REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Laboratory Testing in Office Setting-GA MCD-PY-1462 08/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates ar e 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 Reimbursem ent 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, a nd 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 o f 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 mandat e, 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 r eferred 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 docume nt 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 Heal th 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 pol icy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 8 Laboratory Testing in Office Setting-GA MCD-PY-1462Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectLaboratory Testing in Office Setting B. BackgroundDuring the course of an office visit with a physician or other qualified healthcare provider, the provider may determine that diagnostic laboratory testing is necessary to establish a diagnosis and/or determine treatment options to manage the members current health issues. W hile most laboratory tests are best performed by an independent laboratory, in some instances, results from these laboratory tests are needed immediately to manage urgent medical conditions or medical emergencies and may be performed appropriately in the p hysicians office. Due to the complexity of laboratory tests and regulations around facilities that perform these tests, only laboratory procedures on the short turnaround time ( STAT ) code list may be performed in the office, while all other tests should b e referred to an independent, contracted lab oratory provider. C. Definitions Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Laboratory A facility for the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings . These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body. Facilities only collecting or preparing specimens (or both) or only serving as a mailing servi ce and not performing testing are not considered laboratories. Laboratory Procedures Defined in the Current Procedural Terminology (CPT) in the ranges 80300 through 89398 and panels 80047 through 80076. D. PolicyI. CareSource will reimburse for laboratory procedures performed in the physicians office when ALL the following apply: A. The test results are needed immediately in order to manage urgent or emergent medical situations. B. The CPT code for the test is on the short turnaroun d time (STAT) code list . C. The place of service (POS) 11 is used. II. All other laboratory procedures performed in the office may not be reimbursed and should be referred to an independent, contracted laboratory provider. E. Conditions of CoverageIt 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 Laboratory Testing in Office Setting-GA MCD-PY-1462Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 inclusion of a code in this policy does not imply any right to reimbursement or guarant ee claims payment. Please refer to the individual fee schedule for appropriate codes. Place of Service (POS) CodeDescription 11 – Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis STAT Code ListCPT / HCPCS Descri ption 0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 0223U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavi rus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), includes titer(s), when performe d 0225U Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV – 2), amplified probe technique, including multiplex reverse transcrip tion for RNA targets, each analyte reported as detected or not detected 0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), ELISA, plasma, serum 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when perform ed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), inclu des sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC – MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service 80324 Amphetamines; 1 o r 2 80325 Amphetamines; 3 or 4 80326 Amphetamines; 5 or more 80327 Anabolic steroids; 1 or 2 80328 Anabolic steroids; 3 or more 80329 Analgesics, non-opioid; 1 or 2 80330 Analgesics, non-opioid; 3-5 Laboratory Testing in Office Setting-GA MCD-PY-1462Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 80331 Analgesics, non-opioid; 6 or more80332 Antidepressants, serotonergic class; 1 or 280333 Antidepressants, serotonergic class; 3-5 80334 Antidepressants, serotonergic class; 6 or more 80335 Antidepressants, tricyclic and other cyclicals; 1 or 2 80336 Antidepressants, tricyclic and other cyclicals; 3-5 80337 Antidepressants, tricyclic and other cyclicals; 6 or more 80338 Antidepressants, not otherwise specified 80339 Antiepileptics, not otherwise specified; 1-3 80340 Antiepileptics, not otherwise specified; 4-6 80341 Antiepilept ics, not otherwise specified; 7 or more 80342 Antipsychotics, not otherwise specified; 1-3 80343 Antipsychotics, not otherwise specified; 4-6 80344 Antipsychotics, not otherwise specified; 7 or more 80345 Barbiturates 80346 Benzodiazepines; 1-12 80347 Benzodiazepines; 13 or more 80348 Buprenorphine 80349 Cannabinoids, natural 80350 Cannabinoids, synthetic; 1-3 80351 Cannabinoids, synthetic; 4-6 80352 Cannabinoids, synthetic; 7 or more 80353 Cocaine 80354 Fentanyl 80355 Gabapentin, non-blood 80356 Heroin metabolite 80357 Ketamine and norketamine 80358 Methadone 80359 Methylenedioxyamphetamines (MDA, MDEA, MDMA) 80360 Methylphenidate 80361 Opiates, 1 or more 80362 Opioids and opiate analogs; 1 or 2 80363 Opioids and opiate analogs; 3 or 4 80364 Opioids and opiate analogs; 5 or more 80365 Oxycodone 80366 Pregabalin 80367 Propoxyphene 80368 Sedative hypnotics (non-benzodiazepines) 80369 Skeletal muscle relaxants; 1 or 2 80370 Skeletal muscle relaxants; 3 or more 80371 Stimulants, synthetic 80372 Tapentadol 80373 Tramadol 80374 Stereoisomer (enantiomer) analysis, single drug class 80375 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3 80376 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6 Laboratory Testing in Office Setting-GA MCD-PY-1462Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 80377 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more83992 Phencyclidine (PCP)81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy 81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy 81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy 81003 Urinalysis, by dip stick or tablet reagent for bilirubi n, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 81005 Urinalysis; qualitative or semiquantitative, except immunoassays 81015 Urinalysis; mi croscopic only 81025 Urine pregnancy test, by visual color comparison methods 82043 Albumin; urine (eg, microalbumin), quantitative 82044 Albumin; urine (eg, microalbumin), semiquantitative (eg, reagent strip assay) 82247 Bilirubin; total 82270 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection) 82271 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources 82272 Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening 82465 Cho lesterol, serum or whole blood, total 82565 Creatinine; blood 82731 Fetal fibronectin, cervicovaginal secretions, semi-quantitative 82947 Glucose; quantitative, blood (except reagent strip) 82948 Glucose; blood, reagent strip 82950 Glucose; post glucose dose (includes glucose) 82951 Glucose; tolerance test (GTT), 3 specimens (includes glucose) 82952 Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) 82962 Glucose, blood by glu cose monitoring device(s) cleared by the FDA specifically for home use 83036 Hemoglobin; glycosylated (A1C) 83037 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use 83655 Lead 83861 Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity 83986 pH; body fluid, not otherwise specified 84132 Potassium; serum, plasma or whole blood 84703 Gonadotropin, chorionic (hCG); qualitative 85013 Blood count; spun microhematocrit 85014 Blood count; hematocrit (Hct) 85018 Blood count; hemoglobin (Hgb) Laboratory Testing in Office Setting-GA MCD-PY-1462Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count85027 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)85049 Blood count; platelet, automated 85610 Prothrombin time; 85651 Sedimentation rate, erythrocyte; non-automated 86308 Heterophile antibodies; screening 86318 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip); 86328 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV – 2) (coronavirus disease [COVID-19]) 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); screen 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); titer 86580 Skin test; tuberculosis, intradermal 86756 Antibody; respiratory syncytial virus 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87070 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates 87172 Pinworm exam (eg, cellophane tape prep) 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 87210 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) 87220 Tissue examination by KOH slide of sampl es from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies) 87270 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis 87301 Infectious agent antigen detection by immunoassay technique, (eg, enzym e immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; adenovirus enteric types 40/41 87400 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Influenza, A or B, each 87426 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavir us (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) 87428 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qua litative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B 87430 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], Laboratory Testing in Office Setting-GA MCD-PY-1462Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Streptococcus, group A87490 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 