REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 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 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 con tract (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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents Table of Contents ……………………………………………………………………………………………………….. 1 A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 Effective Date: 04/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d. 2A. SubjectLeft Ventricular Assist Device (LVAD) Supplies B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant ee claims payment. A left ventricular assist device ( LVAD) is a surgically implanted battery-operated, mechanical pump, which helps the left ventricle (main pumping chamber of the heart) pump blood to the rest of the body. It is a treatment for a weakened heart or end stage heart failure. LVADs can be used as: Bridge-to-transplant therapy: A life-saving therapy for patients awaiting a heart transplant. Patients use the LVAD until a heart becomes available. In some cases, the LVAD is able to restore the failing heart, eliminating the need for a transplant. Destination therapy: Some patients are not candidates for heart transplants. In this case, patients can receive long-term treatment using an LVAD, which can prolong and improve patients’ lives. C. Definitions Heart Failure A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently causing symptoms to occur throughout the body. Left-sided heart failure occurs when the heart loses its ability to pump blood preventing organs from receiving enough oxygen. The condition can lead to complications that include right-sided heart failure and organ damage. Ventricular Assist Device (VAD) A surgically attached device to one or both intact ventricles used to assist or augment the ability of a damaged or weakened native heart to pump blood. Improvement in the performance of the native heart may allow the device to be removed. D. Policy I. Dressings and supplies A. CareSource considers reimbursement for LVAD dressings a covered service when all the following criteria are met: 1. The initial dressings supplied under the bundled in-patient benefit at the facility where the LVAD was implanted are expended. Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 Effective Date: 04/01/2025 The REIMBURSEMENTPolicy 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. 32. Dressings necessary for the effective use of a LVAD must be billed using the appropriate supply code . B. LVAD dressings are a disposable supply and , therefore , a purchase-only item . C. Supplies billed with miscellaneous code E1399 will be denied if a more appropriate code is available. II. The following codes are not all inclusive but provide a general reference of unlisted/miscellaneous codes that are generally used incorrectly.Code Description E1399 Durable medical equipment, miscellaneous Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device III. Batteries A. Batteries for LVADs should be billed using the following codes: 1. Q0503: Battery for pneumatic ventricular assist device, replacement only, each. 2. Q0506: Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only B. Batteries billed with miscellaneous code E1399 will be denied. C. A rechargeable battery may be approved with a spare for uninterrupted use. IV. Warranty CareSource may request warranty information regarding the DME item or supply. If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the prior authorization. V. Prior authorization submitted with unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration during review: A. a complete description of the item (including, as applicable, the manufacturer, model or style, and size), a list of all bundled components, and an itemization of all charges B. any other information requested by CareSource VI. Non-covered services A. monitoring of LVADs B. multiple battery packs beyond the pair required for continuous useE. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Codes in this policy reflect Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 Effective Date: 04/01/2025 The REIMBURSEMENTPolicy 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. 4those found in CMS Transmittal 10837 for National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs). A. All unlisted or miscellaneous codes defined within this policy are subject to medical necessity review and prior authorization. B. Prior authorization is not a guarantee of payment. C. Claims must include an invoice. D. CareSource may verify the use of any code through post-payment audit. E. If a more appropriate code is discovered, CareSource may request recoupment.F. Related Policies/Rules Unlisted and Miscellaneous Codes G. Review/Revision History DATE ACTIONDate Issued 12/13/2023 New Policy, approved at Committee.Date Revised 12/18/2024 Added Unlisted and Miscellaneous Codes to section F. Updated references. Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. Artificial Hearts and Related Devices, Including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy. Medicare Coverage Database; 2020. Decision Memo CAG-00453N . Centers for Medicare & Medicaid Services. Accessed November 11, 2024. www.cms.gov 2. Heart failure. National Heart, Blood and Lung Institute. Accessed November 11, 2024. www.nhlbi.nih.gov 3. Left ventricular assist devices (LVADs) . Cleveland Clinic. Accessed November 11, 2024. www.my.clevelandclinic.org 4. NCD-Ventricular Assist Devices (VADs) (20.9.1). Centers for Medicare & Medicaid Services. Accessed November 11, 2024. www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name Policy Number Effective Date Single Dose Vial Claims Modifiers PY-PHARM-0104 01-01-2025 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ……………………………………………………………………………………………………… 4 F. Related Policies/Rules …………………………………………………………………………………………… 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 4 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Single Dose Vial Claims Modifiers Marketplace PY-PHARM-0104 Effective Date: 01-01-202 5 2 A. SubjectThis policy provides guidance for claims billing documentation and reimbursement of single dose injectable vials. B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. This policy describes documentation requirements and reimbursement guidelines for billing of the administered and discarded portion(s) of drugs and biologicals. Providers shall bill and receive reimbursement for both the dose administered and the unused portion of weight-based or variable dosing injectable drugs that are manufactured and supplied only in single dose or single use format. The JW modifier is required to be reported on a claim to report the amount of drug that is discarded and eligible for payment and should be used only for claims that bill single-dose container drugs. The discarded portion of single use or single dose vials must be identified with the JW Modifier as a separate line item from the dose or administered portion. Providers may be reimbursed for the discarded portions of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropriately reported based on the policy reimbursement guidelines. As of July 1, 2023, providers and suppliers are required to report the JZ modifier on all claims that bill for drugs from single-dose containers when there are no discarded amounts. The JZ modifier is reported on a claim to attest that no amount of drug was discarded and should only be used for claims that bill for single-dose container drugs. Claims containing drug administered from multi-dose vials are not subject to this requirement. Under this policy, all claims for separately payable single dose format injectable drugs must include either a JW modifier or a JZ modifier after 7-1-2023 in order to be reimbursed Single Dose Vial Claims Modifiers Marketplace PY-PHARM-0104 Effective Date: 01-01-202 5 3 MODIFIER SHORT DESCRIPTOR LONG DESCRIPTORJW Discarded portion of drug not administered Drug amount discarded/not administered to any patient JZ All drug administered none discarded Zero drug amount discarded/not administered to any patient C. DefinitionsModifier JW refers to the drug amount discarded (wasted)/not administered to any patient. Modifer JZrefers to zero drug amount discarded/not administered to any patient.Discarded Wastage or Unused Portion is defined as the amount of a single use/dose vial or other single use/dose package that remains after administering a dose/quantity of a drug or biological. Single Dose Vial i s defined as a vial of medication intended for administration by injection or infusion that is meant for use in a single patient for a sing le procedure. These vials are labeled as single-dose or single-vial by the manufacturer and typically do not contain a preservative. Multi-Dose Vial is defined as a vial of medication intended for administration by injection or infusion that contains more than one dose of medication. These vials are labeled as multi-dose by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria.D. Policy Modifier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modifier JW. Both details are reimbursable. CareSource will consider reimbursement for: I. