ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Medical Record Documentation Standards for Practitioners-IN MCD – AD-0754 10/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Medical Record Documentation Standards for Practitioners-INMCD-AD-0754Effective Dat e: 10/01/2025 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectMedical Record Documentation Standards for Practitioners B. BackgroundMedical record documentation is a fundamental element required to support medical necessity and is the foundation for coding and billing . Documentation relays important information such as, but not limited to, assessments completed, services provided, coordination of services, timeliness of care, plan of treatment, rationale for orders, health risk factors, member s progress, and response to treatment. C. Definitions A Valid Signature for Services Provided or Ordered o May be h andwritten or electronic . CMS permits stamped signatures if you have a physical disability and can prove to a CMS contractor you are not able to sign due to that disability . o Is legible or can be validated by comparing to a signature log or attestation statement . Certificate of Medical Necessity (CMN) A written statement by a practitioner attesting that a particular item or service is medically necessary for an individual . D. PolicyI. Medical Documentation A. General requirements 1. Each member has thei r own medical record . 2. Entries are legible and include a. date of service b. signature, date, and credentials of practitioner 3. Each page of the record includes the members name and date of service. 4. Documentation indicate s that the services(s) billed we re the services provided . a. If CPT is based on a timed service, the total number of timed minutes and/or start and stop time with CPT codes/type of treatment is documented. b. If CPT is based on a group of members, the following is included : 01. Documentation to support that the member was present at each session. If member is not present for the duration of the visit, document start and stop time for the member . 02. Relationships/credentials of individuals present at each session . 03. Number of participants in group therapy/treatment . c. CPT/modifiers /place of service codes are appropriate for service and provider . d. Note reflects the location of service. Medical Record Documentation Standards for Practitioners-INMCD-AD-0754Effective Dat e: 10/01/2025 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 5. Documentation reflect s medical necessity for payment of services provided and utilization of resources as it relates to the service provided and the needs/desires of the member. 6. Documentation include s a problem list that includes significant illness or medical and behavioral conditions found in history or previous encounters. 7. When making changes in paper medical record a. Change is clearly visible . b. White out is not utilized . c. A single line is through an entry labeled with error, initialed, and dated . 8. When making changes in electronic medical records a. Amendment, correction or delayed entry is identified . b. A reliable way to identify the original content, the modified content, and the date and person modifying the record is provided. 9. When documentation is over multiple pages a. Additional pages from a continuation of a note are clearly identified . b. Continuous pages contain 01. member name 02. date of service 03. page number 10. Content of documentation show s the specific needs of the member for each encounter. Duplication of another note is not acceptable. 11. Best practice standards require documentation to be written within 24 hours of the clinical or therapeutic activity and signed and dated within 14 days. B. Evaluation and management documentation 1. Per CPT guidelines, documentation support s the specific requirements based on the level of service billed. These include a. time b. medical decision making c. complexity 2. Complexity documentation may include a. self-limited or minor problems b. stable chronic c. acute, uncomplicated illness or injury d. undiagnosed new problem with uncertain prognosis e. chronic illnesses with severe exacerbation, progression, or side effects of treatment 3. Risks associated with social determinants of health (SDOH) are documented , if applicable. C. Consents 1. Are maintained in the medical record. a. Consent includes 01. consent to treatment, refusal to consent, or withdrawal of consent 02. authorization for release of information . 03. signature and date D. Referral Documentation Medical Record Documentation Standards for Practitioners-INMCD-AD-0754Effective Dat e: 10/01/2025 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 1. Supports rationale for referral that includes who and what specialty member is referred to . 2. Demonstrates evidence of a. coordination of referrals to specialty practitioners . b. physician review of or documentation of collaboration notes E. Laboratory Testing Documentation (ie , labs, x-rays, biopsies) 1. Documentation s upports rationale for test . 2. An order for the test is present . 3. How test results will guide treatment plan is evident . 4. Physician review of results is evident . 5. Evidence of appropriate timely f ollow up on test results with member . F. Preventative Care Documentation , when appropriate include 1. age appropriate immunization record 2. evidence that preventative screenings/services are offered 3. risk assessments are complete d as appropria te (ie , substance use, suicide , depression ) 4. crisis/safety plan as appropriate II. Durable Medical Equipment Prosthetics Orthotics and Supplies DocumentationRequirements A. Detailed Written Order and Documentation includes 1. members name 2. item of DME ordered (i e, written description, HCPCS code , brand name, model number) 3. prescribing practitioners National Provider Identifier (NPI) 4. signature of the ordering practitioner 5. date of the order 6. order for a supply : a. frequency of use b. quantity to be dispensed 7. duration of use 8. Certificate of Medical Necessity (CMN) , if required a. if a CMN is not required, a prescription with diagnoses is included . 9. information demonstrat ing medical necess ity 10. any changes in the members treatment plan or needs 11. proof of delivery (see II. D.) B. Refill Documentation 1. Documentation of a request for refill must be either a written document received from the member or a contemporaneous written record of a phone conversation/contact between the supplier and the member. 2. The refill request must occur and be documented before shipment. 3. A retrospective attestation statement by the supplier or member is not sufficient. 4. The refill record must include Medical Record Documentation Standards for Practitioners-INMCD-AD-0754Effective Dat e: 10/01/2025 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 a. Members name or authorized representative, if different from the member.b. A description of each item that is being requested . c. Date of the refill request. d. For consumable supplies ie, those that are used up (eg, ostomy or urological supplies, surgical dressings, etc.) the supplier must assess the quantity of each item that the member still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date. C. Verbal Orders 1. When services are provided based on a physicians verbal orders, a nurse orother qualified practitioner responsible for furnishing or supervising the ordered services , must document the orders in the patients clinical record,and sign, date, and time the orders. 2. Verbal orders must be followed up with written orders 3. Suppliers must maintain the written physicians order to support medical necessity in the event of a post-payment review. D. Proof of Delivery1. Proof of Delivery include s the following :a. member s n ame b. delivery a ddress c. item of DME ordered (ie, written description, HCPCS code, brand name, model number) d. quantities delivered e. date d elivered f. member or designee receipt signature with date and d ate of s ignature g. relationship of anyone signing the delivery ticket as a designee of the patient h. a specific statement for the patient to initial stating that they attest that they are satisfied with the way the orthotic or prosthesis device(s) fit and that they were trained on the proper usage and care of the device(s) i. signature of the supplier and date the item was provided to the member 2. If shipped using a third-party, shipping tracking slip or returned postage-paid delivery invoice is acceptable . 3. CareSource is able to determine from the delivery documentation that the supplier properly coded the item(s) , that the item(s) delivered were the same item(s) submitted to for reimbursement, and that the items were intended for and received by a specific member . E. Custom item documentation includes 1. Evidence that the item was uniquely const ructed or substantially modified for a specific member . 2. Description and orders of a physician . 3. Evidence that item is so different from another item for the same purpose that the two items cannot be grouped together for pricing purposes . Medical Record Documentation Standards for Practitioners-INMCD-AD-0754Effective Dat e: 10/01/2025 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.6 III. Falsified DocumentationA. Providers are reminded that deliberate falsification of medical records is a felony offense and is viewed seriously when encountered. Examples of falsifying records include 1. creation of new records when records are requested 2. back-dating entrie s 3. Post-dated entries 4. writing over 5. adding to existing documentation (except where described in amendments, late entries, or corrections) B. Corrections to the medical record legally amended prior to claims submission and/or medical review will be considered in determining the validity of services billed. If these changes appear in the record following payment determination based on medical rev iew, only the original record will be reviewed in determining payment of services billed. C. Appeal of claims denied bas ed on an incomplete record may result in a reversal of the original denial if the information supplied includes pages or components that were part of the original medical record but were not submitted on the initial review. E. Conditions of CoverageN/A F. Related Policies/RulesBehavioral Health Record Documentation Standards for Practitioners G. Review/Revision HistoryDATES ACTIONDate Issued 03/04/2020Date Revised 04/14/2021 04/13/2022 05/25/2022 05/24/202301/17/202405/22/2024 05/07/2025Removed BH Documentation. Updated references.No changes. Updated references Per SIU added Refill Documentation and Verbal Orders to section II Added sec.I.A.12 for completion and signature. Updated references , Approved at Committee . Updated references, Approved at Committee Per 2024 CMS, Added complexity requirements. Updated references. Policy Approved at Committee Updated references. Policy Approved at Committee Date Effective 10/01/2025 Date Archived H. References1. Customized Items, 42 C.F.R. 414.224 (2023). Medical Record Documentation Standards for Practitioners-INMCD-AD-0754Effective Dat e: 10/01/2025 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.7 2. Documentation Guidelines for Evaluation and Management Services. Centers forMedicare & Medicaid Services; 1997. Accessed April 11, 2025. www.cms.gov 3. Documentation Matters Toolkit. Centers for Medicare & Medicaid Services. July 15, 2020. Accessed April 11, 2025. www.cms.gov 4. Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS): Scope and Conditions, 42 C.F.R. 410.38 (2023). 5. Electronic Health Records Provider. Centers for Medicare & Medicaid Services; 2015. Accessed April 2, 2025. www.cms.gov 6. Evaluation and Management Services. Medicare Learning Network ICN 006764 . Centers for Medicare & Medicaid Services; 2017. Accessed April 11, 2025. www.cms.gov 7. Guidelines for medical record documentation . NCQA. Accessed April 11, 2025. www.ncqa.org 8. Pub 10-08 Medicare Program Integrity Transmittal 442. Centers for Medicare & Medicaid Services; 2012. Accessed April 11, 2025. www.cms.gov IN-MED-P-3914424 Issue date 03/04/2020 Approved OMPP 06/24/2025
ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Itemized Billing-IN MCD-AD-0865 10/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Itemized Billing-IN MCD-AD-0865Effective Dat e: 10/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectItemized Billing B. BackgroundItemized bill review is the analysis of inpatient facility itemized billing statement s against CareSource policies and industry standard guidelines, as well as state and/or federal billing guidelines. CareSource may request an itemized bill for an inpatient facility claim to verify that billed revenue codes represent charges for appropriately billed items, supplies , and services. Routine items, supplies, and services are to be included in the primary inpatient room and board charge and are not separately reimbursable. C. Definitions Inpatient Hospital Claim Claims submitted for a member who has been formally admitted by a physician order for bed occupancy to receiv e inpatient hospital services with the expectation that the member will remain at least overnight . Itemized Bill A comprehensive list of all services and goods provided during the inpatient hospital stay, listing the costs and descriptions associated with the service and/or good. D. PolicyI. CareSource follows the CMS Provider Reimbursement Manual guidelines , chapter 22 , section s 2202.6 and 2203. A. Routine services defined by CMS chapter and section above are services included by the provider in a daily service charge , sometimes referred to as the room and board charge. B. Routine services are composed of two broad components: (1) general routine service s, and (2) special care units (SCU), including coronary care units (CCU) and intensive care units (ICU). Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made . II. Diagnostic-related group (DRG) high dollar claims exceeding $25,000 require an itemized bill for review. III. Hoosier Healthwise (HHW) member claims require an itemized bill on claims exceeding $150 ,000. IV. The following supplies, items, and services are typically not separately billable and therefore are not reimbursable from the general room and board charge or primary service charge. This list contains examples only and is not an all-inclusive list :A. capital/medical equipment B. fluoroscope C. hydration flushes Itemized Billing-IN MCD-AD-0865Effective Dat e: 10/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 D. implants and suppliesE. inpatient private duty nursing F. oximetry G. rental equipment H. routine supplies V. If upon review of the itemized bill, charges are determined to exceed state or federal reimbursement guidelines or CareSource specific policy , then reimbursement will be reduced accordingly. VI. Provider exception requests to reimbursement reductions may be requested via standard provider appeal process and should include supporting documentation (eg ,medical records or op erative notes to support requested payment exception).E. Conditions of CoverageN/A F. Related Policies/RulesN/A G. Review/Revision HistoryDATES ACTIONDate Issued 10/14/2020Date Revised 05/25/2022 10/11/202304/09/2025Annual Review: updated formatting, references, added section D. II Updated references; Approved at Committee Revised inpatient definition , added D. III. ; approved at Committee. Date Effective 10/01/2025 Date Archived H. References1. Determination of cost of services. The Provider Reimbursement Manual , I. Centers for Medicare and Medicaid Services. Publication 15-1. Revised April 16, 2024. Accessed March 27, 2025 . www.cms.gov 2. Outlier payments. Centers for Medicare and Medicaid Services. September 10, 2024 . Accessed March 27, 2025 . www.cms.gov 3. Payments for Outlier Cases, 42 C.F.R. 412.80 -.84 (202 4). IN-MED-P-2484811 Issue Date 10/14/2020 Approved OMPP 06/23/2025
ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Policy Development Process-IN MCD-AD-0915 08/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Policy Development Process-IN MCD-AD-0915Effective Dat e: 08/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectPolicy Development Process B. BackgroundCareSource utilizes a systematic way to develop policies through a standard operating procedure that improves efficiency, increases productivity and quality, and provides consistent policy products to stakeholders. This process starts with the identification of a policy need , including policy intent and triage, and then , tho rough research and collaboration leads CareSource to determine best practice for members. According to the tenets 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 or more restrictive than the limitations that apply to medical conditions as covered by CareSource polic ies . The policy development process ensures quality and consistency among both medical/surgical and behavioral health policies. C. Definitions Administrative Policies Policies written to provide guidance to providers on administration of behavioral or physical health benefits. AllMed A vendor with independent, external review specialists, who complete impartial medical reviews prior to final medical policy approval and implementation. Business Owner An individual who identifies a gap in information or benefits and recommends or requests that a topic be researched for possible creation or clarification of medical necessity criteria, reimbursement information or administrative conditions to assist in providing consistent and quality services to CareSource members. The business owner supports the development of a policy. Clinical Policy Governance Committee (CPGC) The official governing body, comprised of medical and behavioral health subject matter experts charged with the approval of new or revised clinical policies relating to medical necessity determinations. The CPGC is responsible for determining whether the proposed clinical policy is clearly defined, clinically evidenced-based, assures a high level of member safety and quality of care, and articulates a business value. Medical/Clinical Policies Policies written with medical criteria, including current evidence-based research, best practice, studies, etc., which will determine what the member must meet for the provider to deliver a service. PolicyTech Policy and procedure lifecycle management software for policy development and revision d esigned to centralize, build, and simplify policy and procedure workflows. Users have tools, such as workflow automation, document creation and review, remote access, versioning, audit-ready reporting, and employee assessments. Reimbursement Policy Addresses a topic in what must be met from a provider regarding billing/claims criteria to receive reimbursement for services provided. Subject Matter Experts (SME) A person who is an authority on a particular topic or subject matter. Policy Development Process-IN MCD-AD-0915Effective Dat e: 08/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 D. PolicyI. Pre-Policy Development A. The business owner enters a policy intake into PolicyTech to start the policy development process. B. To determine the intent, need, and priority of the request, c ollaboration occurs between the policy writer, business owner, member benefits cod er, member benefits analyst, configuration, a nd an appropriate business owner , such as a subject matter expert (SME) and/or medical director. C. If it is determined that there is a need for a policy, collaboration occurs between a multidisciplinary team to review codes and configuration, if applicable , and management determine s if codes need sent to analytics to provide the policy team with additional data, such as financial data, claims and/or usage of benefits by members. II. Policy DevelopmentA. The policy writer researches the topic to develop a draft policy . This includes but is not limited to the following resources : 1. state/federal regulations 2. state contracts 3. standard of care guidelines (ie, MCG Health , InterQual, American Society of Addiction Medicine) 4. Hayes 5. UpToDate 6. Policy Reporter 7. provider and member materials 8. professional society recommendations 9. published studies 10. feedback from external sources 11. subject matter experts , including medical /surgical and/ or behavioral B. After the policy is approved in the PolicyTech system on several levels by subject matter experts, management, writers, applicable departments and others, a final policy revision is reviewed and approved by the following: 1. Benefits, Coding and Support 2. Configuration 3. Utilization Management 4. Independent, external medical review specialists, when applicable 5. CPGC 6. State approval, if applicable III. Post Policy DevelopmentProviders and members of the health partner community are notified of new policies and of changes to existing policies via CareSource s marketing process. A standard operating procedure guides a uniform , consistent process allow ing for adequate notice of new criteria or revisions as outlined by state or company requirements. Upon adequate notice, policies are posted on CareSources website. Policy Development Process-IN MCD-AD-0915Effective Dat e: 08/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 E. Conditions of CoverageN/A F. Related Policies/RulesN/A G. Review/Revision HistoryDATES ACTIONDate Issued 09/30/2020Date Revised 12/10/2021 09/1 4/2022 09/13/2023 04/09/2025 Updated definitions, resources for research. Annual review. No substantive changes. Annual review; Approved at Committee Annual review; Approved at Committee Date Effective 08/01/2025 Date Archived H. References1. Mental Health Parity and Addiction Equity Act. US Centers for Medicare and Medicaid Services. Accessed March 27, 2025. www.cms.gov IN -MED P-3822080 Issue Date 09/30/2020 Approved OMPP 0 5/14/202 5
ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Court Mandated Health Services-IN MCD-AD-0797 08/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. 2 G. Review/Revision History ………………………….. ………………………….. ……………………….. 2 H. References ………………………….. ………………………….. ………………………….. …………….. 3 Court Mandated Health Services-IN MCD-AD-0797Effective Dat e: 08/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectCourt Mandated Health Services B. BackgroundCourt mandated health services are treatments ordered as a result of criminal, civil or custodial judicial proceedings. Services may include withdrawal management, medication assisted treatment, community-based services, behavioral health inpatient or outpatient treatment, medical inpatient or outpatient treatment , and/or other treatment related to ones overall health. C. Definitions Court Mandated Health Services Court order issued upon the decision of a judge or the result of a judicial proceeding for health-related services. Emergency Detention A person detained under reasonable grounds to be believed to have a mental illness, is either dangerous or gravely disabled, and is in immediate need of hospitalization and treatment. D. PolicyI. Court mandated health services are subject to all existing CareSource policies and procedures , including medical necessity determination and prior authorization as necessary. II. If court ordered health services are determined as not meet ing medical necessity criteria, the member will be referred to care management to ensure access to proper treatment and services and assist in coordination of necessary care. III. If a member is subject to an emergency detention under IND . CODE 12-26-5, services will be reimbursed regardless of medical necessity criteria for the earlier of : a period not to exceed 14 days, excluding Saturdays, Sundays, and legal holidays ; OR, the date of a final hearing under IND . CODE 12-26-5-11. Services provided from a final order after a final hearing will be subject to medical neces sity criteria according to clinical care guidelines established and published by the State . E. Conditions of CoverageN/A F. Related Policies/Rules N/A G. Review/Revision History DATES ACTIONDate Issued 02/19/2020 New PolicyDate Revised 11/10/2021 08/23/2022 10/11/2023 Reviewed, No changes . Annual review Annual review: added Emergency Detention definition Court Mandated Health Services-IN MCD-AD-0797Effective Dat e: 08/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 05/08/202402/26/2025and DIII, updated References; Approved at CommitteeD. III. revised to comply with H.B. 1216; Approved at Committee Annual review, Approved at Committee. Date Effective 08/01/2025 Date Archived H. References1. Authority of a Court to Order Detention , IND . CODE 12-26-5-0.5(c) (202 4). 2. Medically Necessary, IND . CODE 12-15-5-13.5 (202 4). 3. Me ntal Health Detention as Medically Necessary, IND . CODE 27-8-5-15.9 (202 4). IN-MED-P-3771901 Issue Date 02/19/2020 Approved OMPP 04/30/205
ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Against Medical Advice-IN MCD-AD-0792 08/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 3 H. References ………………………….. ………………………….. ………………………….. …………………….. 3 Against Medical Advice-IN MCD-AD-0792Effective Dat e: 08/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectAgainst Medical Advice B. BackgroundStudies show that approximately 1-2% of all hospitalizations result in discharge against medical advice (AMA) . Discharges AMA are at higher risk for inadequately treated medical conditions, readmissions, and /or negative health outcomes when compared to planned discharges. Documented reasons for leaving AMA may include lack of satisfaction with the treatment team , team members or facility, a general mistrust of medical systems, underutilization of social support, and/or a lack of health insurance or low socio-economic status. Additionally, research indicates that some previously diagnosed conditions substantially impact rates of AMA discharge. Patients with psychiatric conditions, substance use disorders, and human immunodeficiency virus are at the most significant risk for an AMA discharge. C. Definitions Against Medical Advice (AMA) A patient chooses to leave the hospital or acute care setting before a practitioner writes the order for discharge. Also known as self – directed discharge. D. PolicyI. CareSource will only pay for services, procedures, and supplies rendered. II. The discharge status code on the submitted claim must indicate that the member left AMA .III. If a member leaves AMA in the emergency room and the facility has submitted a prior authorization for inpatient services, only the emergency room visit will be considered for payment. IV. Claims are subject to retrospective review, and CareSource reserves the right to adjust reimbursement in accordance with the policies above.E. Conditions of Coverage Member must be eligible at the time the service, procedure , or supply was provided, and the service, procedure, or supply must be a covered benefit. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Medical necessity reviews do not guarantee reimbursement. All services, procedures, and supplies are subject to review for medical necessity. F. Related Policies/RulesMedical Necessity Determinations Against Medical Advice-IN MCD-AD-0792Effective Dat e: 08/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 G. Review/Revision HistoryDATE ACTIONDate Issued 09/01/2020Date Revised 02/10/2022 04/06/2023 03/27/2024 02/26/2025Annual review .Annual review. Approved at Committee. Annual review: removed (AMA) from title, revised background, added to AMA definition, revised conditions of coverage, and updated references. Approved at Committee. Annual review: updated references. Approved at Committee. Date Effective 08/01/2025 Date Archived H. References1. Abuguyan F. Negative outcomes pertaining to patients that leave against medical advice: a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci . 2024;28(5):1976-1986. doi: 10.26355/eurrev_202403_35612 2. Acquadro-Pacera G, Valente M, Facci G, et al. Exploring the differences in the utilization of the emergency department between migrant and non-migrant populations: a systematic review. BMC Public Health . 2024;24(1):963. doi:10.1186/s12889-024-18472-3 3. Albayati A, Douedi S, Alshami A, et al. Why do patients leave against medical advice? reasons, consequences, prevention, and interventions. Healthcare (Basel) . 2021;9(2):111. doi:10.3390/healthcare9020111 4. Alhajeri SS, Atfah IA, Yahya AMB, et al. Leaving against medical advice: current problems and plausible solutions. Cureus . 2024;16(7):e64230. doi:10.7759/cureus.64230 5. Alper E, OMalley T, Greenwald J. Hospital discharge and readmission . Updated February 3, 2023. Accessed January 7, 2025 . www.uptodate.com 6. Gaur A, Gilham E, Machin L, et al. Discharge against medical advice: the causes, consequences and possible corrective measures. Br JHosp Med (Lond) . 2024;85(8):1-14. doi:10.12968/hmed.2024.0231 7. Hasan O, et al. Leaving against medical advice from in-patients departments rate, reasons and predicting risk factors for re-visiting hospital retrospective cohort from a tertiary care hospital. Int JHealth Policy Manag . 2019;8(8):474-479. doi:10.15171/ijhpm.2019.26 8. Holmes EG, Cooley BS, Fleisch SB, et al. Against medical advice discharge: a narrative review and recommendations for a systematic approach. Am JMed . 2021;134(6):721-726. doi:10.1016/j.amjmed.2020.12.027 9. Khalili M, Teimouri A, Shahramian I, et al. Discharge against medical advice in paediatric patients. JTaibah Univ Med Sci . 2019;14(3):262-267 . doi:10.1016/j.jtumed. 2019.03.001 Against Medical Advice-IN MCD-AD-0792Effective Dat e: 08/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 10. Levenson J. Psychological factors affecting other medical conditions: management.UpToDate. Updated July 18, 2024 . Accessed January 7, 2025 . www.uptodate.com 11. Spooner KK, Saunders JJ, Chima CC, et al. Increased risk of 30-day hospital readmission among patients discharged against medical advice: a nationwide analysis. Ann Epidemiol . 2020;52:77-85. doi:10.1016/j.annepidem.2020.07.021 12. Tan SY, Feng JY, Joyce C, et al. Association of hospital discharge against medical advice with readmission and in-hospital mortality. JAMA Netw Open . 2020;3(6):e206009. doi:10.1001/jamanetworkopen.2020.6009 IN-MED-P-3731721 Issue date 09/01/2020 Approved OMPP 05/02/2025