87492 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87802 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group B 87803 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) obs ervation; Clostridium difficile toxin A 87804 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza 87806 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies 87807 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus 87808 Infectious agent antigen detection by immunoassay with direct optica l (ie, visual) observation; Trichomonas vaginalis 87811 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87880 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A 87905 Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid) C9803 Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), any specimen source G0480 Drug test(s), definitive, utilizing (1) drug identification methods able to identify i ndividual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including meta bolite(s) if performed G0481 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/M S (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for mat rix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and Laboratory Testing in Office Setting-GA MCD-PY-1462Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 mass spectral drift); qualitative or quantitative, all so urces, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed G0659 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomer s (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), p erformed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitat ive or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes G2023 Specimen collection for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source Q0111 Wet mounts, including preparat ions of vaginal, cervical or skin specimens Q0112 All potassium hydroxide (KOH) preparations U0001 CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel U0002 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, mult iple types or subtypes (includes all targets), non-CDC U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique, making use of h igh throughput technologies as described by CMS-2020-01-R U0004 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by C MS-2020-01-R F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 08/28/2024 New policy. Approved at Committee.Date Revised 12/18/2024 Review: policy pulled from implementation to remove CLIA and QW modifier language . Approved at Committee. Date Effective 08/01/2025 Date Archived H. References1. CPT Code Detail. Optum Encoder Pro; 202 4. Accessed December 18 , 2024 . www.encoderprofp.com 2. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions, 42 U.S.C. 410.32 (2023). 3. HCPCS Code Detail. Optum Encoder Pro; 202 4. Accessed December 18 , 2024 . www.encoderprofp.com 4. Laboratory Requirements, 42 U. S.C. 493 ( 2023 ). 5. Laboratory Services, 42 U.S.C. 441.17 (2023). Laboratory Testing in Office Setting-GA MCD-PY-1462Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.9 6. Other Laboratory and X-Ray Services, 42 U.S.C. 440.30 (2023).7. Place of Service Code Set. Centers for Medicare and Medicaid Services; 202 4. Accessed December 18 , 2024 . www.cms.gov 8. Policies and Procedures, II: Physician Services. Georgia Dept of Community Health, Division of Medicaid; 202 4. Revised July 1, 202 4. Accessed December 18 , 2024 . www.mmis.georgia.gov 9. Policies and Procedures, II: Diagnostic Screening and Preventive Services. Georgia Dept of Community Health, Division of Medicaid; 202 4. Revised July 1, 2024. Accessed December 18 , 2024 . www.mmis.georgia .gov GA-MED-P-3611852 Issue date 08/28/2024 Approved DCH 04/30/2025
REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Interest Payments-GA MCD-PY-1326 08/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A.Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments-GA MCD-PY-1326 Effective Date: 08/01/2025 The REIMBURSEMENT Policy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.2 A. Subject Interest Pay ments B. Background Reimbursement policies are designed to assist providers when submitting claims toCareSource. 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 bees tablished based upon a review of the actual services provided to a member and will bedet ermined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility.I t is the responsibility of the submitting provider to submit the most accurat e and appr opriate CPT/HCPCS /ICD-10 code(s) for the product or service that is bei ng pr ovided. The inclusion of a code in this policy does not imply any right t o r eimbursement or guarantee claims payment. C. Definitions Adjusted Claim A claim that is the result of a request by the provider orCareSource to change historical data or reimbursement of an original claim.Clean Claim A claim that has no defect, impropriety, or special circumstance,including incomplete documentation to delay timely payment. A provider submits ac lean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and additional elements, or revisions to data elements, of which the provider has knowledge.Original Claim The initial complete claim for one or more benefits on an application form.Prompt Payment Prompt payment is defined by state and/or f ederal regulati on def ining timeliness and interest requirements.D.PolicyI. C areSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations. (O.C.G.A. 33-24-59.5, O.C.G.A. 33-21A-7 (Second Pass)) I I. Payment of interest on original claims is made when CareSource fails to adjudicate original claims within the applicable state and federal prompt pay timeframes on c lean claims. II I. Payment of interest on adjusted claims starts on the date the provider disputes t he or iginal payment with CareSource. I V. CareSource considers interest payment on claims that were not paid accurately onpr ior processing attempts. If CareSource had the information to pay the claim correctly on a previous payment but failed to do so, CareSource will pay the claim Interest Payments-GA MCD-PY-1326 Effective Date: 08/01/2025 The REIMBURSEMENT Policy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.3 within the allotted timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe. V.C areSource only pays interest on claim payment that is occurring under Prompt Pa y r egulations. A contractual adjustment of a claim is not subject to state and federal regulations for interest payment. VI . CareSource performs regular reviews of paid claims to correct claim payment.A. Reviews can include items , such as retroactive eligibility updates, authorizati on updat es, coordination of benefits (COB) updates, and fee schedule updates.B. Reviews include proactive measures to correct claim payment when it has beendet ermined that a systemic issue paid claims incorrectly.C. Claims are not subject to interest payment when CareSource takes proactiv e m easures to pay claims correctly. E.Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. F. Related Policies/Rules NA G.Review/Revision History DATE ACTION Date Issued 03/31/2021 New Policy Date Revised 04/27/2022 04/12/2023 01/ 31/2024 01/15/2025 No changes; Updated references No changes; Updated references. Approved by committee. Updated references. Approved at Committee Updated references. Approved at Committee Date Effective 08/01/2025 Date Archived H.R eferences1. Appropriations Available for Joint Financing, 31 U.S.C. 7109 (2022).2. Bundling of Provider Complaints and Appeals , G A CODE ANN . 33-21A-7(2023).3. Interest Penalties, 31 U.S.C. 3902 (2022).4. Interest Rates . Bureau of the Fiscal Service. (January 2017-June 2024).Accessed December 3, 2024. www.fiscal.treasury.gov5. Notice of new interest rate for medicare overpayments and underpayments . C enters for Medicare & Medicaid Services . Updated October 10, 2023. Accessed December 3, 2024. www.cms.gov6. Prompt Payment by MA Organization, 42 C.F.R. 422.520 (2022). Interest Payments-GA MCD-PY-1326 Effective Date: 08/01/2025 The REIMBURSEMENT Policy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.4 7. Prompt Payment Interest Rate; Contract Disputes Act. Accessed December 3,2024. www.fiscal.treasury.gov8. Social Security Association. Sec 1816(c)(2)(B ). Accessed December 3, 2024. www.ssa.govGA-MED-P-3611852 Issue Date 03/31/2021 Approved DCH 04/30/2025
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Diagnostic Colonoscopy and/or Sigmoidoscopy-GA MCD-PY-1598 08/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Diagnostic Colonoscopy and/or Sigmoidoscopy-GA MCD-PY-1598 Effective Dat e: 08/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDiagnostic Colonoscopy and/or Sigmoidos copy B. BackgroundColo no scopies and sigmoidoscopies pertain to procedures that involve direct visual examination of the lower gastrointestinal tract using a flexible tube fitted with a camera. The procedures identify polyps, tumors, and other intestinal irregularities or health i ssues and are performed by medical professionals, typically gastroenterologists or colorectal surgeons. Both procedures are valuable tools in diagnosing and monitoring gastrointestinal conditions. Specific clinical indications and area of examination deter mine which procedure will be utilized. There are different billing procedures for screening versus diagnostic colonoscopies andsigmoidoscopies. Screening procedures are typically performed as part of preventive services for cancer or other health issues. Diagnostic procedures can include patient signs or symptoms in the lower gastrointestinal tract (eg, constipation, rectal bleeding, blood in stool, diarrhea), polyps within the past 10 years or other positive-stool-based tests or computed tomography (C T) colonographies that require follow-up. Similarly, some screening procedures can become diagnostic procedures if practitioners find health issues to