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not administered to another patient. CareSource will NOT consider reimbursement for: I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. NOTE: The JZ modifier is required when there are no discarded amounts of a single-dose container drug for which the JW modifier would be required if there were discarded Single Dose Vial Claims Modifiers Marketplace PY-PHARM-0104 Effective Date: 01-01-202 5 4 amounts. The JZ modifier is required to attest that there were no discarded amounts, and no JW modifier amount is reported.E. Conditions of Coverage Providers must not use the JW modifier for medications manufactured in a multi-dose vial format. Providers must choose the most appropriate vial size(s) required to prepar e a dose to minimize waste of the discarded portion of the injectable vials. Claims considered for reimbursement must not exceed the package size of the vial used for preparation of the dose. Providers must not bill for vial contents overfill. Providers must not use the JW modifier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modifer is only applied to the amount of drug or biological that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modifier. 1. Claim Line #1 HCPCS code for drug administered and the amount admistered to the patient. 2. Claim Line #2 HCPCS code for drug discarded (wasted) with JW modifier appended to indicate waste and the amount discarded (wasted). The JZ Modifier is applied when zero amounts of a single-dose container drug is discarded. F. Related Policies/Rules Chapter 17, Section 40.1 of CMS Medicare Claims Processing Manual G. Review/Revision History DATE ACTIONDate Issued 01-22-2023 Original effective dateDate Revised 08-25-2023 Updated policy to include JZ modifier. Updated policy name and references. 10-11-2024 Annual review. No changes.Date Effective 01-01-202 5Date Archived H. References1. Billing and Coding: JW and JZ Modifier Billing Guidelines Article-Billing and Coding: JW and JZ Modifier Billing Guidelines (A55932) (cms.gov)2. New JZ Claims Modifer for Certain Medicare Part BDrugs https://www.cms.gov/files/document/mm13056-new-jz-claims-modifier-certain-medicare-part-b- drugs.pdf3. Discarded Drugs and Biologicals JW Modifier and JZ Modifier Policy FAQs. jw-modifier-faqs.pdf (cms.gov) The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Pre-Exposure Prophylaxis Preventive Services – MP-PY-1450 01/01/2025 Kentucky inactive as of 01/01/2026 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450Effective Dat e: 01/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectPre-Exposure Prophylaxis (PrEP) Preventive Services B. BackgroundAn estimated 1.2 million individuals in the United States are human immunodeficiency virus positive (HIV +), with a n estimated 30,635 new infections in 2020 . Though treatable, HIV infection is incurable and associated with s ignificant health complications. Effective strategies to prevent HIV infection remain a key public health priority. To prevent the spread of HIV, t he Centers for Disease Control and Prevention (CDC) recommends the use of antiretroviral pre-exposure prophylaxis (PrEP) in sexually active individuals who are at high risk of HI Vexposure as well as individuals who use drugs intravenously. Studies have shown that PrEP significantly reduce s the transmission of HIV to persons who are currently HIV -. The Federal Patient Protection and Preventive Care Act of 2010 requires insuranceplans cover preventive medicine services with a recommendation of A or Bby the U.S. Preventive Services Task Force (USPSTF). The USPSTF assigns one of five letter grades (A, B, C, D, or I) which describes the strength of a recommendation and communicates its importance to providers. Grade A The USPSTF recommends the service; there is high certainty that the net benefit is substantial. Grade B The USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Grade C The USPSTF recommends selectively offering or providing the service to individual patients based on professional judgement and patient preferences. There is at least moderate certainty that the net benefit is small. Grade D The USPSTF recommends against the service; there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Grade I The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of the service. The USPSTF recommends clinicians prescribe PrEP with effective antiretroviral therapy to individuals who are at increased risk of HIV acquisition to decrease the risk ofacquiring HIV infection (Grade A). To achieve the benefit of PrEP, it is important for individuals to receive counseling about antiretroviral medication adherence, safer sex practices, and regular testing for HIV and other related infections. Prior to receiving a prescription for PrEP, individuals may require counseling and laboratory testing to evaluate the need for PrEP as well as establish a baseline health status. As PrEP is only effective with medication adherence, follow-up appointments with or without laboratory testing are often necessary. As of October 1, 2023, ICD-10 code Z29.81 (encounter for HIV pre-exposure prophylaxis) is available for providers to use on medical claims. Insurance plans are not required to provide coverage for these preventive services when delivered by out-of-network providers. Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450Effective Dat e: 01/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. Definitions Pre-Exposure Prophyaxis (PrEP) Antiretroviral medication that helps prevent individuals from acquiring HIV. USPSTF An independent, volunteer panel of national experts that makes evidence-based recommendations about clinical preventive services. D. PolicyI. CareSource will provide PrEP and related services to members who qualify as high risk, follow ing USPSTF guidelines for the prevention of HIV . These services are classified as preventive with no cost share . Please refer to the most recently published USPSTF guideline for clarification of high risk and current coverage recommendations. II. CareSource covers the following without cost-sharing when associated with PreP:A. FDA-approved PrEP antiretroviral medications B. baseline and monitoring services, including 1. HIV testing 2. hepatitis Band Ctesting 3. creatinine testing and calculated estimated creatine clearance (eCrCI) or glomerular filtration rate (eGFR) 4. pregnancy testing (as appropriate) 5. sexually transmitted infection (STI) screening and counseling 6. adherence counseling C. office visits associated with PrEP III. The following code set has been provided for informational purposes only . These codes may be used to identify a service as part of PrEP preventive services. In order for a service in Section II to be identified as part of PrEP preventive services and cost sharing to be waived, providers need to follow the below coding steps: A. Use ICD-10 code Z29.81 on the claim, or B. Use ICD-10 code Z20.6 or Z11.4, and at least one of the other below codes on the claim. ICD-10Code Code Description Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z11.4 Encounter for screening for human immunodeficiency virus [HIV] Z11.59 Encounter for screening for other viral diseases Z11.8 Encounter for screening for other infectious and parasitic diseases Z11.9 Encounter for screening for infectious and parasitic diseases, unspecified Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV] Z20.828 Contact with and (suspected) exposure to other viral communicable diseases Z20.89 Contact with and (suspected) exposure to other communicable diseases Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450Effective Dat e: 01/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Z20.9 Contact with and (suspected) exposure to unspecified communicable diseaseZ29.89 Encounter for other specified prophylactic measuresZ32.00 Encounter for pregnancy test, result unknown Z32.01 Encounter for pregnancy test, result positive Z32.02 Encounter for pregnancy test, result negative Z51.81 Encounter for therapeutic drug level monitoring Z70.0 Counseling related to sexual attitude Z70.1 Counseling related to patients sexual behavior and orientation Z70.3 Counseling related to combined concerns regarding sexual attitude, behavior and orientation Z71.7 Human immunodeficiency virus [HIV] counseling Z72.51 High risk heterosexual behavior Z72.52 High