Department of Community Health Division of Medicaid. (20 21, July 1). PART II Policies and Procedures for Physician Services. Retrieved September 13, 20 21 from www.mmis.georgia.gov 5. American Academy of Professional Coders. (2013, August 1). From Antepartum to Postpartum, Get the CPT OB Basics. Retrieved September 13, 20 21 from www.aapc.com 6. American Academy of Professional Coders. (2011, December). Code Obstetrical Care with Confidence. Retrieved on September 13, 2021 from www.aapc.com 7. EncoderPro.com for Payers Professional. (2019) Retrieved September 13, 2021, from www .encoderprofp.com 8. The American College of Obstetricians and Gynecologists. (n.d.). Coding for Postpartum Services (The 4 th Trimester). Retrieved September 13, 2021, from www.acog.org 9. The American College of Obstetricians and Gynecologists. (n.d.). Reportin g a Services with Modifier 22. Retrieved September 13, 2021, from www.acog.org 10. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Induction of Labor. Retrieved September 13, 2021, www.acog.org 11. Ameri can College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Planned Cesarean Delivery. Retrieved September 13, 2021 from www.acog.org 12. American College of Obstetricians and Gynecologists. (2019), April Correct Coding Initiative Version 25.1. Retrieved September 13, 2021 from www.acog.org 13. American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Care. Retrieve d September 13, 2021, from www.acog.org 14. American College of Obstetricians and Gynecologists. (2019, January). Preterm Labor and Birth. Retrieved September 13, 2021from www.acog.org The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.GA-MED-P-904550 Issue Date 07/01/2017 Approved DCH 09/27/2021
REIMBURSEMENT POLICY STATEMENTGEORGIA M EDICAID Policy Name Policy Number Effective Date Payment to Out of Network Providers PY-1171 12/01/2021 Policy Type Medical Administrative Medicaid REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-stand ard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Pol icy at any time.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Cov erage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Payment to Out of Network ProvidersGEORGIA MEDICAIDPY-1171 Effective Date: 12/01/2021 2 A. SubjectPayment to Out of Network Providers B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies a re not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Heal th care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or s ervi ce that is being provided. Theinclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.This policy is intended to define the reimbursement rate for claims received from providers who are not contracted ( out of network) providers with CareSource.C. Definitions Emergency Services Emergency health care services are used to treat an emergency medical condition. Emergency Medical Condition A medical condition that manifests itself by signs and symptoms of sufficient severity or acuity, including severe pain, such that a prudent layperson would reasonably have cause to believe constitutes a condition that the absence of immediate medical attention could reasonably be expected to result in: o Placin g the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; o Serious impairment to bodily functions; or o Serious dysfunction of any bodily organ or part. Out of Network Providers th at are not part of CareSources network or do not have a signed contract. D. Policy CareSources standard reimbursement approach to out of network providers is as follows: I. Preauthorized, medically necessary services rendered to CareSource members by ou t-of-network providers will be reimbursed at A. 90 % of the Medicaid Fee schedule; and B. 60% of the Medicaid Fee schedule for labs. C. In the case where billed rate for any service provided is lower than the calculated allowed amount , CareSource will reimburse claim line s with the lesser of billed charges and the calculated allowed amount as shown in A or Babove. Payment to Out of Network ProvidersGEORGIA MEDICAIDPY-1171 Effective Date: 12/01/2021 3 II. In the event of any conflict between this policy and any written agreement between the provider and CareSource, tha t written agreement will be the governing document. III. Exclusions:A. Emergency Health Care Services will be reimbursed based on state regulations.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes alo ng with appropriate modifiers. Please refer to the individua l fee schedule s for appropriate codes . F. Related Policies/Rules N/A G. Review/Revision History DATE ACTIONDate Issued 09/15/2021 New policyDate Revised Date Effective 12/01/2021 Date Archived H. References N/A The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved. GA-MED-P-904550 Issue Date 09/1 5/2021 Approved DCH 09/27/2021