address (eg, mass needing biopsy, polyps) while performing initial screening procedures . Both screening and diagnostic procedures utilize the same equipment, so it is imperative to maintain thorough documentation in the members medical records to substantiate medical necessity of these tests and differentiate between screening and diagnostic ser vices . This policy exclusively pertains to diagnostic colonoscopies and does not apply topreventive screenings that follow US Preventive Services Task Force (USPSTF) or other preventive guidelines. Refer to the appropriate Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes for screenings (ie, G0104, G0105, G0121). Providers are encouraged to use modifiers when procedures meet modifier criteria. CareSource follows the Georgia Department of Community Health (DCH) Provid er Manuals and information, as well as the Georgia Code. Any information provided in those sources supersede this policy, which is provided as a courtesy only. C. Definitions Colonoscopy A procedure in which a physician inserts a flexible tube fitted with a camera through the anus into the rectum to examine the entire length of the colon from the rectum to the cecum and may include the terminal ileum allowing for screening and diagnosis of health issues. Sigmoidoscopy A procedure similar to a colonoscopy that examines the lower third of the large intestine , the rectum, sigmoid colon and possibly a portion of the descending colon, for screening and diagnosing health conditions. Diagnostic Colonoscopy and/or Sigmoidoscopy-GA MCD-PY-1598 Effective Dat e: 08/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. PolicyI. CareSource requires appropriate documentation of medical necessity and valid diagnosis codes for reimbursement of diagnostic colonoscopies and sigmoidoscopies. Claims submitted without supporting medical necessity or correct coding will be denied. Refer to the approp riate DCH provider manual for assistance with documentation. II. CareSource follows DCH guidelines regarding billing for diagnostic colonoscopies and sigmoidoscopies. A. Reimbursement requests must include a procedure code with a diagnosis code that best describes the condition for which the service was performed. B. If the service begins as a screening procedure but results in a diagnostic or therapeutic procedure at the same operative session, health care providers should report an appropriate screening International Classification of Diseases (ICD) diagnosis code as the primary diagnosis and the diagnostic or abnormal finding ICD diagnosis code as the secondary or subsequent diagnosis. C. If the member is symptomatic or the claim for these services indicates a primary diagnosis of something other than preventive or wellness, colonoscopy examinations will be covered as a diagnostic service , not a preventive health care service . III. If, during a screening colonoscopy and/or sigmoidoscopy, a lesion or growth is detected that results in a biopsy or removal, the appropriate diagnostic procedure classified with biopsy or removal should be billed, not screening codes. All procedures must be performed by a Doctor of Medicine or Osteopathy. E. Conditions of CoverageI. ICD-10 codes must be coded to the highest level of specificity. II. CareSource reserves the right to request medical record documentation from providers.F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATE ACTIONDate Issued 03/26/2025 New policy. Approved at Committee.Date Revised Date Effective 08/01/2025 Date Archived Diagnostic Colonoscopy and/or Sigmoidoscopy-GA MCD-PY-1598 Effective Dat e: 08/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 H. References 1. American Society for Gastrointestinal Endoscopy Standards of Practice Committee; Early DS, Ben-Menachem T, Decker G, et al . Appropriate use of GI endoscopy. Gastrointest Endosc . 2012;75(6):1127-1131. doi:10.1016/j.gie.2012.01.1 2. Colonoscopy ACG: A-0129. MCG. 28th ed. Updated March 14, 2024. Accessed March 12, 2025. www.careguidelines.com 3. Colonoscopy. American Cancer Society. Accessed March 12, 2025. www.cancer.org 4. Flexible sigmoidoscopy. Mayo Clinic. Accessed March 12, 2025. www.mayoclinic.org 5. Policies and Procedures for Physician Services, Part II . Georgia Department of Community Health. Revised January 1, 2025. Accessed March 12, 2025. www.mmis.georgia.gov 6. Sigmoidoscopy ACG: A-0128. MCG. 28th ed. Updated March 14, 2024. Accessed March 12, 2025. www.careguidelines.com GA-MED-P-3837726 Issue Date 03/26/2025 Approved DCH 05/07/2025
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Obstetrical Care-Total Cost-GA MCD-PY-0231 04/01/ 2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectObstetrical Care Total Cost B. BackgroundObstetrical care is health care treatment provided in relation to pregnancy and delivery of a newborn child , including care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members receive in a hospital or birthing center , as well all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification ofmedical necessity for these services. Proper billing and submission guidelines must be followed , including the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. C. Definitions Prenatal Profile Initial laboratory services. Initial and Prenatal Visit Practitioner visit to determine if member is pregnant. Total Obstetrical Care Antepartum care, delivery, and postpartum care. High Risk Delivery Labor management and delivery for an unstable or critically ill pregnant patient. Premature Birth Delivery before 37 weeks of pregnancy. Pregnancy For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days. D. PolicyI. Obstetrical Care A. Initial visit and prenatal profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and Management (E/M) codes are utilized when services are provided to diagnose the pregnancy. These are not part of antepartum care. B. Total obstetrical care for uncomplicated care provided to the member including antepartum, delivery, and postpartum care includes 1. If a member meets all the following criteria, the practitioner designated in the member s medical record must bill for total obstetrical care under th e practitioners number : Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 a. Member i s eligible for Medicaid for the duration of pregnancy b. Member i s cared for by one practitioner or group practice for the antepartum care, delivery, and postpartum care , and c. The a ttending physician is designated in the medical record with services billed under that practitioner tax identification number. 2. Billing for total obstetrical care cannot be submitted until the date of delivery. 3. Total obstetrical care cannot be billed for a delivery of less than 20 week s gestation. 4. Total obstetrical care codes are as follows: a. A corresponding obstetrical diagnosis with outcome of birth must be listed on the claim. An ICD-10 code from category Z34 should be listed as the first diagnosis for routine obstetric care. b. Reimbursement is provided for 1 of the following codes per pregnancy: 5. Modifiers a. A modifier UB, UC, and UD appended to the billed delivery procedure code is required , or the delivery claim will be denied. b. Deliveries with modifiers UB or UD must show medical necessity , and medical documentation may be requested. c. Use appropriate modifiers (not all-inclusive): Modifier Description22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. UB Medically-necessary delivery prior to 39 weeks of gestation . UC Delivery at 39 weeks of gestation or later . UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 Code s Description 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps and postpartum care), after previous cesarean delivery 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 weeks gestation)6. Services (not all-inclusive):Services included that may NOTbe billed separatelyServices excluded and therefore may be billed separately Admission history Greater than 13 antepartum visits due to high-risk condition Admission to hospital Complications of pregnancy Artificial rupture of membranes Surgical complications or other problems related to pregnancy Care provided for an uncomplicated pregnancy including delivery as well as antepartum and postpartum Cephalic version Cesarean delivery Ultrasonography Cesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean delivery Fetal nonstress test Classic cesarean section Maternal or fetal echography Each month up to 28 weeks gestation Fetal echocardiography procedures Every other week from 29 to 36 weeks gestation Fetal biophysical profile Fetal heart tones Amniocentesis, any method Hospital/office visits following cesarean section or vaginal delivery Chorionic villus sampling, any method Initial/subsequent history Fetal contraction stress test Low cervical cesarean section Hospital and observation care visits for premature labor prior to 36 weeks of gestation Management of uncomplicated labor High risk pregnancies requiring more visits or more laboratory data Physical Exams Conditions unrelated to pregnancy i.e., hypertension, glucose intolerance Recording of weight/blood pressures Treatment and management of complications during the postpartum period that require additional services Routine chemical urinalysis Laboratory tests outside of routine chemical urinalysis Routine prenatal visits Cordocentesis Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Successful vaginal delivery after previous cesarean deliveryOB ultrasounds Patients with previous cesarean delivery who present with the expectation of a vaginal delivery RH immune globulin administration Vaginal delivery with or without episiotomy or forceps Weekly from 36 weeks until deliveryII. Multiple gestations A. Diagnosis code (s) for multiple gestations must be included . B. Total obstetrical care billing for multiple gestations should include 1 procedure code and a delivery only code for each subsequent delivery with the appropriate diagnosis code and modifier for the multiple gestations. C. When all deliveries are performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 may be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. III. High risk deliveriesA. High risk pregnancy with appropriate trimester should be the first listed diagnosis for prenatal outpatient visits and from the ICD-10 category O09 supervision of high-risk pregnancy. B. Modifier 22 may be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be allinclusive and is subject to updates.Codes Description59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 07/01/2017 New Policy.Date Revised 04/01/2020 10/26/202211/06 /2024New title used to be Global Obstetrical Services policy broken into two policies. Updated definitions, reorganized topics, removed unbundled information, updated most content, included modifiers and updated codes. Periodic review. Editorial changes and reference updates only. Periodic review. Updated references. Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. Policies and Procedures for Physician Services . Georgia Dept of Community 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps and postpartum care), after previous cesarean delivery 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery. Modifiers Description 22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 51 To indicate that a second and any subsequent vaginal births occurred identifying multiple procedures were performed 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 59 Distinct procedural services UB Medically necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 Health, Division of Medicaid; 2024. Accessed October 1 5, 202 4. www.mmis.georgia.gov 2. ACOG Committee Opinion: optimizing postpartum care. Obstet Gynecol . Opinion No. 736. 2018;131(5):e140-e150. doi:10.1097/AOG.0000000000002633 GA-MED-P-3459100 Issue Date 07/01/2017 Approved DCH 12/30/202 4
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Obstetrical Care-Unbundled Cost-GA MCD-PY-0924 04/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 8 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 8 H. References ………………………….. ………………………….. ………………………….. …………………….. 9 Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectObstetrical Care Unbundled CostB. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS)/International Classification of Disease-10 (ICD-10) code(s) for the product orservice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Obstetrical care refers to the health care treatment given in relation to pregnancy anddelivery of a newborn child. This include s care during the prenatal period, labor, birthing,and the postpartum period. CareSource covers obstetrical services members r e c e 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 w e l l as 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 themedical 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 CPT codes, 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 is applicable to obstetricians-gynecologists (OB/GYNs),obstetricians (OBs), gynecologists (GYNs), and nurse-midwives.C. Definitions High risk delivery Labor management and delivery for an unstable or critically ill pregnant patient. Initial and Prenatal Visit Practitioner visit to determine whether member is pregnant . Pregnancy For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days. Premature Birth Delivery before 3 7 weeks of pr egnancy. Prenatal Profile Initial laboratory services. Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Unbundled ( Partial) Obstetrical Care The practitioner bill s delivery, antepartum care, and postpartum care independently of one another. o Antepartum Care (Prenatal) The 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 then weekly visits until delivery. o Delivery Services Admission 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. o 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 and ongoing care a re needed , concluding with a postpartum visit no later than 12 weeks after birth. 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 s available based on what services the practitioner performed. The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. 1. Unbundled o bstetric care s hould be billed when any of the following occur : a. The member has a change of insurer during pregnancy b. The member has received part of the obstetrical care ( antenatal care , deliver, or postpartum care) elsewhere (eg , from another group practice ) c. The member leaves the pratitioners 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 (eg , midwife to MD) for a cesarean delivery e. The member has an unattended precipitous delivery f. Termination of pregnancy without delivery (eg , 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 Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 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 . c. E/M codes for antepartum care are limited to 3. d. Use the appropriate modifier (This list may not be all inclusive): NOTE: For Federally Qualified Health Centers/Rural Health Clinics(FQHC/RHC) members antepartum E/M visit limits do not apply. Modifier Description24 To indicate that the E/M visit was not related to typical postpartum care during the global period e. Only one code, either 59425 or 59426 can be billed per pregnancy.f. Antepartum care only code includes the 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 history 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) Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Services included that may NOT bebibilled separatelyServices excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or forceps Vaginal delivery after prior cesarean sectionPrevious cesarean delivery who present with expectation of vaginal delivery Successful vaginal delivery after previous cesarean deliveryCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean deliveryCesarean deliveryClassic cesarean section Low cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesia Artificial 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 24 hours of deliveryd. Modifiers 1. A modifier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 2. Deliveries with modifiers UB or UD must show medical necessity and medical documentation may be request ed . e. Use the appropriate modifier (This list may not be all inclusive): Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 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 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 b. Modifiers1. A modifier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 2. 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): 1. Admission history 2. Admission to hospital 3. Artificial rupture of membranes 4. Care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 5. Hospital/office visits following cesarean section or vaginal delivery 6. Management of uncomplicated labor 7. Physical exam 8. Vaginal delivery with or without episiotomy or forceps 9. Caesarean delivery 10. Classic cesarean section 11. Low cesarean section 12. Successful vaginal delivery after previous cesarean delivery 13. Previous cesarean delivery who present with the expectation of a vaginal delivery Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 14. Caesarean delivery following unsuccessful vaginal delivery attempt after previous cesarean delivery d. Postpartum care only – If postpartum care only was provided: 1. Use code 59430 postpartum care only. 2. Only one 59430 can be billed per pregnancy as this includes all E/M pregnancy related visits provided for postpartum care. 3. There is no 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. 4. Postpartum care may include; and therefore are NOT allowed to be billed separately (This list may not be all inclusive) : a. Hospital, office and outpatient visits following cesarean section or vaginal delivery b. 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 5. The following are billable separately during the postpartum period (This list may not be all inclusive): a. Conditions unrelated t o pregnancy i.e. respiratory tract infection b. 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 ev aluation 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 procedures 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. Documentation must be submitted with the claim demonstrating the reason and the additional work provided . IV . High Risk DeliveriesA. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 Supervision of high-risk pregnancy. Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 B. 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) 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 . The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code DescriptionE/M For antepartum care 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 Obstetrical Care – Total Cost G. Review/Revision HistoryDATE ACTIONDate Issued 07/01/2017 New Policy. Date Revised 04/01/2020 New 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 (e.g. Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.9 09/15/202110/12/202211/06/202359425, 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. Added that E/M antepartum visit limitations do not apply to FQHC/RHC Periodic review. Updated references. Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. American Academy of Professional Coders. Code Obstetrical Care with Confidence. December 1, 2011. Accesssed October 14, 202 4. www.aapc.com 2. American College of Obstetricians and Gynecologists. Billing for care after the initial outpatient postpartum visit: the fourth trimester. Accessed October 14, 2024. www.acog.org 3. American College of Obstetricians and Gynecologists. Optimizing postpartum care. Obstet Gynecol . ACOG Committee Opinion No. 736. 2018;131(5):e140-e150. Accessed October 14, 2024. www.acog.org 4. American College of Obstetricians and Gynecologists. Preterm Labor and Birth. Updated April 2023. Accessed October 14, 2024. www.acog.org 5. Policies and Procedures for Physician Services . Georgia Dept of Community Health, Division of Medical Assistance Plans; 2024. Accessed October 14, 2024. www.mmis.georgia.gov GA-MED-P-3459100 Issue Date 07/01/2017 Approved DCH 1 2/30 /202 4