risk homosexual behavior Z72.53 High risk bisexual behavior Z72.89 Other problems related to lifestyle Z77.21 Contact with and (suspected) exposure to potentially hazardous body fluids Z77.9 Other contact with and (suspected) exposures hazardous to health Z79.899 Other long term (current) drug therapy W46.0XXA Contact with hypodermic needle, initial encounter W46.0XXD Contact with hypodermic needle, subsequent encounter W46.1XXA Contact with contaminated hypodermic needle, initial encounter W46.1XXD Contact with contaminated hypodermic needle, subsequent encounter IV. ExclusionsClaims received from the emergency department would not generally qualify as PrEP preventive services. E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 09/27/2023 New Policy. Approved at Committee.Date Revised 10/09 /2024 Review: updated references. Approved at Committee. Date Effective 01/01/2025 Date Archived Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450Effective Dat e: 01/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 I. References1. Assistant Secretary for Public Affairs. About the Affordable Care Act. United States Dept of Health and Human Services. Reviewed March 17, 2022. Accessed September 11, 2024. www.hhs.gov 2. Billing Coding Guide for HIV Prevention . National Alliance of State & Territorial AIDS Directors; 2016. Accessed September 11, 2024 . www.nastad.org 3. Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas, 2021. Accessed September 11, 2024 . www.cdc.gov 4. Centers for Medicare and Medicaid Services. FAQs about Affordable Care Act implementation part 54. July 28, 2022. Accessed September 11, 2024 . www.cms.gov 5. Coverage of Preventive Health Services, 29 C.F.R. 2590.715-2713 (2023). 6. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention. About HIV. Centers for Disease Control and Prevention. Reviewed January 24, 2024 . Accessed September 11, 2024 . www.cdc.gov 7. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention. About PrEP. Centers for Disease Control and Prevention. Reviewed May 6, 2024 . Accessed September 11, 2024 . www.cdc.gov 8. Krakower D, Mayer KH. HIV pre-exposure prophylaxis. UpToDate. Updated October 12, 2023 . Accessed September 11, 2024 . www.uptodate.com 9. Mayer KH, Molina JM, Thompson MA, et al. Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER): primary results from a randomised, double-blind, multicentre, active – controlled , phase 3, non-inferiority trial. Lancet . 2020;396(10246):239-254. doi:10.1016/S0140-6736(20)31065-5 10. Patient Protection and Affordable Care Act, 42 U.S.C. 18001-18122 (202 4). 11. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2021 Update: Clinical Providers Supplement. Centers for Disease Control and Prevention; 2021. Accessed September 11, 2024 . www.cdc.gov 12. Pre-Exposure Prophylaxis for the Prevention of HIV Infection: A Systematic Review for the U.S. Preventive Services Task Force. December 2022. Accessed September 11, 2024 . www.uspreventiveservicestaskforce.org 13. Task force at a glance. United States Preventive Services Task Force. Accessed September 11, 2024 . www.uspreventiveservicestaskforce.org 14. U.S. Preventive Services Task Force. Preexposure prophylaxis to prevent acquisition of HIV: US Preventive Services Task Force recommendation statement. JAMA . 2023;330(8):736-745. doi:1 0.1001/jama.2023.14461 15. U.S. Preventive Services Task Force. Grade Definitions. June 2018. Accessed September 11, 2024 . www.uspreventiveservicestaskforce.org 16. US Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2021 Update: A Clinical Practice Guideline . US Centers for Disease Control and Prevention; 2021. Accessed September 11, 2024 . www.cdc.gov 17. What does FDA regulate ? United States Food and Drug Administration. Reviewed March 29, 2024 . Accessed September 11, 2024 . www.fda.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Partial Hospitalization Program-Behavioral Health-MP-PY – 1480 09/01/2024 Kentucky Inactive 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Po licies p repared by CareSource an d its affiliates are in tended to provide a g eneral reference regarding billin g , co d ing an d d ocumentation g uidelines. Co ding meth odology, regulatory req uiremen ts, in d ustry-stan d ard claims ed itin g lo g ic, ben efi ts d esig n an d o th er facto rs are co n sid ered in d evelo p in g Reimbursemen t Po licies. In ad d ition to th is Po licy, Reimbursement o f services is subject to member ben efits an d eligibility o n th e d ate of service, m ed ical n ecessity, ad herence to p lan p olicies an d p rocedures, claims ed itin g lo g ic, p ro vid er co n tractual ag reemen t, an d ap p licable referral, auth orization, n otification an d utilization man agement g uid elin es. Med ically n ecessary services in clud e, but are n o t limited to , those h ealth care services o r supplies th at are p roper an d n ecessary for th e d iagnosis o r treatment o f d isease, i llnes s, o r in jury an d without which th e patient can be exp ected to suffer p rolonged, increased o r n ew mo rbidity, impairmen t o f fun cti o n , d ysfunction o f a bo d y o rgan o r part, o r significant p ain an d d isco mfo rt. Th ese services meet th e stan d ard s o f g o o d med ical p ractice in th e lo cal area, are th e lo west cost alternative, an d are n o t p ro vid ed main ly fo r th e co n ven ien ce o f th e member o r p ro vider. Med ically n ecessary services also include th ose services d efined in an y federal o r state coverage mand ate, Evid en ce o f Co verag e d o cumen ts, Med ical Po licy Statemen ts, Pro vid er Man uals, Member Han d bo o ks, an d /o r o th er p o licies an d p ro ced ures. Th is Po licy does n ot en sure an auth orization o r Reimbursement o f services. Please refer to th e p lan con tract (o ften referred to as th e Evid en ce o f Coverage) for th e service(s) referenced h erein. If th ere is a co nflict between th is Po licy an d the p lan con tract (i.e., Evid ence o f Co verage), th en th e p lan contract (i.e., Evidence o f Co verage) will be th e co ntrollin g d o cumen t used to ma ke th e d etermination. CareSo urce an d its affiliates may use reasonable d iscretion in interpreting an d ap plying th is Po licy to services p ro vid ed in a p articular case an d may mo d ify th is Po licy at an y time. Acco rding to th e rules o f Men tal Health Parity Ad diction Eq uity Act (MHPAEA), co verag e fo r th e d iag n o sis an d treatmen t o f a beh avioral h ealth d isorder will not be subject to an y limitations th at are less favorable th an th e limitatio n s th at ap p ly to med ical co n d itio n s as co vered un d er th is p o licy.T his policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Con ten tsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. ….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………… 2 C. Def initions ………………………….. ………………………….. ………………………….. ………………………….. 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……. 3 E. State-Specif ic Inf ormation ………………………….. ………………………….. ………………………….. ……. 5 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……….. 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ………… 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ………. 5 I. Ref erences ………………………….. ………………………….. ………………………….. ………………………… 5 Partial Hospitalization Program-Behavioral Health-MP-PY-1480 Ef f ective Dat e: 09/01/2024 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inthe REIMBURSEMENT Policy Statement Policy and is app roved.2 A. Su bjectPartial Hospitalization Program Behavioral Health B. Backgrou n dPartial hospitalization programs (PHPs) are structured to provide intensive psychiatric or substance use disorder (SUD) care through active treatment that utilizes a combination of the clinically recognized items and services described in 1861(f f ) of the Social Security Act. The treatment program closely resembles a highly structured, short-term hospital inpatient program , providing treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation. PHPs involve incorporating an individualized treatment plan describing a coordination of services wrapped around the needs of the member and a multidisciplinary team approach to care under the direction of a physician with a high degree of structure and scheduling. Acc ording to current practice guidelines, treatment goals should be measurable, f unctional, time-f ramed, medically necessary, and directly related to the reason f or admission. Items and services provided can include the f ollowing: individual and group therapy with physicians, psychologists, other mental health prof essionals to the extent authorized under state law occupational therapy requiring the skills of a qualif ied occupational therapist services of social workers, trained psychiatric nurses, and