REIMBURSEMENT POL ICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Interest Payments PY-1326 09/01/2021-0 0/ 0 0/ 2022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..2 E. Conditions of Co v er ag e ………………………………………………………………………………………..3 F. Related Policies/Rules …………………………………………………………………………………………. 3 G. Review/Revision His t or y ……………………………………………………………………………………….3 H. Ref er en ce s …………………………………………………………………………………………………………3 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding b illin g , coding a nd documentation guidelines. Coding methodology, regulatory requirements, indust ry-sta ndard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Po licy, Reimbursement of services is subject to member benefits a n d e lig ib ility on the date of service, me d ical necessity, adherence to pla n po licie s and procedures, cla ims editing lo gic, provider contractual agreement, an d applicable re f e rral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does n ot ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between th is Po licy and the plan contract (i .e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Policy to serv ice s provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and t rea t me nt of a behavioral health disorder will not be subject to any limita tio n s that are less favorable than the limita tio ns that apply to medical conditions as covered under this policy. 2 A. Subjec tInterest Payments In teres t Pay men ts GEORGIA MEDICAID PY-1326 Effec ti v e Date: 09/01/2021B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote ac c u r at e coding an d policy clarif ication. These proprietary policies ar e not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the ac t u al services provided to a member an d will be determined when the claim is received f or processing. Health care providers and their office s t af f ar e encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the mo st ac c u r at e and appropriate CPT/HCPCS/ICD-10 code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.C. Def initions0078 Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. 0078 Clean Claim A clean claim has no def ect, impropriety, or special circumstance, including incomplete documentation t h at delays timely payment. A provider submits a clean claim by providing the required d at a elements on the s t an d ar d claims f o r ms t h at ar e ac c u r at e at t h e time of payment, along with any attachments and additional elements, or revisions to data elements, attachments and addi tional elements, of which the provider has knowledge. 0078 Original Claim The initial complete claim f or one or more benefits on an application f orm. 0078 Pro mp t Paymen t Prompt payment is def ined by State and/or Federal regulation def ining timeliness and interest requirements. D. Polic yI. We strictly adhere to all regulatory guidelines r elat in g to interest. We f ollow the guidelines outlined in Prompt Payment regulations. (O.C.G.A. 33-24-59.5, O.C.G.A. 33-21A-7 (Second Pass)) II. Payment of interest on original claims is made when CareSource f ails to adjudicate original claims within the applicable state and f ederal prompt pay timef rames on clean claims. III. Payment of interest on adjusted claims starts on the d at e the provider disputes the original payment with CareSource. IV. CareSource considers interest pa yment on claims that were not p aid accurately on prior processing attempts. If CareSource had the inf ormation to pay the claim correctly on a previous payment but f ailed to do so, CareSource will pay the claim
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date COVID-19 Vaccine Reimbursement PY-PHARM-0074 03/15/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. 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. Thi s Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o 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. Car eSource 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. Ac cording 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 …………………………………………………………………………………………………………………. 2 E. Conditions of Cov erage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 03/15/20212A. Subject COVID-19 Vaccine Reimbursement 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 /NDC 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 2019 novel coronavirus, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes the disease known as coronavirus disease 2019 (COVID-19). The Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) f or the following vaccines for the prevention of COVID-19: Pfizer-Bio NTech, Moderna, and Janssen as of February 2021. The Pfizer-BioNTech and Moderna vaccines are offered as a two-dose series. The Janssen vaccine is offered as a single-dose vaccine. The EUA allows the vaccines to be widely distributed in the United States. The Advisory Committee on Immunization Practices (ACIP) has issued interim recommendations for the use of Pfizer-BioNTech, Moderna, and Janssen COVID-19 vaccines for the prevention of COV ID-19 in the U.S. The interim recommendations are derived from the EUA of the vaccines, other data sources, general best practice guidelines for immunization, and expert opinion. The Centers of Medicare and Medicaid Services (CMS) and State Medicaid programs have released toolkits, guidance and bulletins on coverage and reimbursement. Additional considerations will be updated as additional information become available or if additional vaccine products are authorized. C. Policy This reimbursement policy outlines the reimbursement rates for COVID-19 vaccine and associated vaccine administration fees. Providers may bill CareSource through our standard claims processes. The following list(s) of codes is provided as a reference. This list may not be all inc lusive and is subject to updates. Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 03/15/20213HCPCS CodeDescription Reimbursement 91300 SARSCOV2 VAC 30MCG/0.3ML IM (Pfizer-Biontech Covid-19 Vaccine) $0.0 0* 0001A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose (Pfizer-Biontech Covid-19 Vaccine Administration First Dose) $40.00 0002A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose (Pfizer-Biontech Covid-19 Vaccine Administration Second Dose) $40.00 91301 SARSCOV2 VAC 100MCG/0.5ML IM (Moderna Covid-19 Vaccine) $0.0 0* 0011A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose (Moderna Covid-19 Vaccine Administration First Dose) $40.00 0012A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose (Moderna Covid-19 Vaccine Administration Second Dose) $40.00 91303 SARSCOV2 VAC AD26 .5ML IM (Janssen Covid-19 Vaccine) $0.00* 0031A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5×10 10 viral particles/0.5mL dosage, single dose (Janssen Covid-19 Vaccine Administration) $40.00 Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 03/15/20214*Providers should note that the vaccine is available at no charge to providers at this time. Therefore, CareSour ce will pay at zero until further notice. Providers are still ask to bill the vaccine codes for data collection purposes. Pharmacies should submit claims through their pharmacy claims platform through our pharmacy benefits manager, Express Scripts , utilizing appropriate NDC codes and POS National Council for Presription Drug Programs (NCPDP) codes for administration. Please visit the Express Scripts Pharmacist Resource Center for additional information. D. 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. E. Related Policies/Rules COVID-19 Vaccination Administrative Policy F. Review/Revision History DATE ACTIONDate Issued 12/18/2020 New policyDate Revised 03/03/2021 Policy revised to include information about Janssen COVID-19 vaccine. Reimbursement amoun ts updated. Date Effective 03/15/2021 Date Archived G. References 1. Centers for Medicare & Medicaid Services. Toolkit on COVID-19 Vaccine: Health Insurance Issuers and Medicare Advantage Plans. 2. Centers for Medicare & Medicaid Services. Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost Sharing under Medicaid, the Childrens Health Insurance Program, and Basic Health Program . 3. Georgia Department of Community Health. Medicaid-PeachCare Notification 01/11/2021: Oupatient Fee-For-Service Pharmacy Program Important Information. The Reimbursement Policy Statement detai led above has r eceived due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date COVID-19 Vaccine Reimbursement PY-PHARM-0074 12/18/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, 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. Thi s 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. Car eSource 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. Ac cording 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 …………………………………………………………………………………………………………………. 2 E. Conditions of Cov erage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 12/18/20202A. Subject COVID-19 Vaccine Reimbursement 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 /NDC 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 2019 novel coronavirus, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes the disease known as coronavirus disease 2019 (COVID-19). The Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) for two vaccines for the prevention of COVID-19: Pfizer-BioTech and Moderna as of December 2020. Both vaccines are offered as a two-dose series. The EUA allows the vaccines to be widely distributed in the United States. The Advisory Committee on Immunization Practices (ACIP) has issued interim recommendations for the use of Pfizer-BioNTech and Moderna COVID-19 vaccines for the prevention of COVID-19 in the U.S. The interim recommendations are derived from the EUA of the vaccines, other data sources, general best practice guidelines for immunization, and expert opinion. The Centers of Medicare and Medicaid Services (CMS) and State Medicaid programs have released toolkits, guidance and bulletins on coverage and reimbursement. Additional considerations will be updated as additional information become available or if additional vaccine products are authorized. C. Policy This reimbursement policy outlines the reimbursement rates for COVID-19 vaccine and associated vaccine administration