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Coordination of Benefits-GA MCD-PY-1344 03/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Coordination of Benefits-GA MCD-PY-1344Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectCoordination of Benefits B. BackgroundThe purpose of this guideline is to define the order of coverage and how CareSource will coordinate benefit payments as the secondary payer. CareSource coordinate payment for covered services in accordance with the terms of a members benefit plan, applicable state and federal laws, and applicable Centers for Medicare & Medicaid Services ( CMS ) guidance. If CareSource is not the primary carrier, providers bill the primary carrier for all services provide d before submi tting claims to CareSource. Any balance due after receipt of payment from the primary carrier should be submitted to Care Source for 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 the p rovider and CareSource for the provision of services by provider s to individuals enrolled with the plan, including but not limited to contracts titled Provider Agreement and Group Practice Services Agreement . Coordination of Benefits (COB) The process of determining which health plan or insurance policy will pay first and/or determining the payment obligations of each health plan, medical insurance policy, or third party resource when 2 or more health plans, insurance policies , or third party resources cover the same benefits for CareSource members. Explanation of Payment (EOP) A detailed explanation of payment or denial of a claim by an insurance carrier. Primary Carrier The insurance carrier that has been determined to be responsible for primary payment. D. PolicyI. Submitted claims must include the total amount billed, total amount paid by primary carrier, and balance due along with a valid provider signature. Any balance due after receipt of payment from the primary carrier should be submitted to CareSource for consideration , and the claim must include information verifying the payment amount received from the primary plan. II. COB GuidelinesA. When CareSource coordinates benefits with the primary carrier, reimbursement will be made according to the Medicaid contracted maximum allowable minus any payment made by the primary carrier. Any items or services for which another carriers reimbursement amount is equal to or greater than the Medicaid contracted maximum allowable amount will be paid at zero. Claims that pay at zero are considered to be paid claims, not denie d claims. Coordination of Benefits-GA MCD-PY-1344Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 B. When the payment from another insurance carrier is less than the Medicaid contracted amount, CareSource will pay up to the Medicaid contracted total allowed amount. The sum of the payments will not exceed the Medicaid contracted maximum allowable amount as indicated in the CareSource ProviderAgreement . Example 1: Charged Amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $50.00 $10.00 $0 $0 $40.00 CareSource $35.00 $0.00 Summary : In this example, since the primary carrier paid amount of $40.00 is to the Medicaid contracted allowed amount of $35.00, then CareSource pays zero , as indicated in the CareSource Provider Agreement. Example 2: Charged Amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $80.00 $50.00 $0 $0 $30.00CareSource $40.00 $10.00 Summary : In this example, subtract the primary paid amount of $30.00 from theMedicaid contracted allowed amount of $40.00. CareSource will pay $10.00 , as indicated in the CareSource Provider Agreement. Example 3: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance Paid Primary Insurance $200.00 $0 $200.00 $0 $0.00 CareSource $125.00 $125.00 Summary : In this example, subtract the primary paid amount of $0 from theMedicaid contracted allowed amount of $125.00. CareSource will pay $125.00 ,which is the total allowed amount as indicated in the CareSource Provider Agreement. Example 4: Charged 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 Benefits-GA MCD-PY-1344Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Summary : In this example, subtract the primary paid amount of $10.00 from theMedicaid contracted allowed amount of $125.00. CareSource will pay $115.00 , as indicated in the CareSource Provider Agreement. Example 5: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $150.00 $30.00 $100.00 $0 $20.00CareSource $200.00 $180.00 Summary : In this example, subtract the primary paid amount of $20.00 from theMedicaid contracted allowed amount of $200.00. CareSource will pay $180.00 , as indicated in the CareSource Provider Agreement. C. Non-Contracted ProvidersWhen the payment from another insurance carrier is less than the CareSource Medicaid non-participating reimbursement rate, the sum of the payments will not exceed the Care Source Medicaid n on-participating reimbursement rate. III. COB Timely Filing GuidelinesA. If a provider is aware that a member has primary coverage, the provider should submit a copy of the primary payers EOP along with the claim to CareSource within the 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 provider must submit the primary payers EOP. If the initial timely filing period has elapsed, the EOP must be submitted to CareSource within 90 days from the primary payers EOP date. B. If a provider has information that the primary payers policy has terminated or was not in effect during the date of service for the claim(s), the provider must notify CareSource of the dispute within the original timely filing period or within 90 days of the providers actual receipt of the primary payer s EOP date, whichever is greater. C. If the dispute is received within the original timely filing period: 1. CareSource will confirm whether or not the primary payer was in effect during the date of service. If the policy was NOT in effect, CareSource will process the claim(s) that are within the original timely filing period or 90 days of the providers actual receipt of the payer s EOP date. 2. If the policy was in effect, the claim will remain denied for lack of primarypayer s EOP.D. If the provider does not notify CareSource of the dispute within the original timely filing period or if the provider does not submit the primary payer s EOP within 90 Coordination of Benefits-GA MCD-PY-1344Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 days of the providers actual receipt of the primary pa yer s EOP date, the claim will re-deny as not being timely filed. IV. COB Claim Submission to CareSourceA. CareSource follows The Health Insurance Portability and Accountability Act (HIPAA ) guidelines and accepts industry standard codes. It is imperative that claims are filed with the same codes that the primary payer presented on the EOB to ensure that claims are processed correctly. Claim(s) will be denied if there is a mismatch between th e codes on the received claim and the primary payers EOP. B. CareSource applies standard claim adjustment codes . C. Claim Adjustment Group Codes are as follows: 1. CO Contractual Obligation 2. OA Other Adjustment 3. PI Payer Initiated Reductions or 4. PR Patient Responsibility D. When filing claims with patients responsibility, the following Claim Adjustment Reason Codes should be used: 1. PR1 Deductible 2. PR2 Coinsurance or 3. PR3 Copayment E. When filing claims with contractual obligation, please use Adjustment Group Code CO. Contractual obligation can be communicated on the primary payers EOB with several different codes. Use the code reflected on the primary payers EOB. Some examples of these codes are: 24, 45, 222, P24, P25, and 26. The same process should be followed when using Adjustment Group Code OA Other Adjustment. V. Denied COB ClaimsA. Denied COB claims w ill be automatically adjusted when primary insurance has been updated retroactively to show coverage was terminated at the time of service AND the claim was denied for COB within 90 days of CareSource receiving the notification. B. Denied COB claims w ill NOT be automatically adjusted if the updated coverage information was received after 90 days from the denial for COB information. In this case, the provider must request claim adjustment within the original timely filing period or within 90 days from t he date of the EOP denial, whichever is greater. Although CareSource is implementing this COB Adjustment Policy, it is still the providers responsibility to review their accounts and submit COB claims in a timely manner for payment. VI. Disputes for Denied COB ClaimsA If a provider has information that the primary carriers policy has terminated or was not in effect during the date of service for the claim(s), the provider must notify CareSource of the dispute within the original timely filing period or within 90 Coordination of Benefits-GA MCD-PY-1344 Effective Dat e: 03/01/2025 The REIMBURSEMENT Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the REIMBURSEMENT Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 6 days of the original denial date or 90 days from the primary carriers EOP date, whichever is greater. If the dispute is received within the original timely filing period or within 90 days of the original denial date: B. CareSource will confirm whether or not the primary coverage was in effect during the date of service. If the policy was NOT in effect, CareSource will process the claim(s) that are within the original timely filing period. If the initial timely filing period has elapsed, then CareSource will process the claims that are within 90days of the original denial. If the policy was in effect, the claim will remain denied for needing primary carriers EOP. If the provider does not notify CareSource of the disput e within the original timely filing period within 90 days of theCareSource denial or if the provider does not submit the primary carriers EOPwithin 90 days of the p rimary c arrier s EOP date, the claim will re-deny as not being filed timely.E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers , if applicable . Please refer to the individual f ee schedule for appropriate codes.F. Related Policies/RulesNAG. Review/Revision HistoryDATE ACTION Date Issued 10/13/2021 New policy. Approved at PGC Date Revised 11/30/2022 10 / 09 /2024 Editorial and reference updates only. Periodic r eview. Updated references. Approved at Committee. Date Effective 03/01/2025 Date Archived H. References1. Georgia Department of Community Health. Medicaid/PeachCare for Kids ProviderBilling Manual . Access ed October 1. 2024 . ww.mmis.georgia.gov2. CareSource Georgia Medicaid Provider Manual ( Ma y 202 3 ). Access ed October 1.2024 . www.caresource.comGA-MED-P – 3382360 Issue date 10/13/2021DCH Approved 11/26/2024