other staf f trained to work with members with psychiatric diagnoses and SUD drugs and biologicals f urnished f or therapeutic purposes, which cannot as determined in accordance with regulations, be self-administered individualized activity therapies that are not primarily recreational or diversionary f amily counseling with a primary purpose f or treatment of the individuals diagnosis, including counseling services f or caregivers patient training and education to the extent that activities are closely and clearly related to an individuals care and treatment diagnostic services other items and services, in no event to include meals and transportation, reasonable and necessary f or the diagnosis or active treatment of the condition, reasonably expected to improve or maintain the condition and f unctional level, to prevent relapse or hospitalization, and f urnished pursuant to guidelines relating to f requency and duration of services established by regulations (taking into account accepted norms of medical practice and the reasonable expectation of patient improvement) A physician must certif y a members n eed f or a minimum of 20 hours per week oftherapeutic services f or those requir ing a comprehensive, structured, multimodal treatment with medical supervision and coordination due to a diagnosis f rom the Diagnostic and Statistical Manual of Mental Disorders . The diagnosis should severely interf ere with multiple areas of daily lif e, including social, vocational, and/or educational f unctioning , generally of an acute nature. In addition, the member must be able to Partial Hospitalization Program-Behavioral Health-MP-PY-1480 Ef f ective Dat e: 09/01/2024 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inthe REIMBURSEMENT Policy Statement Policy and is app roved.3 participate cognitively and emotionally in the active treatment process while tolerating the intensity of a PHP . Coverage requirements typically involve members discharged f rom an inpatient hospitaltreatment program with the PHP in lieu of continued inpatient treatment or members at reasonable risk of requiring inpatient hospitalization. Whe n PHPs are used to shorten an inpatient stay and transition the member to a less intense level of care, there must be evidence of the need f or PHP services . Recertif ication must address the continuing , serious nature of the psychiatric condition requiring continued active treatmen t. Discharge planning ref lect the types of best practices recognized by prof essional andadvocacy organizations that ensure coordination of needed services and f ollow-up care.These activities include linkages with community resources, supports, and providers in order to promote a members return to a higher level of f unctioning in the least restrictive environment. C. Defin ition s Concurrent Review A request f or prior authorization or a predetermination that is submitted bef ore or during the course of receiving a health care service. Inpatient Services Behavioral health (BH) services provided during an inpatient admission or conf inement f or acute inpatient services in a hospital or treatment setting on a 24-hour basis under the direct care of a physician, including psychiatric hospitalization, inpatient detoxif ication, and em ergency evaluation and stabilization. Intensive Outpatient Program (IOP) Services addressing BH needs provided by f acilities, group practices or clinics at least 3 hours a day, 2 to 3 days a week and usually as a step down f rom acute inpatient care, partial hospitalization care, or residential care but a step up f rom traditio nal outpatient services. Partial Hospitalization Structured, multimodal, active treatment f or BH needs with a treatment period of less than 24 hours, including individual, group and/or f amily psychotherapy, member education and training, and diagnostic services f ocusing on member reintegration into society. Residential Treatment Services f or BH needs that can include individual, f amily and group therapy, nursing services, medication assisted treatment, detoxif ication (ambulatory or subacute), and pharmacological therapy in a congregate living community with 24-hour support. Retrospective Review A request f or medical review that is submitted af ter the health care service has been received. D. PolicyI. Prior authorization is required af ter 5 days per calendar year. CareSource f ollows MCG criteria f or reviews of medical necessity f or mental health requests and ASAM criteria f or review of substance use disorder requests. II. BillingPartial Hospitalization Program-Behavioral Health-MP-PY-1480 Ef f ective Dat e: 09/01/2024 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inthe REIMBURSEMENT Policy Statement Policy and is app roved.4 A. Some prof essional services are separately covered and unbundled . See section260 of Chapter 4 of the Medicare Claims Processing Manual f or additional instructions. B. Under component billing, p roviders must include the f ollowing f or service claims: 1. PHP ambulatory payment classif ications (APCs) f or each provider type a. days with 3 or f ewer services a day b. days with 4 or more services a day 2. Type of bills (TOB) f or institutional billing include the f ollowing: a. TOB 13X outpatient hospital b. TOB 85X critical access hospital (CAH) c. TOB 76X community mental health center (CMHC) 3. Claims must be submitted in sequence f or a continuing course of treatment. Consistency editing will be enf orced f or interim billing of PHP claims. Definition TOB SettingAdmit through discharge 131 13X 851 85X 761 76X Interim First 132 13X 852 85X 762 76X Interim – Continuing 133 13X 853 85X 763 76X Interim Last 134 13X 854 85X 764 76X 4. Hospitals other than CAHs are required to report line item dates of service per revenue code line f or claims and the charge f or each individual covered service f urnished, including required Healthcare Common Procedure Coding System (HCPCS) or CPT codes. Rev enue codes can be f ound in Chapter 4of the Medicare Claims Processing Manual, 100-04 . 5. PHP services are identif ied using condition code 41 on claims. 6. When applicable, add on codes may be used f ollowing an appropriate initial code. 7. Modif iers, including the f ollowing, must be reported: Modifier DescriptionPN Services provided in non-excepted , of f-campus , provider-based departments of a hospital . Use will trigger a payment rate under the Medicare Physician Fee Schedule. PN should be reported with each non-excepted item and service, including those f or which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services . PO Services provided in excepted , of f-campus , provider-based departments of a hospital (services, procedures and surgeries provided at of f-campus Partial Hospitalization Program-Behavioral Health-MP-PY-1480 Ef f ective Dat e: 09/01/2024 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inthe REIMBURSEMENT Policy Statement Policy and is app roved.5 provider-based outpatient departments f or all excepted items and services f urnished ). 8. Providers must report service units f or billed codes. P atient status must be reported . Discharge status codes can located in Chapter 25 of the Medicare Claims Processing Manual, 100-04. III. The f ollowing activities and/or programs are considered not medically necessary:A. day care programs, providing primarily social, recreational, or diversionary activities, custodial or respite care B. programs that maintain psychiatric wellness with no risk of relapse of hospitalization of member C. services f or members otherwise psychiatrically stable or requiring medication management only D. services to inpatient members at a hospital, including meals, self-administration of medication, transportation, and/or vocational training E. members who cannot or ref use to participate with treatment (eg, low cognitive status, volatile behavioral issues) or cannot tolerate the intensity of a PHP F. treatment of chronic conditions without acute exacerbation of symptoms that place the member at risk of relapse or hospitalization E. State-Specific In formationWest Virginia – Benef its f or the f irst 5 days will be provided without any retrospective review of medical necessity. Benef its beginning day 6, and every 6 days thereaf ter, are subject to concurrent review of medical necessity. F. Con dition s of CoverageIn the event of any conf lict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document. G. Related Policies/Ru lesMedical Necessity Determinations Behavioral Health Service Record Documentation Standards H. Review/Revision HistoryDAT E ACT IONDate Issued 05/22/2024 Merged AD-1264 & AD-1263. Converted to a PY policy.Date Revised Date Effective 09/01/2024 Date Archived I. Referen ces1. About the ASAM criteria. American Society of Addiction Medicine. Accessed May 1 4, 2024. www.asam.org 2. Centers f or Medicare and Medicaid Services. CY 2024 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Partial Hospitalization Program-Behavioral Health-MP-PY-1480 Ef f ective Dat e: 09/01/2024 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inthe REIMBURSEMENT Policy Statement Policy and is app roved.6 Final Rule . Centers f or Medicare and Medicaid Services; 2023. CMS Fact SheetCMS 1786-FC. Accessed May 14 , 2024. www.cms.gov 3. Conditions f or Fee Schedule Payment f or Physician Services to Benef iciaries in Providers . 