fees. Providers may bill Ca reSource through our standard claims processes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 12/18/20203HCPCS CodeDescription Reimbursement 91300 SARSCOV2 VAC 30MCG/0.3ML IM (Pfizer-Biontech Covid-19 Vaccine) $0.0 0* 0001A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose (Pfizer-Biontech Covid-19 Vaccine Administration First Dose) $10.00 0002A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose (Pfizer-Biontech Covid-19 Vaccine Administration Second Dose) $10.00 91301 SARSCOV2 VAC 100MCG/0.5ML IM (Moderna Covid-19 Vaccine) $0.0 0* 0011A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage ; first dose (Moderna Covid-19 Vaccine Administration First Dose) $10.00 0012A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spi ke protein, preservative free, 100 mcg/0.5mL dosage; second dose (Moderna Covid-19 Vaccine Administration Second Dose) $10.00 *Providers should note that the vaccine is available at no charge to providers at this time. Therefore, CareSource will pay at zero until further notice. Providers are still ask to bill the vaccine codes for data collection purposes. Pharmacies should submit claims through their pharmacy claims platform through our pharmacy benefits manager, Express Scripts , utilizing appropriate NDC codes and POS National Council for Presription Drug Programs (NCPDP) codes for administration. Please visit the Express Scripts Pharmacist Resource Center for additional information. Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 12/18/20204D. 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. E. Related Policies/Rules COVID-19 Vaccination Administrative Policy F. Review/Revision History DATE ACTIONDate Issued 12/18/2020 New policyDate Revised Date Effective 12/18/2020 Date Archived G. References 1. Centers for Medicare & Medicaid Services. Toolkit on COVID-19 Vaccine: Health Insurance Issuers and Medicare Advantage Plans. 2. Centers for Medicare & Medicaid Services. Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost Sharing under Medicaid, the Childrens Health Insurance Program, and Basic Health Program . 3. Georgia Department of Community Health. Medi caid-PeachCare Notification 01/11/2021: Oupatient Fee-For-Service Pharmacy Program Important Information. The Reimbursement Policy Statement detai led above has r eceived due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Date Effective Drug Testing PY-0156 04/01/2021-11/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 6 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 6 Reimbursement Policy St at ement : 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, ben efits 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 dis ease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of go od 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 idence 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 contr act (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 sub ject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. 2 A. SubjectDrug Testing Drug TestingGEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encouraged to use self-service channels to verify members 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 does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Drug testing is a part of medical care during the initial assessment, ongoing monitoring,and recovery phase f or members with subst ance use disorder (SUD); for members who are at risk f or abuse/misuse of drugs; or f or other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of concern. Ur ine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive/qualitative and conf irmatory/quantitative. Drug testing is sometimes also ref erred to as toxicology testing. C. Def initions Presumptive/Qualitative test – The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory/Quantitative test – A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or def initive testing. Early and Periodic Screening, Diagnostic and Treatment (EPSDT ) – This benefit provides comprehensive and preventive health care services f or children under age 21 who are enrolled in Medicaid. Rando m drug test – A laboratory drug test administered at an irregular interval that is not known in advance by the member. Independent laboratory – A laboratory certif ied to perform diagnostic and/or clinical tests independent of an institution or a providers office. Participating/non-participating – Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Residential services – Psychiatric Residential Treatment Facilit y (PRTF) services provide comprehensive mental health and substance abuse treatment to children, adolescents, and young adults 21 years of age or younger who, due to severe emotional disturbance, are in need of quality active treatment that can only be 3 Drug TestingGEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 provided in an inpatient treatment setting and f or whom alternative, less restrictive f orms of treatment have been unsuccessf ul or are not medically indicated. PRTFs serve as the most intensive, inpatient treatment f or youth/young adults with severe behavioral health disorders. 