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Dental Services Rendered in a Hospital or Ambu latory Surgery Center – GA MCD-PY-0847 08/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory r equirements, 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, b ut are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairm ent 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 proced ures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be sub ject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Dental Services Rendered in a Hospital orAmbulatory Surgery Center-GA MCD-PY-0847Effective Dat e: 08/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDental Services Rendered in a Hospital or Ambulatory Surgery Center B. BackgroundThe decision to perform dental care in a particular place of service is based on a wide variety of factors, including the age and special health care needs (physical, intellectual and developmental disabilities , long-term medical conditions) of the individ ual, in addition to the type, number, and complexity of procedures planned. These factors also determine the type of anesthesia used during the procedure. Most dental care can be provided in a dental office setting with local anesthesia or localanesthesia supplemented with non-pharmacological behavior guidance (basic to advanced techniques) and/or pharmacological options. Basic non-pharmacological behavior guidance includes communication guidance, positive pre-visit imagery, direct obser vation, tell-show-do, ask-tell-ask, voice control, non-verbal communication, positive reinforcement and descriptive praise, distraction, and desensitization. Pharmacological options may include nitrous oxide, oral conscious sedation and intravenous (IV) se dation (mild, moderate, or deep), or monitored general anesthesia by trained certified individuals in each level of sedation dentistry. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require the use of general anesthesia as medically necessary in a healthcare facility , such as an ambulatory surg ery center , hospital operating room, or short procedure unit (SPU) . C. Definitions Ambulatory Surg ery Center (ASC) Any freestanding institution, building, or facility or part thereof, devoted primarily to the provision of surgical treatment to patients not requiring hospitalization, as provided under provisions of GA. CODE ANN . 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 24 hours or longer. It is not under the operation or control of a hospital. 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 treatmen t on a regular and organized basis and has been regulated and certified by the state as such. Inpatient Hospital A nonpsychiatric facility which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and reha bilitation services by or under the supervision of physicians to patients admitted for a variety of medical conditions. Monitored Anesthesia Care (MAC) 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. Outpatient Hospital A facility which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require admission or an overnight stay . Dental Services Rendered in a Hospital orAmbulatory Surgery Center-GA MCD-PY-0847Effective Dat e: 08/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Sedation Continuum When patients undergo procedural sedation/analgesia, a sedation continuum is entered . Several levels have been formal ly defined along this continuum, as follows: o Minimal Sedation (Anxiolysis ) A drug-induced state during which patients respo nd normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. o Moderate Sedation/Analgesia (Conscious Sedation) A drug-induced depressio n 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 f unction is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. o Deep Sedation/Analgesia A drug-induced depression of consciousness during which patient s 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 ven tilation may be inadequate. Cardiovascular function is usually maintained. o General Anesthesia A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory fun ction 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 f unction may be impaired. Note: Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation should be able to rescue patients who enter a state of deep sedation , while those administer ing deep sedation 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 seda tion. It is not appropriate to continue the procedure at an unintended level of sedation. Short Procedure Unit (SPU) A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic, or medical services. D. PolicyThis policy is intended to provide guidance on the process for obtaining authorization and reimbursement for dental services performed in a place of service (ASC or hospital Dental Services Rendered in a Hospital orAmbulatory Surgery Center-GA MCD-PY-0847Effective Dat e: 08/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 OR/SPU) and reimbursement for related facility charges (eg, operating room, anesth esia, medical consults).CareSource Dental Benefits : Coverage for professional services performed by thedentist/oral surgeon in the POS (ASC or Hospital OR/SPU) and reimbursement for these services may be provided through the dental benefit once approved via the CareSource process of dental utilization review for medical necessity of services and requested place of service. Medical necessity criteria and clinical policies are in the respective CareSource Dental Office Reference Manual located upon provider portal account login. CareSource Medical Benefits : Coverage and reimbursement for facility charges (eg,operating room, anesthesia) related to dental services perfo rmed in POS (ASC orOR/SPU), are eligible for coverage and reimbursement under the member’s medical benefit when the dental services have been approved via the CareSource Dental Utilization Management process to be performed in Hospital/ASC. The two-step process for dental services and facility services should be followed forobtaining authorization prior to submitting claims for reimbursemen t:I. Ste p 1 – Dental authorization for services to be performed in a (OR/SPU or ASC) A prior authorization is required for all dental services performed in a hospital inpatient or outpatient facility, or an ambulatory surgery center facility. 1. Requests for dental services in POS (19, 21, 22, 24) are submitted by the treating dental provid er to the CareSource Dental Authorization Determination Department via the partner vendor SKYGEN Provider Portal . The provider must include the correct POS on dental c laim and add in authorization notes request is for hospital or ASC setting. 2. All requested dental services (treatment plan) should be included in the authorization request, in addition to at least one (1) unit of D9420 , that identifies the request as hospital/ASC request. 3. The CareSource Dental UM department reviews for appropriate medical necessity requirements listed in the CareSource GA Office Reference Manual Section 7.5.10 Coverage and Clinical Guidelines Adjunctive Services. 4. If the dental author ization is approved, an automated CareSource approval letter to the requesting dentist will be sent and this can also be viewed in the SKYGEN provider portal. 5. If the dental authorization request is not approved, a Notice of Adverse Benefit Determination letter will be issued to the submitting dental provider. II. Step 2 Facility authorization processOnce dental services to be performed in hospital/ASC approval has been obtained , providers are required to administer services at CareSource participating hospitals and must obtain facility authorization . 1. For facility authorization , the facility provider (hospital or ASC) may submit the request on the CareSou rce Provider Portal at CareSource.com or the preferred method for submission of medical prior authorization requests is through the use Dental Services Rendered in a Hospital orAmbulatory Surgery Center-GA MCD-PY-0847Effective Dat e: 08/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 of Georgias Department of Community Health (DCH) centralized prior authorization portal. This feature allows submission of prior authorization requests through a centralized source, the Georgia Medicaid Management Information System (GAMMIS) 2. The dental p rovider may also request a Facility Certification by calling CareSource directly at 800.488.0134 and select option to Request an Authorization . 