42 C.F.R. 415.102 (2023). 4. Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, 136 Stat. 4459. 5. Def initions. 42 U.S.C. 1395 (2011). 6. Diagnostic and Statistical Manual of Mental Disorders (5th ed, Text Revised) . American Psychiatric Association; 2022. Accessed May 14 , 2024 . doi:10.1176/appi.books.9780890425787 7. Further Additional Continuing Appropriations and Other Extensions Act, 2024, Pub. L. No. 118-35, 138 Stat. 3. 8. Georgia Marketplace Evidence of Coverage . CareSource; 2024. Accessed May 14 , 2024 . www.caresource.com 9. Indiana Marketplace Evidence of Coverage . CareSource; 2024. Accessed May 14 , 2024. www.caresource.com 10. Kentucky Marketplace Evidence of Coverage . CareSource; 2024. Accessed May 14 , 2024 . www.caresource.com 11. Medical Insurance (SMI) Benef its, 42 C.F.R. 410.42, 410.71, 410.73 to 76, and 410.78 (2023). 12. Medicare Benefit Policy Manual Chapter 6 . Centers f or Medicare and Medicaid Services. Issued December 21, 2023. Accessed May 14 , 2024. www.cms.gov 13. Medicare Claims Processing Manual, Chapter 4 , 100-04 . Centers f or Medicare and Medicaid Services. Issued January 25, 2024. Accessed Ma y 14, 2024. www.cms.gov 14. Medication-Assisted Opioid Withdrawal: B-909-OPD. MCG Health . 2 8th ed. Updated February 1, 2024 . Accessed May 14 , 2024. www.careweb.careguidelines.com 15. Ohio Marketplace Evidence of Coverage . CareSource; 2024. Accessed May 14 , 2024 . www.caresource.com 16. Outpatient Opioid Maintenance Therapy: B-910-OPD. MCG Health. 2 8th ed. Updated February 1, 2024 . Accessed May 14, 2024. www.careweb.careguidelines.com 17. Partial Hospitalization Services: Conditions and Exclusions , 42 C.F.R. 410.43 (2023). 18. Requirements f or Medical and Other Health Services Furnished by Providers under Medicare Part B , 42 C.F.R. 424.24 (2023). 19. Substance Abuse and Mental Health Services Administration. Clinical Issues in Intensive Outpatient Treatment for Substance Use Disorders: Advisory . U.S. Dept. of Health and Human Services; 2021. Publication # PEP20-02-01-021. Accessed May 14 , 2024. www.samhsa.gov 20. Substance Abuse and Mental Health Services Administration. TIP 47: Clinical Issues in Intensive Outpatient Treatment for Substance Use Disorders. U.S. Dept. of Health and Human Services; 20 13 . Publication # SMA-13-4182 . Accessed May 14 , 2024. www.samhsa.gov 21. Substance Use Disorder, W. VA. CODE 33-25A-8r (2022). 22. West Virginia Marketplace Evidence of Coverage . CareSource; 2024. Accessed May 14, 2024 . www.caresource.com
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Intensive Outpatient Program-Behavioral Health-MP-PY – 1477 09/01/2024 Kentucky Inactive 01/01/2026 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 4 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 I. References ………………………….. ………………………….. ………………………….. ……………………. 6 Intensive Outpatient Program-Behavioral Health-MP-PY-1477Effective Dat e: 09/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectIntensive Outpatient Program Behavioral Health B. BackgroundThe Consolidated Appropriations Act of 2023 (CAA, 2023) established Medicare coverage and payment for I ntensive Outpatient Program (IOP) services provided on or after January 1, 2024 for individuals with mental health conditions and/or substance use disorder (SUD) needs provided in hospital outpatient departments (HOPD), critical access hospital (CAH) outpatient departments, community mental health centers (CMHC), rural health clinics (RHCs), and federally qualified health centers (FQHCs). IOP services m ay a lso be furnished in opioid treatment programs (OTPs) for the treatment of opioid use disorder (OUD). Per federal guidelines, IOPs incorporate items and services prescribed by a physicianfor an individual determined, not less frequently than once every other month, to need services for a minimum of 9 hours per week. An IOP is active treatment provided under the supervision of a physician pursuant to an individualized, written plan of treatment established and periodically reviewed by a physician in consultation with appropriate staff participating in the program. In addition to documenting the physicians diagnosis, type, amount, frequency, and duration of the items and services provided to the member, the treatment plan describes a coordination of services wrapped around the needs of the member and includes a multidisciplinary team approach to care. Treatment goals will be measurable, functional, time-framed, directly related to admission reason, and medically necessary. Items and services provided can include the following: individual and group therapy with physicians , psychologists , other mental health professionals to the extent authorized under state law occupational therapy requiring the skills of a qualified occupational therapist services of social workers, trained psychiatric nurses, and other staff trained to work with members with psychiatric diagnoses drugs and biologicals furnished for therapeutic purposes , which cannot, as determined in accordance with regulations, be self-administered individualized activity therapies that are not primarily recreational or diversionary family counseling with a primary purpose for treatment of the individuals diagnosis , including counseling services for caregivers patient training and education to the extent that activities are closely and clearly related to individuals care and treatment diagnostic services other items and services , in no event to include meals and transportation , that are reasonable and necessary for the diagnosis or active treatment of the individuals condition, reasonably expected to improve or maintain the individuals condition and functional level , to prevent relapse or hospitalization, and furnished pursuant to guidelines relating to frequency and duration of services established by regulation s Intensive Outpatient Program-Behavioral Health-MP-PY-1477Effective Dat e: 09/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 (taking into account accepted norms of medical practice and the reasonable expectation of patient improvement)IOPs for substance use disorders (SUDs) offer services to members seeking primary treatment, step-down care from inpatient, residential, and withdrawal management settings, or step-up treatment from individual or group outpatient treatment. To assist members with fulfill ing individualized treatment plan goals, IOP services may incorporate other in-house treatment and peer services, encourage attendance at mutual-support groups, and collaborat e with local community providers to secure needed services (eg, me dication-assisted treatment, psychological assessments, vocational rehabilitation services, and trauma-specific treatment). Advantages of IOP treatment have been thoroughly documented in peer-reviewedliterature. Day, evening, and weekend programming offer s flexibility in treatment delivery and allow s clients to maintain responsibilities outside treatment, including work, caregiving, parenting, and education. Less restrictive , comprehensive treatment offer s more intensive services than traditional outpatient while avoiding the restrictions of residential treatment. Services are provided over a longer period than most residential treatment programs , and most are available in l ocal communities , creating less disrupti on for clients manag ing day-to-day responsibilities. Continuity of care and support are increased as well, as members engaged in IOP treatment often use local community services and mutual-support groups outside the program that remain intact after completin g treatment. IOP programs provide opportunities to practice recovery skills in real time, allowing members to apply newly acquired skills with family and friends and in other circumstances while still engaged in treatment. C. Definitions American Society of Addiction Medicine (ASAM) A professional medical society dedicated to increasing access and improving the quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of pati ents with addiction. ASAM Intensive Outpatient Level of Care (LOC ) 2.1 9 or more hours of SUD treatment services a week (adults) or 6 or more hours (adolescents) to treat multidimensional