1 NOTE: Clinical guidelines, definitions, standards, and scenarios f or drug testing are outlined in detail within the CareSource Drug Testing Medical Policy. Please ref er to this policy f or in-depth information on medical necessity f or drug testing, documentation requirements, and CareSource monitoring and review of drug testing claims. D. Poli cyI. General Criteria f or Coverage A. Documentation must support medical necessity. B. Documentation must include the ICD-10 code demonstrating appropriate indication f or UDT. C. The submitted CPT/HCPCS code must accurately describe the service perf ormed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims f orms. II. Prior Authorization (PA)A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they f all within the standards of care under EPDST guidelines. 1. PA is required f or UDT f or members when a conf irmatory test f or greater than 14 drug classes (Codes G0482 & G0483) are ordered . These higher number drug panels are rarely indicated f or routine urine drug testing as lower number panels are suf f icient for modifying treatment plans in the majority of cases. 2. PA is not required in an emergency room setting. UDT utilization will be monitored by CareSource. 3. PA needs to make a clear case f or medical necessity f or the level of testing being requested. B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process is complete i.e. f reezing specimen. C. Must submit appropriate clinical documentation with PA request to determ ine appropriate medical necessity. D. If needed, the licensed practitioner that is operating in his/her scope of practice must obtain the prior authorization. III. Quantity LimitationsA. CareSource will reimburse up to 25 UDT in a calendar year f or each member. 1. Each CPT code is counted as one test toward the 25 total drug tests in a calendar year. 1 www.m m is.georgia .gov4 Drug TestingGEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 2. UDT G0482 and G0483 (requiring a PA as noted above) will also count toward the 25 total UDT in a calendar year. B. Only one presumptive testing CPT code may be billed per member per day. C. Only one conf irmatory testing CPT code (drug class) may be billed per member per day. IV. LaboratoryA. Drug testing conducted f or CareSource members by non-participating labs or f acilities is not billable to and will not be reimbursed by CareSource, even if suc h tests were ordered by a participating provider. B. Non-participating providers are not covered for drug testing laboratory services. C. CareSource laboratories perf orming drug testing services must bill CareSource directly. CareSource does not allow pass-throu gh billing of services . Any claim submitted by a provider which includes services ordered by that provider, but are perf ormed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource. V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive health care service f or children under age 21. VI. Non-Urine TestingA. CareSource will reimburse blood testing in emergency room settings. B. Drug testing with blood samples perf ormed in any other setting outside of an emergency room is a non-covered benefit. C. Hair, saliva, or other body f luid testing f or controlled substance monitoring has limited support in medical evidence and is not covered VII. Conf irmatory TestingA. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource. B. Conf irmatory testing must be individualized f or the member and medically necessary. Routine conf irmatory dru g tests with negative presumptive results are not covered by CareSource. C. Conf irmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modif ication of treatment plan, consultation with specialist and one of the f ollowing: a. Presumptive testing was negative f or prescription medications and provider was expecting the test to be positive f or prescribed medication and member reports taking medication as prescribed; b. Presumptive testing was positive f or prescription drug with abuse potential that was not prescribed by provider and the member disputes the presumptive testing results; c. Presumptive testing was positive f or illegal drug and the member disputes the presumpti ve testing results; or d. A substance or metabolite is needed to be identif ied that cannot be identif ied by presumptive testing. (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VIII. Non-Billable Drug Testing5 A. Testing that is not individualized such as1. Ref lexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing required by third parties such as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing f or pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery f or physicians, dentists, veterinarians, pharmacists, etc.). 4. School entry or testing f or athletics. 5. Testing required for military service. 6. Testing in residential f acility, partial hospital, or sober living as a condition to remain in that community. 