ADMINISTRATIVE POLICY STATEMENT Indiana Medicaid Policy Name & Number Date Effective Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation-IN MCD-AD-1092 06/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y s tandards, and published MCO clinical policy 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 wit hout which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation-IN MCD-AD-1092 Effective Date: 06/01/2025 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 2 A. SubjectElectrocardiogram (EKG/ECG) Interpretation and Imaging InterpretationB. BackgroundAn electrocardiogram (EKG/ECG) is a non-invasive test that records the electrical activity of the heart and may be used when a possible cardiac issue occurs . The recording is reviewed by a physician who provides an interpretation and written report.An EKG/ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspects together as one serv ice. For the purpose of this policy, EKG will be used to represent both EKG and ECG.C. DefinitionsElectrocardiogram (EKG/ECG) A test that records the electrical activity of the heart.Imaging Several different technologies that are used to view the human body in order to diagnose, monitor, or treat medical conditions.D. PolicyI. Electrocardiogram (EKG/ECG) InterpretationA. CareSource will reimburse the first EKG interpretation claim that is received for the member on the date of service.1. If another claim for the same EKG interpretation is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service.2. CareSource will not reimburse for duplicate claims, for the same service on the same date of service for the same member, without the appropriate modifier.B. If a second EKG interpretation is medically necessary, on the same date of service, before the member is discharged, modifier 76 or modifier 77 must be appended to the second EKG interpretation for reimbursement.II. Imaging InterpretationA. CareSource will reimburse the first imaging interpretation claim that is received for the member on the date of service.1. If another claim for the same imaging interpretation is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service.2. CareSource will not reimburse for duplicate claims, for the same service on the same date of service for the same member without the appropriate modifier.B. If a second imaging interpretation is medically necessary, on the same date of service, before the member is discharged, modifier 76 or modifier 77 must be appended to the second imaging interpretation for reimbursement. Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation-IN MCD-AD-1092 Effective Date: 06/01/2025 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 3 III. CareSource expects providers to work with other departments within the providers organization to determine which department will submit the claim to prevent duplicate claim submissions.E. Conditions of CoverageCareSource expects provider to use appropriate standard billing guidelines. Modifiers are listed below only as a reference.Modifier Description 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional I maging Modifiers Modifier Description 26 Professional Component TC Technical component F. Related Policies/RulesModifier 26 and TC: Professional and Technical ComponentG. Review/Revision HistoryDATES ACTION Date Issued 03/31/2021 New policy Date Revised 09/14/2022 09/13/2023 01/29/2025 No changes to content. Edited definition wording. Removed place of service language. Updated references. Approved at Committee. Annual review . Updated background, definition, and references. Added Imaging modifiers. Approved at Committee. Date Effective 06/01/2025 Date Archived H. References1. Hussain S, Mubeen I, Ullah N, et al. Modern diagnostic imaging technique applications and risk factors in the medical field: a review. Biomed Res Int .2022;5164970. doi:10.1155/2022/51649702. Sattar Y, Chhabra L. Electrocardiogram . StatPearls Publishing; 2025. UpdatedJanuary, 2025. Accessed January 6, 2025. www.ncbi.nlm.nih.gov3. Medical Imaging. US Food and Drug Administration. Published August 28, 2018. Accessed January 6, 2025. www.fda.gov4. What are medical coding modifiers? American Academy of Professional Coders.Reviewed August 19, 2022. Accessed January 6, 2025. www.aapc.com Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation-IN MCD-AD-1092 Effective Date: 06/01/2025 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 4 IN-MED-P – 3654112 Issue Date 03/31/2021 Approved OMPP 03/27/2025
ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Retrospective Authorization Review-IN MCD-AD-1335 04/01/ 2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Retrospective Authorization Review-IN MCD-AD-1335 Effective Dat e: 04/01/2025 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectRetrospective Authorization Review B. BackgroundA retrospective review is a request for an initial review for authorization of care, service , or benefit for which a prior authorization (PA) is required but was not obtained prior to the delivery of the care, service , or benefit. Occasionally, situations arise where a PA cannot be reasonably obtained. In these cases, CareSource will conduct a retrospective review of medical services received by members in accordance with Indiana Administrative Code 405 IAC 5-3-9. Retrospective reviews are performed by licensed clinicians who are supported by licensed physicians. A decision is rendered following receipt of all necessary documentation to make a determination. In the event of an adverse benefitdetermination, the provider and/or member are notified of the decision and supporting rationale.C. Definitions Clinical Review Criteria The written screening procedures, decision abstracts, clinical protocols and practice guidelines used by CareSource to determine the medical necessity and appropriateness of health care services. Retrospective Authorization Review The process of reviewing and making a coverage decision for a service or procedure that has already been performed (e.g. , post service decision). Prior Authorization Utilization review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with CareSources requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision. D. PolicyI. CareSource conducts retrospective authorization review s after services have begun or supplies have been delivered only under the following circumstances: A. Pending or retroactive member eligibility. The prior authorization request must be submitted within 12 months of the date of the issuance of the member’s Medicaid card. B. Mechanical or administrative delays or errors by the office. The prior authorization request must be submitted within 30 calendar days of the date of service or date of discharge . C. Services rendered outside Indiana by a provider who has not yet received a provider manual. The prior authorization request must be submitted within 30 calendar days of the date of service or date of discharge . D. Transportation services authorized under 405 IAC 5-30. The prior authorization request must be submitted within 12 months of the date of service. Retrospective Authorization Review-IN MCD-AD-1335 Effective Dat e: 04/01/2025 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 E. The provider was unaware that the member was eligible for services at the time services were rendered. The prior authorization request must be submitted within60 calendar days of the date of service or date of discharge prior authorization will be granted in this situation only if the following conditions are met: 1. The provider’s records document that the member refused or was physically unable to provide the member identification ( RID) number. 2. The provider can substantiate that the provider continually pursued reimbursement from the patient until Medicaid eligibility was discovered. 3. The prior authorization request must be submitted within 60 calendar days of the date of service or date of dischar ge . II. Requests for retrospective authorization review are submitted via telephone, fax, in writing , or electronically through the provider portal to the CareSource UtilizationManagement Department. Members may request, orally or in writing, a post service review of initial services or continuation of previously requested services in the event a provider does not request a service within appropriate timelines. Practitioners/ providers must submit a request for post service review in writing via telephone, fax, in writing , or electronically through the provider portal. III. Healthcare practitioners/providers are required to submit the diagnosis and procedure/product codes in order for the service to be considered for authorization. IV. Healthcare practitioners/ providers should indicate/notate that they are requesting aretrospective authorization review.V. Supporting documentation of the exception circumstance for which the member/healthcare practitioners/providers believe they meet applicable criteria for must be provided with the Retrospective Authorization Review Request. If supporting documentation is no t provided, the Prior Authorization Request Form will beadministratively denied for timeliness.E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 05/24/2023 New policy . Approved at Committee.Date Revised 11/06/2024 Periodic review. Updated reference. Approved at Committee. Date Effective 04/01/2025 Date Archived Retrospective Authorization Review-IN MCD-AD-1335 Effective Dat e: 04/01/2025 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 H. References 1. CareSource Provider Manual Indiana Medicaid . CareSource; 202 4. Accessed October 21, 202 4. www.caresource.com. 2. Indiana General Assembly. Indiana Administrative Code Medicaid Services: 405 IAC 5-3-9. Accessed October 21, 2024. www.iag.iga.in.gov . IN-MED-P-3431853 Issue date 05/24/2023 Approved OMPP 01/16/2025
ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Claims Editing and Review-IN MCD-AD-1183 04/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Claims Editing and Review-IN MCD-AD-1183Effective Dat e: 04/01/202 5The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectClaims Editing and Review B. BackgroundAll health care providers are expected to utilize the same standard coding sets and rules to codify the services provided during encounters with patients. This codification is used to bill insurance carriers for reimbursement, known as a claim . In the codification process, there are rules that must be followed to appropriately codify the encounter into a claim, which is then sent to the insurance carrier for reimbursement. All claims submitted to CareSource for reimbursement consideration are subject to claims editing. This ensures that appropriate coding sets are used and, rules are applied in billing by the provider. This also ensures that appropriate reimbursement is made tothe provider for services rendered. This policy aims to outline the source of edits and rules CareSource utilizes for claims editing and review.C. DefinitionsNA D. PolicyI. To ensure appropriate and timely reimbursement for services rendered to enrollees, CareSource utilizes automated claims editing to enforce appropriate coding and billing practices by providers when submitting claims. A. Appropriate coding and billing of claims allows for the accurate adjudication and reimbursement for services rendered to a CareSource enrollee. B. All claims submitted to CareSource are subject to this editing. II. CareSource models edits and rules onA. Industry standard coding rules, manuals, guidelines, directives, and relevant state and federal regulations for claims editing B. Resources used to source these coding and billing standards include, but are not limited to, the following list: 1. X12 or ASC X12 – The Accredited Standards Committee (ASC) X12 – claim submission rules and edits applied to inbound electronic claims – www.x12.org 2. WEDI SNIP or SNIP – Workgroups for Electronic Data Interchange Strategic National Implementation Process claim submission rules and edits applied to inbound electronic claims related to HIPAA compliant file exchanges 3. Current Procedural Terminology (CPT) Manual from AMA (American Medical Association) 4. HCPCS – Healthcare Common