instability, particularly services meeting complex needs of members with addiction and co-occurring conditions. Concurrent Review A request for prior authorization or a predetermination that is submitted before or during the course of receiving a health care service. Intensive Outpatient Program (IOP) Behavioral health (BH) services provided by facilities, group practices or clinics at least 3 hours a day, 2 to 3 days a week and usually as a step down from acute inpatient care, partial hospitalization care, or residential care but a step up from traditional outpatient services . Partial Hospitalization Structured, multimodal, active treatment for BH needs with a treatment period of less than 24 hours, including individual, group and/or family psychotherapy, member education and training, and diagnostic services focusing on member reintegration into society. Intensive Outpatient Program-Behavioral Health-MP-PY-1477Effective Dat e: 09/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Residential Treatment Services for BH needs that can include individual, family and group therapy, nursing services, medication assisted treatment, detoxification (ambulatory or subacute), and pharmacological therapy in a congregate living community with 24-hour support. Retrospective Review A request for medical review that is submitted after the health care service has been received. D. PolicyI. Prior authorization is required after 5 days per calendar year. CareSource follows MCG criteria for reviews of medical necessity for mental health requests and ASAM criteria for review of substance use disorder requests. II. BillingA. Some professional services are separately covered and unbundled. See section 261 of Chapter 4 of the Medicare Claims Processing Manual for additional instructions. B. Under component billing for IOP services, p roviders must include the following components for service claims: 1. IOP ambulatory payment classifications (APCs) for each provider type a. days with 3 services a day b. days with 4 or more services a day 2. Type of bills (TOB) for institutional billing a. TOB 13X outpatient hospital b. TOB 85X critical access hospital (CAH) c. TOB 76X community mental health center (CMHC) 3. Claims must be submitted in sequence for a continuing course of treatment. Consistency editing will be enforced for interim billing of IOP claims. Definition TOB SettingAdmit through discharge 131 13X 851 85X 761 76X Interim First 132 13X 852 85X 762 76X Interim – Continuing 133 13X 853 85X 763 76X Interim Last 134 13X 854 85X 764 76X 4. Hospitals are required to report a revenue code and the charge for each individual covered service furnished under an IOP, including required Healthcare Common Procedure Coding System (HCPCS) or CPT codes.Intensive Outpatient Program-Behavioral Health-MP-PY-1477Effective Dat e: 09/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Revenue codes can be found in Chapter 4 of the Medicare ClaimsProcessing Manual, 100-04. 5. IOP services are identified on claims using condition code 92. 6. When applicable, add on codes may be used following an appropriate initial code. 7. Modifiers, including the following, must be reported: Modifier DescriptionPN Services provided in non-excepted , off-campus , provider-based departments of a hospital . Use will trigger a payment rate under the Medicare Physician Fee Schedule. PN should be reported with each non-excepted item and service, including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services . PO Services provided in excepted , off-campus , provider-based departments of a hospital (services, procedures and surgeries provided at off-campus provider – based outpatient departments for all excepted items and services furnished ). 8. Providers must report service units, dates of service, and patient status. Discharge status codes can located in Chapter 25 of the Medicare ClaimsProcessing Manual, 100-04. III. The following activities and/or programs are considered not medically necessary:A. day care programs providing primarily social, recreational, or diversionary activities, custodial or respite care B. programs that maintain psychiatric wellness, in which there is no risk of relapse of hospitalization of member C. services for members otherwise psychiatrically stable or requir ing medication management only D. services to inpatient members at a hospital, including meals, self-administration of medication, transportation, and/or vocational training E. members who cannot or refuse to participate in treatment (eg , low cognitive status, volatile behavioral issues) or cannot tolerate the intensity of an IOP F. treatment of chronic conditions without acute exacerbation of symptoms that place the member at risk of relapse or hospitalization E. State-Specific InformationWest Virginia – Benefits for the first 5 days of IOP will be provided without any retrospective review of medical necessity. Benefits beginning day 6, and every 6 days thereafter, are subject to concurrent review of medical necessity. F. Conditions of CoverageIn the event of any conflict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document. Intensive Outpatient Program-Behavioral Health-MP-PY-1477Effective Dat e: 09/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 G. Related Policies/RulesMedical Necessity Determinations Behavioral Health Service Record Documentation Standards H. Review/Revision HistoryDATE ACTIONDate Issued 05/22/2024 Merged AD-1262 and AD-1261. Converted to PY policy.Date Revised Date Effective 09/01/2024 Date Archived I. References1. About the ASAM criteria. American Society of Addiction Medicine. Accessed May 13, 2024. www.asam.org 2. Centers for Medicare and Medicaid Services. CY 2024 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule. Centers for Medicare and Medicaid Services; 2023. CMS Fact Sheet CMS 1786-FC. Accessed May 13 , 2024. www.cms.gov 3. Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, 136 Stat. 4459. 4. Definitions. 42 U.S.C. 1395 (2011). 5. Diagnostic and Statistical Manual of Mental Disorders (5th ed, Text Revised) . American Psychiatric Association; 2022. Accessed May 13 , 2024 . doi:10.1176/appi.books.9780890425787 6. Further Additional Continuing Appropriations and Other Extensions Act, 2024, Pub. L. No. 118-35, 138 Stat. 3. 7. Georgia Marketplace Evidence of Coverage . CareSource; 2024. Accessed May 13 , 2024 . www.caresource.com 8. Indiana Marketplace Evidence of Coverage . CareSource; 2024. Accessed May 13 , 2024 . www.caresource.com 9. Intensive Outpatient Behavioral Health Level of Care, Adult: B-901-IOP. MCG Health. 2 8th ed. Updated February 1, 2024 . Accessed May 13 , 2024 . www.careweb.careguidelines.com 10. Intensive Outpatient Behavioral Health Level of Care, Child or Adolescent: B-902 – IOP. MCG Health. 2 8th ed. Updated February 1, 2024 . Accessed May 13, 2023. www.careweb.careguidelines.com 11. Kentucky Marketplace Evidence of Coverage . CareSource; 2024. Accessed May 13 , 2024 . www.caresource.com 12. Medical Insurance (SMI) Benefits, 42 C.F.R. 410.42, 410.71, 410.73 to 76, and 410.78 (2023). 13. Medicare Claims Processing Manual, 100-04 . Centers for Medicare and Medicaid Services. Updated December 20, 2023. Accessed May 13 , 2024. www.cms.gov 14. Medicare Learning Network. Billing Requirements for Intensive Outpatient Program Services with New Condition Code 92 . Centers for Medicaid and Medicare Services; 2023. MLN Matters Number MM13496. Accessed May 13 , 2024. www.cms.gov Intensive Outpatient Program-Behavioral Health-MP-PY-1477Effective Dat e: 09/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 15. Medication-Assisted Opioid Withdrawal: B-909-OPD. MCG Health . 2 8th ed. UpdatedFebruary 1, 2024 . Accessed May 13 , 2024. www.careweb.careguidelines.com 16. Ohio Marketplace Evidence of Coverage . CareSource; 2024. Accessed May 13 , 2024 . www.caresource.com 17. Outpatient Opioid Maintenance Therapy: B-910-OPD. MCG Health. 2 8th ed. Updated February 1, 2024 . Accessed May 13 , 2024. www.careweb.careguidelines.com 18. Substance Abuse and Mental Health Services Administration. Clinical Issues in Intensive Outpatient Treatment for Substance Use Disorders: Advisory . U.S. Dept. of Health and Human Services; 2021. Publication # PEP20-02-01-021 . Accessed May 13 , 2024. www.samhsa.gov 19. Substance Abuse and Mental Health Services Administration. TIP 47: Clinical Issues in Intensive Outpatient Treatment for Substance Use Disorders. US Dept of Health and Human Services; 20 13 . Publication # SMA-13-4182 . Accessed May 13 , 2024. www.samhsa.gov 20. Substance-Related Disorders, Intensive Outpatient Program: B-015-IOP. MCG Health. 2 8th ed. Updated February 1, 2024 . Accessed May 13 , 2024. www.careweb.careguidelines.com 21. Substance Use Disorder, W. VA. CODE 33-25A-8r (2022). 22. Watkins L, Patton S, Drexler K, et al. Clinical effectiveness of an intensive outpatient program for integrated treatment of comorbid substance abuse and mental health disorders. Cognitive Behav Pract . 2023;30(3):354-366. doi:10.1016/j.cbpra.2022.05.005 23. West Virginia Marketplace Evidence of Coverage . CareSource; 2024. Accessed May 13 , 2024 . www.caresource.com 24. Withdrawal Management, Adult, Intensive Outpatient Program: B-031-IOP. MCG Health. 2 8th ed. Updated February 1, 2024 . Accessed May 13 , 2024. www.careweb.careguidelines.com