7. Testing with another pay source that is primary such as a county, state or f ederal agency. 8. Testing f or marriage license. 9. Forensic. 10. Testing f or other admin purposes. 11. Routine physical/medical examination EXCEPT f or the EPSDT program. C. Testing f or validity of specimen It is included in the payment f or the test and will not be reimbursed separately. D. Blood drug testing when completed outside of the emergency room. E. Hair, saliva, or other body f luid testing f or controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing f ollowing a negative presumptive expected result. I. Custom Prof iles, standing orders, drug screen panel, custom panel, blanket orders, ref lex testing or conduct additional testing as needed orders. K. A conf irmatory test p rior to discussing results of presumptive test with member. NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule for appropriate codes. 6 F. RELATED POLIC IES/RULESCareSo urce Drug Testing Medical Policy G. REVIEW/REVISION HISTORY Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 DATE ACTIONDate Issued 11/29/2017Date Revised 09/01/2019 07/22/202009/02/2020Up d ated clinical indications, quantity limits, and prior autho rizatio ns requirements Up d ated IV Up d ated codes and removed PA for non-p articipating Date Effective 04/01/2021 Date Archived 11/30/2021 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. REFERENCES1. A. Jaf f e, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016, January). Review and recommendations f or drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . 2(1): 28-45. doi: 10.17756/jrdsas.2016-025 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of def initive drug testing results in their work with substance – use patients: A qualitative study. International Journal of Mental Health and Addiction. (14) 64-80. doi: 10.1007/s11469-015-9569-7 3. American Society of Addiction Medici ne. (2017, May/June). Appropriate use of drug testing in clinical addiction medicine. 11(3) 163-173. doi: 10.1097/ADM.0000000000000323 4. Andersson, H. W., Wenaas, M., & Nordf jrn, T. (2019). Relapse af ter inpatient substance use treatment: A prospective cohort study among users of illicit substances. Addictive Behaviors, (90)222-228. doi:10.1016/j.addbeh.2018.11.008 5. American Society of Addi ction Medicine (2010, October) . Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings . Retrieved August 12, 2020 from www.asam.org. 6. Dowel l, D., Haegerich, T. M., & Chou, R. (2016, March). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016 . Retrieved August 12, 2020 f rom www.cdc.gov 7. eCFR Code of Federal Regulations. 42 Code of Federal Regulations (CFR) Part 8. (n.d.). Retrieved August 12, 2020 f rom www.ecfr.gov 8. Gourlay, D. L., Heit, H. H., & Caplan, Y. H. (2015, August 31). Urine Drug Testing in Clinical Practice The Art and Science of Patient Care (Edition 6). PharmaCom Group Inc./Center for Independent Healthcare Education 9. Jarvis, M, Williams, J, Hurf ord, M, Li ndsay, D, Lincoln, P, Giles, L, Luongo, P,..Saf arian, T. (2017, April 5). Appropriate Use of Drug Testing in Clinical Addiction Medication. Journal of Addiction Medicine . Retrieved August 12, 2020 f rom www.dca.ca. gov 10. Medicare Learning Network. (2020, May). CLIA Program and Medicare Laboratory Services. Retrieved August 12, 2020 f rom www.cms.gov 7 Drug TestingGEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 11. National Academies of Sciences, Engineering, and Medicine. 2017. Pain Owen, G, Burton, A, Schade, C, Passik, S. (2012). Urine Drug Testing: Current management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use . Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24781 .Recommendations and Best Practices. Pain Physician Journal . 15, ES119-ES133. Retrieved August 12, 2020 from www.painphysicianjournal 12. Reisf ield, MD, G. M., Webb, PhD, F. J., Bertholf, PhD, R. L., Sloan, MD, P. A., & Wilson, MD, G. R. (2007). Family physicians prof iciency in urine drug test interpretation. Journal of Opioid Management , 3(6), 333. doi:10.5055/jom.2007.0022 13. Substance Abuse and Mental Health Services Administration. Clinical Drug Testing in Primary Care. Technical Assistance Publication (TAP) 32. HHS Publication No. (SMA) 12-4668. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. 14. Stanos, S. P. (2017, October 10). Presidents Message. National Academies of Sciences, Engineerin g, and Medicine (NASEM). Pain Medicine. 18(10). 1835-1836. doi:10.1093/pm/pnx224 15. U.S. Department of Veterans Af fairs. (2017, February). VA/DoD Clinical Practice Guideline f or Opioid Therapy for Chronic Pain. Retrieved August 12, 2020 from www.va.gov 16. Agency Medical Directors Group. (2010). Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. Retrieved August 12, 2020 f rom www.agencymed directors.wa.gov 17. GAMMIS. Policies and Procedures for Ind ependent Laboratory Services (2020, July). Retrieved February 26, 2019 from www.mmis.georgia.gov 18. GAMMIS. Policies and Procedures for Physician Services (2020, July 1). Retrieved February 26, 2019 f ro m www.mmis.georgia.gov Th e Reimbursemen t Po licy Statemen t d etailed above h as received d ue co nsideratio n as d efined in th eReimbursemen t Po licy Statemen t Po licy an d is ap proved .GA-MED-P-383892 Issue d ate 11/29/2017 DCH Ap p ro ved 12/31/2020