procedure Coding System Level II coding guidelines 5. UB Editor – Manual from the American Hospital Association (AHA) Coding directives Claims Editing and Review-IN MCD-AD-1183Effective Dat e: 04/01/202 5The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 6. International Classification of Diseases, Tenth Edition Clinical Modifications(ICD-10-CM ) manual 7. Center for Medicare and Medicaid (CMS) rules and notifications a. CMS Billing rules and instructions (www.cms.gov) b. Medicare NCCI Instructions/ Manual c. Medicaid NCCI Instructions/ Manual d. National Coverage Determination (NCD ) & Local Coverage Determination (LCD ) Bulletins e. National Physician Fee Schedule (NPFS) instructions 8. Food and Drug Administration (FDA) guidelines (www.fda.gov) 9. Center of Disease Control (CDC) guidelines ( www.cdc.gov ) a. The Advisory Committee on Immunization Practices (ACIP) (www. cdc.gov ) 10. U.S. Preventive Services Task Force (www.uspreventiveservicestaskforce.org) 11. Indiana Medicaid: Office of Medicaid Policy & Planning (OMPP)(in.gov/fssa/ompp) 12. State and National recognized Medical Association and Specialty Experts including, but not limited to: a. American College of Radiology b. American Academy of Pediatrics c. American College of Obstetricians and Gynecologists 13. CareSources Website (www.caresource.com) a. policies b. provider manuals c. provider notifications III. CareSource strives to keep our editing current with all changes as the changes occur; as such, edits may be added, modified, or removed based on changes, clarifications, and new directives received from these resources and any other resources that may become applicable. IV. CareSource sends providers the outcomes of the edits through the standard Explanation of Payment (EOP) process. Providers EOPs indicate the failures by the use of industry standard CARC and RARC coding system. The provider can obtainadditional information by reviewing CareSource’s Provider Portal and/or the CareSource Provider Manual (www.CareSource.com).V. Providers may file a dispute and provide additional information to support the providers position for reconsideration of reimbursement. Instruction to file a dispute related to a denial or rejection of a claim can be found at our website (www.CareSource.c om); please refer to the Provider Manual, under Claim DisputeProcess.Claims Editing and Review-IN MCD-AD-1183Effective Dat e: 04/01/202 5The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 04/27/2022 New policyDate Revised 05/10/2023 09/25 /2024 Annual review. Updated II. B. 11. Approved at Committee. Annual review. Updated II. B. 6, 7, 9, 11 and 12. Approved at Committee. Date Effective 04/01/2025 Date Archived H. ReferencesNA IN-MED-P-3351488 Issue date 4/27/2022 Approved OMPP 12/18/2024
ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 11/01 /2024 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those h ealth care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and wit hout which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body or gan 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 als o include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of servi ces. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Admini strative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 17 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……. 17 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 17 H. References ………………………….. ………………………….. ………………………….. …………………… 17 Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectBehavioral Health Service Record Documentation Standards B. BackgroundMedical record documentation is a fundamental element required to support medical necessity and is the foundation for coding and billing. Documentation relays important information, such as but not limited to assessments completed, services provided, coordination of serv ices, timeliness of care, plan of care/treatment, rationale for orders, health risk factors, members progress towards goals of the treatment plan, and response to treatment. Chronological documentation of member care contributes to high quality care and a llows other healthcare professionals to plan treatment, monitor wellness and interventions over time, and ensures continuity of care. Medical record documentation serves as a legal document that verifies care provided to individuals. Information in the record may be used to validate place(s) of service, medical necessity and appropriateness of diagnostics and/or therapeutic services prov ided, or that services provided have been accurately reported. According to therules of the Mental Health Parity and Addictions Equity Act (MHPAEA), coverage for the diagnosis and treatment of behavioral health (BH) conditions will not be subject to any limitations that are less favorable than limitations that apply to medical or surgical conditions as covered under this policy.Specific documentation requirements for applied behavior analysis for the treatment of autism, home and community-based services, and other therapy services can be locatedin specific provider modules on the States website. The Indiana Family and SocialServices Administrations (FSSA) Indiana Health Coverage Programs (IHCP) provides guidance on behavioral health (BH) services and record requirements, including program certification requirements, service definitions, and information on specialized programs on the State website (eg, Behavioral and Primary Healthcare Coordination Service) . Provider manuals also document appropriate places of service for service provision and allowable performing provider , in addition to billing and reimbursement parameters, which this policy does not address. This policy is provided as a courtesy only. Any information located in IHCP Provider Manuals supersede information in this policy, including updates that may occur prior to policy reviews. C. Definitions Health Services Provider Psychology ( HS PP) A BH professional licensed in psychology who may certify a mental health diagnosis within a plan of treatment. Individual Plan of Care (POC) A written plan developed for each member (42 C.F.R. 456.180-81 ) to improve conditions so that inpatient care not necessary. Individually Identifiable Health Information A subset of health information, including demographic in formation collected from an individual, and o created or received by a health care provider, health plan, employer, or health care clearinghouse Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 o relate d to past /present /future physical or BH condition of an individual, the provision of health care, or the past /present /future payment for health care that identifies the individual there is a reasonable basis to believe information can identify the individual Medically Necessary Service A covered service required for the care or well – being of members provided in accordance with generally accepted standards of medical or professional practice. Mental Health Diagnosis The evaluation of mental, emotional, behavioral, and addictive disorders by a licensed BH professional using the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) compl ying with 1) education, training, experience and licensure requirements in Ind. Code 25-23-6-11 – 4, and 2) the professionals scope of practice. This does not include physical diagnoses. Mental Health Parity and Addictions Equity Act (MHPAEA) A 2008 federal law that generally prevents group health plans and health insurance issuers who provide mental health and substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations than on medical/surgical (M/S) coverage. Protected Health Information (PHI) Individually identifiable health information that is transmitted or maintained by electronic media or in any other form or medium . Provider Fraud Intentional deception or misrepresentation made by a person with knowledge that deception could result in some unauthorized benefit to self or another person, including any act that constitutes fraud under applicable federal or state law. Substance Abuse and Mental Health Services Administration (SAMHSA) A the agency within the US Dept of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. D. PolicyI. General Guidelines A. CareSource supports the IHCPs efforts to prevent provider fraud, including 1. altering medical records to generate medical payments 2. billing for services or supplies not rendered or for more costly services than those rendered (upcoding) 3. billing for group vs individual sessions 4. misrepresenting services (eg, billing a covered code but providing a noncovered service) 5. billing more than the charge to the public 6. services provided by unlicensed or unqualified personnel 7. soliciting, offering or receiving a kickback, bribe or rebate from medical providers for referrals or use of a product or service B. Records will fully disclose and document the extent of services provided to members and will be completed when services are rendered and prior to associated claim submission. C. All providers will maintain medical or other records as necessary to fully disclose and document the extent of services provided for a period of 7 years from the Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 date of service . A claim form copy submitted by the provider for reimbursement is not sufficient documentation, in and of itself, for compliance . D. Medical or other records, or both, shall include, at the minimum, the following : 1. identity of the member to whom service was rendered 2. provider identity, including dated signature or initials 3. identity and position of the provider employee rendering the service, if applicable , including dated signature or initials 4. date of the service 5. diagnosis of the condition of the member (relevant to physicians only) 6. detailed statement describing services rendered, including duration of services rendered 7. location at which services were rendered 8. amount claimed for each specific service 9. written evidence of physician involvement, including a legible signature or initials, and personal member evaluation to document acute medical needs 10. when required under Medicaid rules, physician progress notes as to medical necessity and effectiveness of treatment and ongoing evaluations to assess progress and redefine goals 11. X-rays, mammograms, electrocardiograms, ultrasounds, and other electronic imaging records, if applicable E. IHCP does not cover the following BH services: 1. biofeedback 2. broken or missed appointments 3. day care or partial day care 4. hypnosis and hypnotherapy 5. experimental drugs, treatments, procedures 6. acupuncture 7. hyperthermia 8. cognitive rehabilitation, except for treatment of traumatic brain injury (see IHCP Therapy Service s Provider Manual ) F. Release(s) of Information (ROI) ROIs must be valid (not expired), filled out completely with respect to requested elements, and consistent with requested information. Plain language must be used, and the covered entity must provide the individual with a copy of the signed authorization i f seeking disclosure of PHI . Core elements of ROIs include 1. a description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion 2. name or other specific identification of the person(s) or group authorized to make the requested use or disclosure 3. name or other specific identification of the person(s) or group to whom the covered entity may make the requested use or disclosure 4. a description of each purpose of the requested use or disclosure (At the request of the individual is a sufficient description of the purpose when an individual initiates the authorization and does not, or elects not to, provide a statement of the purpos e.) Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 5. an expiration date or event that relates to the individual or the purpose of the use or disclosure (End of the research study, none, or similar language is sufficient if the authorization is for a use or disclosure of protected health information for r esearch, including for the creation and maintenance of a research database or research repository.) 6. a legible signature of the individual and date (If the authorization is signed by a personal representative of the individual, a description of such representative’s authority to act for the individual must also be provided.) 7. required statements that place a member on notice of the following: a. member right to revoke authorization in writing, exceptions to revocation, and how the member may revoke authorization b. the ability or inability to condition treatment, payment, enrollment, or eligibility for benefit on the authorization c. the potential for information disclosed to be subject to redisclosure by the recipient and no longer protected by the ROI G. Physical Examination Prior to a Mental Health Diagnosis If a BH professional licensed under Ind. Code 25-23.6 performs an evaluation to determine a mental health diagnosis of a member and determines that the member either 1) has not seen a physician, advance practice registered nurse (APRN) or a physician assistant (PA) within the previous 12 months, or 2) may have a physical condition that requires medical attention , the BH professional will document all actions in the member record and will 1. advise the member to schedule, and assist with the scheduling of, a physical examination at the earliest opportunity 2. provide the member with a list of practitioners to contact to schedule a physical examination, including the name, address and telephone numbers 3. coordinate member care as appropriate with the practitioner, unless the member declined consent to the coordination of care H. Outpatient treatment plan supervision may be conducted by the following licensed professionals with a masters degree and within the scope of practice, education, and training: 1. clinical social worker s 2. mental health counselor s 3. clinical addiction counselor s 4. marriage and family therapist s I. Mental health safety plans must be individualized, collaboratively developed with the member, and in a standard format that includes the following information: 1. member name, address, and contact information 2. early warning signs that a crisis may be developing 3. internal coping strategies 4. contact information for individuals and social settings that may provide distraction for the member 5. contact information for persons from whom the member can ask help 6. contact information for professionals or agencies the member can contact at the onset of or during a crisis Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.6 7. a plan for making the environment safe for the member8. 1 thing that matters most to the member making life worth living 9. other information, including issues concerning physical health, if necessary J. Interactive complexity (IC) is an add-on code specific for BH services referring to communication difficulties during service delivery and reported in conjunction with other codes only. Difficulties may include services with members who have other individuals legally responsible for care, those who request others to be involved during the visit, or those who require the involvement of other 3rd parties (eg, parole officers, school official s, child welfare agency personnel). IC may be reported when 1 of the following is present: 1. the need to manage maladaptive communication among participants complicates delivery of care 2. caregiver emotions or behaviors interfering with implementation of the treatment plan 3. evidence or disclosure of a sentinel event and mandated report to a 3rd party (eg, abuse or neglect with report to state agency) with initiation of discussion of the event and/or report with the member and other visit participants 4. use of play equipment, physical devices, interpreter, or translator to overcome significant language barriers II. Outpatient Behavioral Health (BH) ServicesThe IHCPs Behavioral Health Services Provider Manual provides details on billing and reimbursement, particularly claim details, revenue code detail, and modifier information, including both professional and/or facility services. Medical record documentation must identify services and length of time of each session with the information available for audit purposes. A physician or other health professional (see the IHCPs Behavioral Health Services Provider Manual for a full list and details) must certify th e diagnosis . The physician, psychiatrist, or HSPP is responsible for supervising the plan of treatment as follows 1. document a visit with the member during the intake process or review the medical information obtained by the practitioner within 7 days of intake 2. document seeing the member or reviewing medical information to certify the service as medically necessary on the basis of information provided by the practitioner at intervals not to exceed 90 days All reviews must be documented in writing . A cosignature is not sufficient . Some services (eg, medicaid rehabilitation option services , urine drug testing , 1915i wavier services ) are extensively covered in other IHCP provider manuals. This section serves to provide clarification on documentation requirements from the Behavioral Health Services Provider Module for some services . A. Annual Depression Screening This service is limited to 1 unit per member per provider per rolling 12-month period with no PA requirement. Validated, standardized tests must be documented (eg, Patient Health Questionnaire, Beck Depression Inventory). Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.7 B. Applied Behavior Analysis (ABA)IHCP publishes coverage criteria , practitioner requirements , and PA requisites for the provision of ABA, which also require s documented supervision of practitioners. Records must be available for audit, if requested. Documentation requirements include the following: 1. diagnosis of Autism Spectrum Disorder by a qualified healthcare provider 2. completion of a comprehensive, diagnostic evaluation using the most recent DSM and including a recommended treatment referral 3. completion of an individualized treatment plan, including a. identification of behavioral, psychological, family and medical concerns b. measurable short-term, intermediate, and long-term goals that 01. are appropriate for age and level of impairment 02. are based on standardized assessments relative to age-expected norms 03. address behaviors and impairments for which the intervention is to be applied 04. include baseline measurements and progress to date in the following : (1). social skills (2). communication skills (3). language skills (4). adaptive functioning (5). restricted, repetitive patterns of behavior, interests, or activities (6). self-injurious, violent, destructive, or other maladaptive behavior 05. anticipated timeline for goal achievement based on the initial assessment and subsequent interim assessments over the duration of the intervention c. number of hours per week requested, with justification and supporting documentation for the specific number of hours based on member needs (see the Service Limits for ABA Therapy section for guidelines) d. a clear schedule of services planned and documentation that all identified interventions are consistent with ABA techniques e. plans for parent/guardian training and school transition f. documentation that ABA services will be delivered by an appropriate provider (see Practitioner Requirements for ABA Therapy ) Given that a member continues to meet criteria for ABA, documentation requirements for the continuation of services include 1. documentation of symptoms meet ing criteria for autism and rationale that the member would benefit from ABA 2. individualized treatment plan is submitted with the following updates: a. measurable progress to date for each goal in the treatment plan b. revised anticipated timeline for goal achievement based on the initial assessment and subsequent interim assessments over the duration of the intervention c. clinically significant progress in the following areas: 01. social skills Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.8 02. communication skills03. language skills 04. adaptive functioning 05. behavior d. updates to any section of the plan as applicable (eg, hours per week, schedule of activities, parent/guardian training, school transition) 3. documentation that ABA services are delivered by an appropriate provider C. Crisis Intervention A short-term emergency service, available 24 hours a day, 7 days a week, for face-to-face contact with the member including, but not limited to, crisis assessment, planning and counseling specific to the crisis, intervention at the site of the crisis when clinically appropriate, and prehospital assessment. It does not apply to group settings, time spent in inpatient settings, routine intakes provided after traditional hours, or for non-face-to-face services and is limited to acute episodes despite other BH service provision . Collateral contacts must be in addition to member contact. Documentation requirements include the following: 1. member at imminent risk of harm to self or others documented within 1 hour of initial contract with provider or member is experiencing a new symptom plac ing member at risk documented within 4 hours