3. The facility request should include the facility services requested (ie, operating room charges, anesthesia), the Dental Authorization Approval Letter, and the dental authorization number. 4. CareSource Medical Utilization Management team will complete ALL of the following: a. Verify that facility is in network . b. Review the dental pre-determination letter (PDL) or dental authorization . c. Complete the administrative approval for facility fee and anesthesia. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted. CDT code D9420 (technical component) for facility fee and HC PCS/CPT code 00170 for general anesthesia only require administrative review if dental authorization already obtained . d. Fax a Facility Approval to the hospital/ASC which can also be viewed in the CareSource Provider Portal . E. Conditions of CoverageFacility Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT /CDT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates . Revenue codes and additional information can be found in the Department of Community Health and ASC Policy manual s. Outpatient Hospital Facility (SPU) POS (19, 22) : Ambulatory Surgical Center POS (24) o Use CDT code D9420 for the technical component of the operating room facility fee charge Time is calculated as 1 unit = 30 minutes, where the maximum units reimbursable per date of service is 6. o Use CPT 00170 for anesthesia for intraoral treatments, including biopsy. Time units for physician and CRNA services both personally performed and medically directed are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. Total minutes are listed as the units (ie, 75 minutes) 75 = 5 units (of 15-minute increments). CMS Base units = 5. Maximum state allowances may be applicable. o Recovery room is intended for cases when a patient requires recovery from deep sedation or anesthesia. Recovery room use is reimbursable only when billed for the same date of service as a surgery that is not considered a common office procedure. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-GA MCD-PY-0847Effective Dat e: 08/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 o Hospital add-on (HAO) services only applicable if state or contract required.Separate reimbursement may not be applicable. Maximum allowances may be applicable . Inpatient Hospital Facility POS (21) o All services as well as any additional room and board fees would have to be pre – certified and receive medical necessity review. Services are subject to benefit provisions . Dental/Oral Surgery Professional Services o The scope of this policy is limited to medical plan coverage of the facility and/or general anesthesia serv ices provided in conjunction with dental treatment, and not the dental or oral surgery services . For information on dental benefits, please consult the CareSource Office Reference Manual for clinical guidelines, policies, and procedures and the provider contracted fee schedule. F. Rela ted Policies/RulesDental Health Partner Provider Manual G. Review/Revision HistoryDATE ACTIONDate Issued 10/ 01/2019 New PolicyDate Revised 08/1 9/2020 01/28/2022 04/10 /2024Removed PA for CPT 00170. Annual Review. Removed tables, simplified coding information. Annual review: updated references, updated process, simplified background and definitions . Approved at Committee. Date Effective 08/01/2024 Date Archived H. References1. American Academ y of Pediatric Dentistry. Management of dental patients with special health care needs. Am Acad Pediatr Dent . 202 3:337-344. Accessed February 13, 2024. www.aapd.org 2. American Academy of Pediatric Dentistry. Policy on hospitalization and operating room access for oral care of infants, children, adolesce nts, and individuals with special health care needs. Am Acad Pediatr Dent . 202 3:169-170 . Accessed February 13, 2024. www.aapd.org 3. American Academy of Pediatric Dentistry. Policy on third-party reimbursement for management of patients with specia l health c are needs. Am Acad Pediatr Dent . 202 3:181-184. Accessed February 13, 2024. www.aapd. org 4. Committee on Quality Management and Departmental Administration. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. Updated October 23 , 2019 . Accessed February 13, 2024 . www.asahq.org Dental Services Rendered in a Hospital orAmbulatory Surgery Center-GA MCD-PY-0847Effective Dat e: 08/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 5. Policies and Procedures, II: Ambulatory Surgical and Birthing Center Services .Georgia Dept of Community Health; 202 4. Accessed February 13, 2024 . www.mmis.georgia.gov 6. Policies and Procedures , II: Dental Services . Georgia Dept of Community Health; 2023. Accessed February 13, 2024 . www.mmis.georgia.gov 7. Policies and Procedure s, II: Hospital Services . Georgia Dept of Community Health; 2023. Accessed February 13, 2024 . www.mmis.georgia .gov GA-MED-P-2844050 Issue date 10/1/2019 Approved DCH 05/09/2024
REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Overpayment Recovery-GA MCD-PY-1112 06/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements , industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m e dical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of func tion, 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 contra ct (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to s ervices provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Overpayment Recovery-GA MCD-PY-1112Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectOverpayment Recovery B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies 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 wi ll be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate a ndappropriate CPT/HCPCS code(s) for the product or s ervice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Retrospective review of claims paid to providers assist Car eSource with ensuringac curacy in the payment process. CareSource will request voluntary repayment from providers 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 o a partial payment o a reduced payment o a penalty applied o an additional payment o a supplemental payment Overpayment Any payment made to a network provider by a managed care organization (MCO) to which the network provider is not entitled under Title XIX of 42 C.F.R. o A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Explanation of Payment (EOP ) A statement c ontain ing payment and adjustment information for claims provider s ha ve submitted for payment. Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the me mber. Overpayment Recovery-GA MCD-PY-1112Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 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 ar e not limited to: o payments made for an ineligible member o ineligible service payments o payments made for a service not received o duplicate payments Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. Provider Level Balancing (PLB ) Adjustments to the total check/remit amount occur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment. (Beginning Segment for Payment Order/Remittance Advice (BPR ), which means total payment within the EOP ). Forwarding Balance (FB) 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 remittance advice. It only indicates that a past claim has been adjusted to a different dollar amount and that funds are owed to CareSource. D. PolicyI. CareSource will provide all the following information when seeking reco very of an overpayment made to a provider : A. the name and patient account number of the member to whom the service (s) were provided B. the date(s) of services provided C. the amount of overpayment D. the reason for the recoupment 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 timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. III. Coordination of Benefit 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. Overpayment Recovery-GA MCD-PY-1112Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.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 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 eligibilit y status. B. Advanced notification will occur 30 days in advance of recovery. 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 credit 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 ow ed to CareSource. This information will be displayed on the EOP in the PLB section. B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $2 difference. b. The $10 negative balance is not considered to be an ov erpayment subject to the guidelines outlined in section D.I D.IV. 2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D.IV. b. The reduced payment will trigger a 30-day advanced notification with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negat ive balance has been offset, unless otherwise negotiated. D. Providers are notified of negative balances through EOPs and 835s ,and are expected to use this information to reconcile and maintain accounts receivable (AR) for reconciliation of negative balances. E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. Providers are expected to maintain AR for the reconciliation of negative balances when th at occur s. Overpayment Recovery-GA MCD-PY-1112 Effective Dat e: 06/01/2024 The REIMBURSEMENT Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the REIMBURSEMENT Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 5 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.E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate mo difiers, if applicable. Please refer to the individual fee schedule for appropriate codes.F. Related Policies/RulesCareSource Provider Agreement, ARTICLE V. CLAIMS AND PAYMENTSG. Review/Revision HistoryDATE ACTION Date Issued 05/05/2020 New policy Date Revised 10/13/2021 10/26/2022 01/31/2024 Updated definitions. Added D.V. and D.VI. Updated references. Approved at PGC. No changes to content. Updated references Annual review. Removed IV. C. Updated references. Approved at Committee. Date Effective 06/01/202 4 Date Archived H. References1. GA . CODE 33-20A-62 (2022)GA-MED-P – 2699854 05/05/2020 Issue date Approved DCH 02/29/2024