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-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 serv ice(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 (MHP AEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center PY-0847 01/01/2021-07/31/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of Contents Reimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject …………………………………………………………………………………………………………………. 2 B. Background …………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………….. 2 D. Policy …………………………………………………………………………………………………………………… 4 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 8 G. Review/Revision History …………………………………………………………………………………………. 8 H. References …………………………………………………………………………………………………………… 8 2 A. SubjectDental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Most dental care can be provided in a traditional dental office setting with local anesthesia and if medically nec essary, a continuum of behavior guidance strategies, ranging from simple communicative techniques to nitrous oxide, enteral or parenteral sedation. Monitored Anesthesia Care or Sedation (Minimal, Moderate or Deep) may be a 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 Anesthesiologist s (ASA), there are certain situations where appropriate candidates may require as a medical necessity, general anesthesia in a healthcare facility such as an Ambulatory Surgical Center or Outpatient Hospital facility.C. D EFINITIONS Ambulatory Surgical 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 admit 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 hospit al. The term does not include individual 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 Hospital-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 nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.3 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 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 hospitalization or institutionalization. SPU Short procedure unit-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 spontaneous ventilation is adequate. Cardiovascular func tion is usually maintained. 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. ** Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. 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 positive 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 how an individual patient will respond. Hence, 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 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.4 D. PolicyDental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 Most 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 surgical 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 in a Hospital or Ambulatory Surgical 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 setting. 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, and ASC facility requests is the 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 mandated 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 authorization A. A prior authorization is required for all Hospital Inpatient or Outpatient Facility or Ambulatory Surgery 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 the 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 surgical 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. 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 AND; 02. Review the pre-determination letter (PDL) or authorization AND; 03. Determine medical necessity for any other non-dental CPT/HCPCS codes submitted AND; 04. The Medical Management approval of D9420 is sent via a letter 5 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center GEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 to the facility, member, and Treating Dentist. This letter indicates approval of D9420 for (19) Off Campus-Outpatient Hospital, (21) Inpatient Hospital, (22) On Campus-Outpatient Hospital, or (24) Ambulatory Surgical Center setting and General Anesthesia Services if applicable. I I. Additional guidelines on the benefit limits/frequencies of D9420 can be found in theDental Health Partner Provider Manual. NOTE: Please remember that the provider who submits the authorization for the dental therapeutic services must be the provider that performs the services. If the authorized 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 Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes.T he following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates.R evenue codes and additional information can be found in the Department ofCommunity Health and ASC Policy manuals as well as the Dental Health PartnerProvider Manual.Outpatient Hospital