of initial contact with provider 2. documentation of resolution of crisis and transition of member to routine care through linkage to services 3. delivery completed in emergency and non-routine fashion 4. member-centered and individually delivered services D. Intensive Outpatient Treatment (IOT) A treatment program that lasts at least 3 hours a day, 3 days per week, and provides multiple service components for SUD in a group setting. The IHCP requires 120 minutes of interventions per 3-hour session with up to 20 minutes of break time per 3 consecu tive hours. Direct service providers are not required to be licensed addiction counselors or clinical addiction counselors but must hold an addiction credential or have training and experience in addiction treatment. Additional d ocumentation requirements a re as follows: 1. age-appropriate services that are individualized 2. access to additional support services, if needed 3. rationale for how the service benefits the member, including group settings E. Medication-Assisted Treatment for Opioid Use Disorder (MOUD) Services are provided as part of a comprehensive treatment plan via 3 medications: methadone, buprenorphine, naltrexone. Documentation requirements include , at a minimum, the following: 1. medical necessity criteria according to IHCP standards 2. drug testing at least 8 times per year at random intervals to verify discontinued of use of all illicit and nonprescribed substances 3. a full evaluation and medical exam completed by provider that demonstrates medical necessity and rationale that services are the most appropriate treatment option Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.9 4. proof of counseling and behavioral therapy services5. member length of treatment OTPs will include documentation in each members record that a good faith effort determined whether the member is enrolled in any other OTP. Members enrolled in an OTP will not obtain treatment in any other OTP except in circumstances involving an inabilit y to access care at the members OTP of record (eg, travel for work or family events, temporary relocation, OTP’s temporary closure). If the medical director or program practitioner of the OTP in which the member is enrolled determines that such circumstan ces exist, the member may seek treatment at another OTP, provided the justification for the particular circumstances are noted in the member’s record at both locations. Initial and Periodic Assessments and Examinations for OT PAdmits1. Initial medical exam s are required for members and are comprised of 2 parts:a. a screening exam to ensure criteria are met for admission with no contraindications for treatment with MOUD b. full history and exam with lab testing as determined to be required by an appropriately licensed practitioner Both parts must be completed by an appropriately licensed practitioner. If the licensed practitioner is not an OTP practitioner, the screening exam must be completed no more than 7 days prior to OTP admission. If the exam is performed outside the OTP, writ ten results and narrative, as well as available lab testing results, must be transmitted consistent with applicable privacy laws to the OTP and verified by an OTP practitioner. A full in-person physical exam, including results of serology and other testsconsidered to be clinically appropriate, must be completed within 14 calendar days of admission and can be completed by a non-OTP practitioner, if the exam is verified by a licensed OTP practitioner as true and accurate and transmitted in accordance with applicable privacy laws. Serology testing and other testing deemed medically appropriate by the lice nsed OTP practitioner based on the screening or full history and exam, drawn no t more than 30 days prior to admission, may form part of the full history and exam. 2. Initial physical and BH assessment s will be conducted with every member admitted to an OTP and will include, but is not limited to, screening for imminent risk of harm to self or others, within 14 calendar days following admission by appropriately licensed/credentialed personnel. Assessment s must address a. the need for and/or response to treatment b. treatment intervention adjustment(s), including MOUD, as necessary c. a patient-centered plan of care The full, initial psychosocial assessment (also to be completed within 14 calendar days of admission) must include preparation of a care plan including a. member goals and mutually agreed-upon actions for meeting goals, including harm reduction interventions Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.10 b. member needs and goals in the areas of education, vocational training, and employment c. the medical and psychiatric, psychosocial, economic, legal, housing, and other recovery support services needed and desiring to pursue d. the recommended frequency with which services are to be provided The plan must be reviewed and updated to reflect responses to treatment and recovery support services and adjustments made that reflect changes in the context of the member’s life, current needs for and interests in medical, psychiatric, social, and psycho logical services, and current needs for and interests in education, vocational training, and employment services. 3. Periodic physical examinations should occur not less than 1 time each year , be documented in the members clinical record, and be conducted by an OTP practitioner, including a. review of MOUD dosing b. member treatment response c. other SUD treatment needs d. member-identified goals e. other relevant physical and psychiatric treatment needs and goal F. Peer Recovery Services Individual face-to-face services delivered as part of MAT services for up to 365 hours (1460 units) per rolling 12-month period without PA (or additional via PA) by qualified individuals certified by the Division of Mental Health and Addiction (DMHA) and under supervision by a practitioner. Documentation must 1. provide proof of a structured, scheduled activity 2. promote socialization, recovery, self-advocacy, development of natural supports, or maintenance of community living skills G. Psychiatric Services Certain psychiatric codes in combination are subject to 20 units per member per provider per rolling 12-month period without PA . See the Psychiatric Service Procedure Codes with 20-Unit Limit table on Mental Health and Addiction Services Codes for additional information. For units beyond this limit, providers must attach a current treatment plan and progress notes explaining the necessity and effectiveness of therapy. 1. Psychiatric diagnostic eva luations have unit limitations in accordance with 405 IAC 5-20-8 (14). Codes used may not be billed on the same day as an evaluation and management ( E/M ) service performed by the same individual for the same member or on the same day as psychotherapy services . 2. Psychotherapy with E/M on the same day must be reported using codes specific for psychotherapy performed with E/M services as add-on codes to the E/M service. The services must be significant and separately identifiable with appropriate modifiers, if appli cable. 3. Psychiatric services with health and behavior assessment or intervention on the same day, providers report only the predominant service performed. Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.11 H. Psychological and Neuropsychological TestingIHCP requires PA for testing. See the Behavioral Health Practitioner Qualifications section of the Behavioral Health Services Manual for additional guidance . Psychological testing includes psych ological diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology (eg, MMPI, Rorschach, WAIS), both face to face time with the client and time interpreting test results and preparing the report. The medical record must indicate the presence of mental illness for which testing is indicated and aid in diagnosis and therapeutic planning, as well as recording test(s) performed, scoring, and interpretation. Reports and other documentation may include 1. client history, mental status, and disposition 2. psychometric, projective and/or developmental tests 3. consultations with referral sources 4. other evaluation /interpretation of hospital records or psychological reports 5. other accumulated data for diagnostic purposes 6. names, signatures, credentials of staff involved in testing and report writing I. Screening and Brief Intervention (SBI) Services SBI identifies and intervenes with members at risk for substance-related problems or injuries using established systems, such as trauma centers, emergency rooms, community clinics, and school clinics, to screen members for substance misuse and, if necessar y, provide brief interventions or referrals to appropriate treatment. Screening is limited to 1 structured SBI per member, every 3 years, by the same provider or 1 time per year per member per provider. Place of Service codes can be located in the Behavior al Health Services Manual . III. Inpatient BH ServicesPsychiatric hospitals must meet conditions according to 405 IAC 5-20-3. Members must meet medical necessity for inpatient services, including certification of need (CON) for services according to 405 Ind. Admin. Code 5-20-5. IHCPs Behavioral Health Services and Inpatient Hospital Services Provider Manual outline s reimbursement details, provider types, restrictions for inpatient stays, and information regarding institutions for mental diseases (IMD). The Prior Authorization module describes instructions for the submission of PA requ ests for inpatient admissions. PA forms can be located on the in.gov website. The IHCP requires providers to include specific documentation of the assessment or reassessment when requesting PA for residential SUD treatment by use of the appropriate forms also located at in.gov. A. Certification of Need (CON) The CON (1261A Form) must be completed by the attending physician or staff physician for members 22 years old and older or for members 21 years old or younger by the physician and an interdisciplinary team (42 CFR 441.152(a) and 42 CFR 441.153). Additional precert details, CON timeframes, and PA criteria are found in the Behavioral Health Services Provider Manual or 405 IAC 5-20-5. B. Plan of Care (POC) Additional information regarding the POC is located in 405 IAC 5-20-4. For members 22 years old or older, the attending or staff physician must develop and Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.12 submit a POC within 14 days of the admission date and must update the plan at least every 90 days. For members 21 years old and younger, a physician and interdisciplinary team must develop and submit a POC