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date 340B Drug Pricing PY-PHARM-0086 01/01/2023Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prep ared 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, 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 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 nece ssary 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 discomfo rt. 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 Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Cov erage ………………………….. ………………………….. ………………………….. ……. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 340B Drug Pricing GEORG IA MEDICAID PY-PHARM-0 086 Effective Date: 01/01/2023 2 A. Subject340B Drug PricingB. BackgroundReimbursement policies are designed to assist you when submitting claims toCareSource. 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 service s 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 pr ovider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. The 340B Drug Pricing Pro gram is a fed eral program, which limits the cost of covered outpatient drugs to eligible health care organizations and covered entities. The purpose of the program was to enable covered entities to stretch scarce federal resources as far as poss ible, reac h more eligible patients and provid e more comprehensive services. This policy describes the claim submission requirements for outpatient pharmacy and provider administered drugs. C. Definitions340 BCovered Entity (CE) A facility t hat is eligibl e to purch ase drugs through the340B Program and appears on the HRSA Office of Pharmacy Affairs InformationSystem (OPAIS).340B Drug Discount Program (340B) Section 340B of the Public Health Service(PHS) Act (1992) that requires drug manufactures parti cipating i n the Medicaid DrugRebate Program to sign a pharmaceutical pricing agreement (PPA) with theSecretary of Health and Human Services.340B Medicaid Exclusion File (MEF) A file established by HRSA to assist 340Bcovered entities and States in the prevention of duplicate discounts for drugs subject to Medicaid rebates.Actual Acquisition Cost The actual prices paid to acquire drug products sold by a specific manufacturer.Care Management Organization (CMO) Organizations, such as CareSource,con tracted by the Georgia Department of Community Health to coordinate services for Medicaid members.Contract Pharmacy A pharmacy under contract with a Covered Entity.Current Proc edural Terminology (CPT) A medical code set maintained by theAmerican Me dical Association to describe and bill for medical, surgical, and diagnostic services. 340B Drug Pricing GEORGIA MEDICAID PY-PHARM-0086 Effective Date: 01/01/2023 3 Fee-for-Service (FFS) – Claims billed directly to Georgia Medicaid for prescriptionsand phys ician administered drugs provided to FFS members Healthcare Common Procedure Coding System ( HCPCS ) A set of health care procedure codes based on CPT.Health Resources and Services Administration (HRSA) The primary federal agency for improving access t o health care services for people who are uninsured,isolated, or medically v ulnerable.National Drug Code (NDC) A drug product that is identified and reported using a unique, three-segment number, which serves as a universal product identifier for the s pecific drug.Covered Outpatient Drug (COD) – A drug which may be dis pensed o nly upon a prescription and is treated as a prescribed drug for the purposes of section1905(12) of the Social Security Act, (with the exception of those defined as not meeting the definition) in paragraphs II and III, Section E. [Conditions of Coverage] in the Medicaid Drug Rebate Program (MDRP) Coverage Rules-AC Reject) policy.Provider Administered Drugs Drugs administered directly by a health care provider to a patient.D. PolicyI. Outpatient Pharmacy (Point-of-Sale) 340B ClaimsA. Effective April 1, 2017, all 340B Covered Entities are required to use a submission clarification code when billing the Georgia Medicaid Division on Fee-for-Service (FFS) and Care Management Organization (CMO) outpatient pharmacy claims per Part II Policie s and Procedures for Pharmacy ServicesManual as published by the Georgia Department of Community Health.B. The Covered Entity must submit claims through their pharmacy claims platform through our pharmacy benefits manager, Express Scripts, and the claim must include :1. A value of 0 8 in the Basis of Cost Determination field, 423-DN2. A value of 20 in the submission clarification code field 420-DK3. National Drug Code ( NDC ) of the drug dispensed4. Actual Acquisition Cost (AAC)C. Express Scripts will indicate on the encounter file any 340B submitted claims toGeorgia Medicaid in order to ensure rebates are not collected on these drugs. It is the responsibility of Express Scripts to review the updated Health Resource and Service Administration (HRSA) 340B discount drug program file quarterly.The pharmacy should bill appropriately and their transactions are subje ct to audit. Please visit the Express Scripts Pharmacist Resource Center for additional information.D. If the product is not purchased at 340B pricing, do not include the basis of cost determination value or the submission clarification code values and bill at th e regular Medicaid (FFS or managed care) rate.E. Contract pharmacies are not allowed to bill for 340B purchased drugs. All 340Bacquired drugs identified and discounted at the clai m level must be carved-out forMedicaid (FFS or managed care). 340B Drug Pricing GEORGIA MEDICAID PY-PHARM-0086 Effective Date: 01/01/2023 4 II. Provider Administered 340B Drug ClaimsA. For Provider Administered Drugs, the 340B Covered Entity must submit the claim on a CMS 1500 or UB-0 4 and the claim must include:1. The HCPCS/CPT code2. National Drug Code ( NDC )3. Actual Acquisition Cost If the dru g is not purchased at 340B pricing, bill at the regular Medicaid (FFS or Managed care) rateB. The Health Resources and Services Administration (HRSA) Medicaid ExclusionFile (MEF) will be used as the sol e means to identify 340B drug claims on the encounter file submission to Georgia Medicaid.E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers , if applica ble . Please refer to the individual f ee schedule for appropriate codes.F. Related Policies/RulesPAD-0 099-GA-MCD Medicaid Drug Rebate Program (MDRP) Coverage Rules-ACRejectG. Review/Revision HistoryDATE ACTION Date Issued 05/13/2021 Date Revised 12/07 /2022 Updated section (D) to align with DCH policy and procedures Date Effective 01/01/2023Date Archived H. References1. Georgia Department of Community Health Division of Medicaid. Part II Policies andProcedures for Pharmacy Services. Revised November 202 2 .part ii policies and procedures manual for pharmacy services oct 202220221128161317.pdf (geo rgia.gov) The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. GA-MED-P-1626554 DCH Approved: 05/05/2023
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Payment to Out of Network Provider-GA MCD-PY-1171 08/01/2023 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include , but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impa irment 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 pro cedures. 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 t he plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying th is Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Paymen t to Out o f Netwo rk Pro vid er-GA MCD-PY-1171Effective Dat e: 08/01/2023The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is app roved.2 A. SubjectPayment to Out of Network Providers 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 a re 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 of fice 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 s ervice 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 f or claims received f rom providers who are not contracted (out of network) providers with CareSource.C. Def initions Emergency Services Emergency health care services are used to treat an emergency medical condition. Emergency Medical Condition A medical condition that manif ests itself by signs and symptoms of suf f icient severity or acuity, including severe pain, suc h 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 Placing 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 f unctions; or o Serious dysf unction of any bodily organ or part. Out of Network Providers that are not part of CareSources network or do not have a signed contr act. D. PolicyCareSources standard reimbursement approach to out of network providers is as f ollows: I. Preauthorized, medically necessary services rendered to CareSource members by out-of-network providers will be reimbursed at A. 90% of the Medicaid Fee schedule; and B. 60% of the Medicaid Fee schedule f or labs. Paymen t to Out o f Netwo rk Pro vid er-GA MCD-PY-1171Effective Dat e: 08/01/2023The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is app roved.3 C. In the case where billed rate f or 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. II. In the event of any conf lict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document. III. Exclusions:A. Emergency Health Care Services will be reimbursed based on state regulations.E. Conditions of CoverageReimbursement is depen dent on, but not limited to, submitting approved HCPCS and CPT codes alo ng with appropriate modif iers. Please refer to the individua l f ee schedule s f or appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 09/15/2021 New policyDate Revised 04/12/2023 No changes. Approved at Committee. Date Effective 08/01/2023 Date Archived H. Ref erencesN/A GA-MED-P-2027601 Is s ue Date 09/15/2021 Ap p ro v ed DCH 05/11/2023
© Copyright CareSource 2025. All rights reserved.
System Details