Facility (SPU) POS (19, 22) CPT Code Description D9420 D9420 for the technical component to the facility SPU/OR use is calculated in time units 1 unit = 30 minutes. The maximum units reimbursable per date of service is 6 units Operating Room-When a hospital outpatient, SPU or organized outpatient clinic operating room is used for patient dental services, a single HCPCS code for reporting the facility technical component of multiple dentoalveolar procedures is used. That code must be utilized rather than reporting the tests or procedures individually. (CPT/HCPCS code 41899, discontinued by State, should not be used). Facility should use D9420 with appropriate billed charges of OR time use for dental services performed. Any other Dcodes listed will be for procedural documentation only and not for reimbursement. 6 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 No HCPCS required Recovery Room – 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 the same date of service as a surgery that is not considered a common office procedure. No HCPCS required HCPCS required for revenue code 0636* Hospital Add-On (HAO) services only applicable if state or contract required. Separate reimbursement may not be applicable. Maximum allowances may be applicable0017000170 is calculated in CMS Base units. The Base unit =5 units. Reimbursement will be subject to maximum allowances. Anesthesia Services-Anesthesiology professional Services for intraoral procedures. 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 min increments). CMS Base units =5. Maximum state allowances may be applicable.Inpatient Hospital Facility POS (21) All of the above facility codes 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 Ambulatory Surgical Center POS (24)CPT Code DescriptionD9420 D9420 for the technical component to the facility or ASC use is calculated in time units 1 unit = 30 minutes. The maximum units reimbursable per date of service is 6 units. Operating Room-A single code for reporting the facility fee must be used for the ASC or Facility should use D9420. (CPT/HCPCS code 41899), discontinued by State, should not be used. CareSources policy is aligned with State policy is D9420 is used a global code for ASC facility services. 7 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 00170 00170 is calculated in CMS Base units. The Base unit =5 units. Reimbursement will be subject to maximum allowances. General Anesthesia for intraoral procedures, including biopsy; not otherwise specified-Anesthesiology professional Services for intraoral procedures. 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 plac e. Total minutes are listed as the units (i.e. 75 minutes) 75 = 6 units (of 15 min increments). CMS Base units =5. Maximum state allowances may be applicable. Dental/Oral Surgery Professional Services 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 Dental Health Partner manual for clinical guidelines, policies and procedures CPT Code Description(D0000 – D9999) Reimbursed according to provider contractual rate Dental Services using the CDT codes-Follow applicable clinical policy guidelines in Dental Health Partner Provider Manual Dental service charges will be paid directly to the TREATING DENTIST PAYEE GORUP All dental services that require authorization must receive prior authorization via Dental Management. ICD-10 and CPT code for Oral or Maxillofacial region Other Services Oral or Macillofacial Services using CPT codes – Follow applicable benefit guidelines in Health Partner manual for CPT code All medical services of th e oral, maxillofacial, head and neck regions performed in the hospital/ASC must receive prior authorization from the Medical Management team 8 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center GEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 F.Related Policies/RulesG. Review/Revision History DATE ACTION Date Issued 10/01/2019 New Policy Date Revised 08/19/2020 Removed PA for CPT 00170. Date Effective 01/01/2021 Date Archived 07/31/2022This 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. Part II Policies and Procedures for Ambulatory Surgical and Birthing Center Services(2020, July). Retrieved on July 3, 2020 from www.mmis.georgia.gov2. P art II Policies and Procedures for Dental Services (2020, July). Retrieved on July30, 2020 from www.mmis.georgia.gov3. P art II Policies and Procedure for Hospital Services (2020, July). Retrieved on July30, 2020 from www.mmis.georgia.gov4. C ontinuum of Depth of Sedation: Definition of General Anesthesia and Levels ofSedation/Analgesia. (2018, October 23). Retrieved July 30, 2020, from www.asahq.org5. A merican Academy of Pediatric Dentistry. Oral Health Policies andRecommendations. (2019). Retrieved July 20, 2020 from www.aapd.org6. A merican Association of Oral and Maxillofacial Surgeons, Ambulatory SurgicalCenter Coding and Billing. Retrieved April 5, 2019 from www.aaoms.orgThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
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