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-MP-PY-1388 04/01/2024 Kentucky Inactive 01/01/2026 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. …. 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. …… 3 I. References ………………………….. ………………………….. ………………………….. …………………….. 3 Preventive Evaluation and Management Services and AcuteCare Visit on Same Date of Service-MP-PY-1388Effective Dat e: 04/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectPreventive Evaluation and Management Services and Acute Care Visit on Same Date of Service B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claim s 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 staf f are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payme nt.CareSource will reimburse participating providers for medically necessary and preventive screening tests as required by federal statue through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF).C. Definitions Preventive Services Exams and screenings that check for health problems with the intention to prevent any problem discovered from worse ning and may in clude, but are not limited to, physical checkups, hearing, vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider for prev entive services are encouraged at every age but are especially important for children under the age of 1 8 years. D. PolicyI. When any of the following prev entive health service codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse only the preventive service code at 100%. The acute care visit service codes will not be reimbursed unless billed with the appropriate modifier to identify separately identifiable services that were rendered by the same physician on the same date of service. A. Preventive Health Service Codes 1. 99381-99387 2. 99391-99397 B. Acute Care Visit Codes 1. 9920 2-99205 2. 99211-99215 Preventive Evaluation and Management Services and AcuteCare Visit on Same Date of Service-MP-PY-1388Effective Dat e: 04/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 II. CareSource reserves the right to request documentation to support billing both services for all claims received. If documentation is requested, it must clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. Documentation must include the following: A. Key elements that support the additional preventive health services that were rendered. B. A separate history paragraph describing the chronic/acute condition that clearly supports additional work needed on the same date of service. C. A clear list in the assessment portion of the documentation of the acute/chronic conditions being managed at the time of the encounter. If there is a portion of the physical exam that is not routinely performed at the time of the preventive service, the pr ovider should clearly identify those exam pieces (eg, a thorough MS and neuro exam of the left hip performed as it relates to the HPI). E. State-Specific InformationNA F. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes. G. Related Policies/RulesModifier 25 Reimbursement policy H. Review/Revision HistoryDATE ACTIONDate Issued 09/14/2022Date Revised 01/17/2024 Annual Review; Approved at Committee. Date Effective 04/01/2024 Date Archived I. References1. Coverage of Preventive Health Services, 26 C.F.R. 54.9815-2713 (2023). 2. Draak K. Successfully bill a preventive service with a sick visit. American Academy Professional Coders. March 1, 2022. Accessed December 20, 2023. www.aapc.com
REIMBURSEMENT POLICY STATEMENT GEORGIA MARKETPLACE Policy Name Policy Number Effective Date Standard Medical Billing Guidance PY-PHARM-0127 – GA-MP 02-01-202 3 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standa rd claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this P olicy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………….. . 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. … 2 B. Background ………………………….. ………………………….. ………………………….. ………………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ….. 3 E. Conditions of Coverage. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …….. 5 H. References ………………………….. ………………………….. ………………………….. ………………………. 5 Standard Billing Reimbursement StatementGEORGIA MARKETPLACEPY-PHARM-0127-GA-MP Effective Date: 02-01-2023 2 A. SubjectStandard Medical Billing Guid ance B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate 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. This reimbursement policy applies to all health care services reported using theCMS 1500 Health Insurance Professional Claim Form (a/k/a HCFA ), the CMS 1450Health Insurance Institutional Claim Form (a/k/a UB04) or its electronic equivalent or any successor form. This policy appli es to all products, all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Additi onally, this policy applies to drugs and biologicals being used for FDA-approved indications or label s. Drugs and biologicals used for indications other than those in the approved labeling may be covered if it is determined that the use is medically accept ed, taking into consideration the major drug compendia, authoritative medical literatures and/or accepted standards of medical practice. C. Definitions Indication is defined as a diagnosis, illness, injury, syndrome, condition, or other clinical parameter for which a drug may be given. FDA approved Indication /Label is the official description of a drug product which includes indication (what the drug is used for); who should take it; adverse events (side effec ts); instructions for uses in pregnancy, children, and other populations; and safety information for the patient. Labels are often found inside drug product packaging. Off-label/Unlabeled use of a drug is defined as a use for a non-FDA approved indication, that is, one that is not listed on the drugs official label/prescribing information. Off-label use is further defined as giving the drug in a way that deviates significantly from the labeled prescribing information for a particular indication. This includes but is not necessarily limited to, dosage, route of administration, duration and frequency of ad ministration, and population to whom the drug would be administered. Standard Billing Reimbursement StatementGEORGIA MARKETPLACEPY-PHARM-0127-GA-MP Effective Date: 02-01-2023 3 Unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label . Drug compendia , defined as summaries of drug information that are compiled by experts who have reviewed clinical data on drugs. CMS (Center for Medicare and Medicaid Services) recognizes the following compendia: American Medical Association Drug Evaluations (AMA-DE), United States Pharmacopoeia-Drug Information (USP-DI) or its successor publication and American Hospital Formulary Service-Drug Information (AHFS-DI) as authoritative sources for use in the determination of a “medical ly-accepted indication” of drugs and biologicals used off – label in an anticancer chemotherapeutic regimen. The USP DI is a database of drug information developed by the U.S. Pharmacopoeia but maintained by Micromedex, which contains medically accepted uses for generic and brand name drug products . D. PolicyCare Source requires that the u se of a drug or biological must be safe and effective and otherwise reasonable and necessary. Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for indications specified on the labeling. Therefore, reimbursement may be provided for the use of an FDA approved drug or biological, if: It was administered on or after t he date of the FDAs approval; It is reasonable and necessary for the individual patient; and All other applicable coverage requirements are met. An unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label may be covered if it is determined that the use is medically necessary , taking into consideration the major drug compendia, authoritative medical literatur e and/or accepted standards of medical practice. The following guidelines identify three categories in which medications would not be reasonable and necessary according to accepted standards of medical practice. Not for Particular Illness Medications gi ven for a purpose other than the treatment of a particular condition, illness, or injury are not covered (except for certain immunizations .) Route of Administration Not Indicated Medication given by injection (parenterally) is not covered if standard me dical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. Excessive Medications Medications administered for treatment of a disease which exceed the freque ncy or duration of dosing indicated by accepted standards of medical practice are not covered. Effective January 1, 1994, off-label, medically accepted indications of Food and Drug Administration (FDA) approved drugs and biologicals used in an anti-neoplas tic chemotherapeutic regimen are identified under the indications described below : Standard Billing Reimbursement StatementGEORGIA MARKETPLACEPY-PHARM-0127-GA-MP Effective Date: 02-01-2023 4 A regimen is a combination of anti-neoplastic agents clinically recognized for the treatment of a specific type of cancer. Off-label, medically accepted indications are supp orted in either one or more of the compendia or in peer-reviewed medical literature. E. Conditions of Coverage A medically accepted indication is one of the following: An FDA approved, labeled indication or a use supported in the American Hospital Formulary Service Drug Information (AHFS-DI), NCCN Drugs and Biologics Compendium, Truven Health Analytics Micromedex Drug Dex , Elsevier/Gold Standard Clinical Pharmacology and Wolters Kluwer Lexi – Drugs as the acceptable compendia based on CMS’ Change Request 619 1 (Compendia as Authoritative Sources for Use in the Determination of a “Medically Accepted Indication” of Drugs and Biologicals Used Off-Label in an Anti-Cancer Chemotherapeutic Regimen); or Articles o f Local Coverage Determinations (LCDs) published by C MS. In general, a use is identified by a compendium as medically accepted if the: Indication is a Category 1 or 2A in NCCN, or Class I, Class IIa, or Class IIb in DrugDex; or, Narrative text in AHFS-DI or Clinical Pharmacology is supportive, or Indication is listed in Lexi-Drugs as Use: Off-Label and rated as Evidence Level A A use is not medically accepted by a compendium if the: Indication is a Category 3 in NCCN or a Class III in DrugDex; or, Narrative text in AHFS or Clinical Pharmacol ogy is not supportive, or Indication is listed in Lexi-Drugs as Use: Unsupported If a use is identified as not indicated by CMS or the FDA, or if a use is specifically identified as not indicated in one or more of the compendia listed, or if it is dete rmined, based on peer-reviewed medical literature, that a particular use of a drug is not safe and effective, the off-label use is not supported and the drug will not be covered. Reimbursement is dependent on, but not limited to claims submissions reporte d usingCMS 1500/HCFA, CMS 1450/UB 04 or electronic equivalent, and must include the following: 11-digit NDC (National Drug Code) HCPCS/CPT Code Correct HCPCS units ( not NDC units) Correct NDC unit of measure PLEASE NOTE THE FOLLOWING: Providers are responsible for sourcing and submitting accurate codes. Multi-source brands are not accepted without an additional medical necessity review for Dispense as Written (DAW). Medical Necessity for DAW policies can be found at CareSource.com under the applicable markets administrative policies tab. Standard Billing Reimbursement StatementGEORGIA MARKETPLACEPY-PHARM-0127-GA-MP Effective Date: 02-01-2023 5 If applicable, individual drug reimbursement information may be found in a drugs Pharmacy Policy .F. Related Policies/Rules G. Review/Revision History DATE ACTIONDate Issued 07/22/2022 Original effective dateDate Revised 12/06/2022 Additions to clarify claims submission requirements, responsibility for sourcing of codes, and MSBs not accepted without additional DAW review. Individual drug reimbursement information may be found in a drugs Pharmacy Policy Date Effective 02/01/2023 Date Archived H. References1. Drugs@FDA Glossary of Terms https://www.fda.gov/drugs/drug-approvals-and-databases/drugsfda – glossary-terms 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publi cations and services https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals 3. United States Federal Food, Drug and Cosmetic Act https://www.fda.gov/regulatory-information/laws-enforced-fda/federal-food-drug-and-cosmetic-act-fdc-act The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTGeorgia Marketplace Policy Name & Number Date Effective Payment to Out of Network Providers-GA MP – PY-1173 02/01/2023 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 ………………………….. ………………………….. ………………………….. ………………….. 4 Paymen t to Out o fNetwo rk Pro vid ers-GA MP-PY-1173Effective Dat e: 02/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is app roved.A. SubjectPayment to Out of Network Providers B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice sta f 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 /ICD-10 code(s) f or the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. 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, such that a prudent layperson would reasonably have cause to believe constitutes a condition that the absence of immediate medical attention could reasonably be expected to resu lt in: o Serious impairment to bodily f unctions; o Serious dysf unction of any bodily organ or part; or o In the case of a pregnant woman who is having contractions: A situation in which there is inadequate time to ef f ect a saf e transf er to another hospital bef ore delivery; or A situation in which transf er may pose a threat to the health or saf ety of the woman or the unborn child. ASP Average Sales Price APC Ambulatory Payment Classif ication D. Policy Per our Evidence of Coverage contract and with some exceptions, out of network providers are not covered within the Marketplace Plans. For those situations where we are required to provide out of network coverage, and the reimbursement approach is not def i ned, CareSources standard reimbursement approach is as f ollows: I. Preauthorized, medically necessary services rendered to CareSource members, by out-of-network providers, will be reimbursed at: Paymen t to Out o fNetwo rk Pro vid ers-GA MP-PY-1173Effective Dat e: 02/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is app roved.A. 60 % of Centers f or Medicare & Medicaid Services (CMS) Medi care Resource-based Relative Value Scale f or Physician Services B. 60 % of CMS Medicare APC f or Ambulatory C. 60 % of CMS Medicare ASP Drug schedule D. 60% CMS Durable Medical Equipment, Prosthetics/Orthotics & Supplies; and Parenteral and Enteral Nutrition Fee Schedule E. 46.5% CMS Lab Fee Schedule f or Independent LABs F. 60 % Skilled Nursing f acility, Hospice, Home Health, Dialysis Facilities II. In the e vent of Emergency Services and unanticipated out of network care,CareSource will adhere to the Federal No Surprises Act, January 1, 2022. A. No prior authorization is required f or Emergency Services. III. If a service or procedure is covered by CareSource and not priced by Medicare, CareSource will use the Georgia Custom Fee Schedule f or Georgia Marketplace f or payment determinations.IV. The f ollowing are exclusions from the established non-participatin g rate: A. Emergency Health Care Services (reimbursed based on state regulations.) B. Urgent care C. COVID vaccination (administration only) D. COVID testing labs E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approv ed HCPCS and CPT codes along with appropriate modif iers , if applicable . Please ref er to the individual fee schedule f or appropriate codes. F. Related Policies/Rules Evidence of Coverage and Health Insurance Contract Georgia G. Review/Revision History DATE ACTIONDate Issued 05/27/2020 New policyDate Revised 12/17/2021 06/22/202212/14/2022No Surprises Act language added. Updated ref erences. Approved by PGC . Updated D.I. percentages. Added IV. Exclusions urgent care and Covid administration. Updated ref erences . Updated D.I. percentages . Updated D. IV. Exclusions . Updated ref erences. Date Effective 02/01/2023 Date Archived Paymen t to Out o fNetwo rk Pro vid ers-GA MP-PY-1173Effective Dat e: 02/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is app roved.H. Ref erences1. American Medical Association. Managed Care. Out-of-Network Care Policy H- 285.904 (2022). Retrieved 1 2/05/2022 f rom www.policysearch.ama-assn.org. 2. Fuchs, B., Hoadley , J . January 19, 2021. Summary of the No Surprises Act. January 1, 2021. Retrieved 1 2/05/2022 f rom www.commonwealthfund.org. 3. Georgia Of f ice of Commissioner of Insurance and Saf ety Fire. (July 1,2021). Chapter 120-2-106. Surprise Billing. Retrieved 12/05/2022 f rom www. rules.sos.ga.gov . 4. No Surprises Act of the 2021 Consolidated Appropriations Act. Pub. L. No. 116-260, 134 Stat . 1182, Division BB, 109. Retrieved 1 2/05/2022 from www.congress.gov.
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