within 14 days of the admission date and review the plan at least every 30 days. The POC is developed as a result of a diagnostic evaluation that includes an examination of the medical, psychological, social and behavioral aspects of the members presenti ng problem and previous treatment interventions. The following components must be documented in each members POC: 1. treatment objectives and goals, including an integrated program of appropriate therapies, activities and experiences to meet objective s 2. at the appropriate time, a post-discharge plan and a plan for coordination of inpatient services with partial discharge plans, including appropriate services in the community to ensure continuity of care when returning to family and community upon discharge Periodic reviews will ensure that appropriate services are being provided and continue to be medically necessary. The reviewing physician or interdisciplinary team will recommend adjustments in the plan, if any. The review and update of the POC must be in writing and part of the members record. C. Criteria for Admission to be Documented 1. Psychiatric admissions must document the following factors: a. current or recent suicide ideation with plan and potential means with lethal intent b. current or recent serious, violent, impulsive and unpredictably dangerous homicidal ideation with plan and potential means with lethal intent c. current or recent harm to self or others with plan and potential means with lethal intent d. unable to care for self due to a psychiatric condition such that imminent, life-threatening deterioration has occurred e. acute psychotic symptoms, severely bizarre thinking, and psychomotor agitation or retardation that cannot be safely treated at a less-restrictive level of car e Emergency acute psychiatric inpatient admissions are available for members with a sudden onset of a psychiatric condition manifesting itself by acute symptoms of such severity that the absence of immediate medical attention could reasonably be expected to result in danger to the individual, others or death of the member. 2. Admission for SUD are based on ASAM Patient Placement Criteria, Level 4. Inpatient detoxification, rehabilitation, and aftercare for chemical dependency is reviewed on a case-by-case basis but will include consideration of a. treatment , evaluation and detoxification based on the stated medical condition and/or primary diagnosis for inpatient admission b. need for safe withdrawal from alcohol or other drugs c. a history of recent convulsions or poorly controlled convulsive disorder d. reasonable evidence exists that detoxification and aftercare cannot be accomplished in an outpatient setting Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.13 3. Criteria to be documented for inpatient detoxification includes the following:a. evidence of symptoms of withdrawal requiring close medical monitoring or continuous observation : b. history of severe withdrawal reaction (eg, seizures, delirium tremens, psychotic episode) c. intoxicated with a history of recent, severe idiosyncratic intoxication (eg, violence, blackouts while under the influence) d. a coexisting medical and/or psychiatric condition requiring medical and psychiatric services e. recent history of alcohol /other drug abuse with inability to control abuse outside a restrictive 24-hour-care environment demonstrated by documented recent failed attempt s f. dependency or abuse contribut es to severe social and/or emotional dysfunction in 1 or more life spheres (eg, vocational, familial , social ) D. Bridge Appointments Bridge appointments are face-to-face, follow-up appointments in an outpatient setting on the day of discharge from an inpatient hospitalization for BH issues when no outpatient appointment is available within 7 days of discharge. The goal is to provide pro per discharge planning while establishing a connection between the member and the outpatient treatment provider. Documentation must be maintained in the members chart indicating the reason the bridge appointment service was necessary. The member must have 1 or more documented and identified barrier (s) to continuing care, such as 1. special needs 2. divorce or custody issues 3. work conflicts 4. inability to schedule within 7 days 5. history of noncompliance 6. complex discharge plans During the bridge appointment, the provider should ensure, at minimum, that 1. Member understands the medication treatment regimen as prescribed . 2. Member has ongoing outpatient care . 3. Fa mily understands discharge instructions for the member . 4. Barriers to continuing care are addressed . 5. any additional questions from the member or family are answered E. Documentation Requirements for Psychiatric Hospitals (42 C.F.R. 482.61) 1. Assessment /Diagnostic Data Medical records must stress the psychiatric components of the record, including a history of findings and treatment provided for condition for which the member is hospitalized, including a. identification data with member’s legal status b. provisional or admitting diagnosis at the time of admission, including the diagnoses of intercurrent diseases c. reasons for admission as stated by the member and/or others significantly involved Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.14 d. social service records, including reports of interviews with member, family members, and others, with an assessment of home plans, family attitudes, and community resource contacts, as well as a social history e. when indicated, a complete neurological examination at the time of the admission physical examination 2. Psychiatric Evaluation Each member must receive a psychiatric evaluation within 60 hours of admission that includes a. a medical history and any previous treatment, including medication b. psychiatric history and any previous treatment, including medication c. substance use and/or withdrawal history, including any treatment d. social history e. mental status f. the onset of illness and the circumstances leading to admission g. a description of member attitudes and behavior h. an e stimated intellectual functioning, memory functioning, and orientation i. an inventory of member assets in descriptive, not interpretative, fashion 3. Treatment Plan A written plan for each client must be based on strengths and disabilities and documented to include all active therapeutic efforts, including the following: a. a substantiated diagnosis b. short-term and long-range goals c. the specific treatment modalities utilized d. the responsibilities of each member of the treatment team e. adequate documentation to justify the diagnosis and the treatment and rehabilitation activities planned 4. Progress Notes Progress notes must be documented in accordance with State scope-of- practice laws and hospital policies by the following qualified practitioners: a. doctor(s) of medicine or osteopathy or other licensed practitioner(s) responsible for care of the member b. nurse(s) c. social worker(s) (or social service staff) d. therapists e. when appropriate, others involved in active treatment modalities The frequency of progress notes is determined by the condition of the member but must be recorded at least weekly for the first 2 months and at least once a month thereafter and must contain recommendations for revisions in the treatment plan as indicated and precise assessment of the patient’s progress in accordance with the original or revised treatment plan. 5. Discharge Planning and Summary Each discharged member record must have a discharge summary, including a. a recapitulation of the members hospitalization b. recommendations from appropriate services concerning follow-up or aftercare Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.15 c. a brief summary of the members condition at dischargeIV. Acute Partial Hospitalization (PH) ServicesPH is subject to PA . P rograms must be highly intensive, time-limited medical services that either provide a transition from inpatient psychiatric hospitalization to community-based care or serve as a substitute for an inpatient admission. Services are individualized with treatment goals that are measurable and medically necessary. Treatment goals must include specific time frames for achievement of goals and be directly related to the reason for admission. Programs must not mix members receiving PH services with members receivin g outpatient BH services. A. Members must have a diagnosed or suspected BH condition and a short-term deficit in daily functioning or a n assessment that indicat es a high probability of serious deterioration of general medical or BH . Documentation requirements include the following: 1. services must be ordered and authorized by a psychiatrist 2. services require PA pursuant to 405 IAC 5-3-13(a) 3. a face-to-face evaluation and an assignment of a BH diagnosis must occur within 24 hours following admission 4. a psychiatrist must actively participate in case review and monitoring of care 5. documentation of active oversight and monitoring of progress by a professional listed in the Behavioral Health Services Module must appear in the member’s clinical record 6. at least 1 individual psychotherapy service or group psychotherapy service must be delivered daily 7. for members under 18 years of age, documentation of active psychotherapy, including a minimum of 1 family encounter per 5 business days of episode of care is required 8. 4-6 hours of active treatment per day provided at least 4 days a week B. Exclusions Services may be provided for consumers of all ages but are not appropriate for the following members: 1. members at imminent risk of harm to self or others 2. members currently residing in a group home or other residential care setting 3. those who cannot actively engage in psychotherapy 4. members with withdrawal risk or symptoms of an SUD whose needs cannot be managed at this level of care 5. those who by virtue of age or medical condition cannot actively participate in group therapie s C. The individualized treatment plan must identify the following: 1. coordinated services to be provided around individual member needs 2. behaviors or symptoms resulting in admission and associated treatments 3. functional changes necessary for transition to a lower intensity of service and means through which progress will be evaluated 4. criteria for discharge and planned transition to community services Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.16 D. Reauthorization criteria for stays exceeding 5 days must document 1 of the following:1. clinical evidence indicates the persistence of problems that caused the admission to the degree that would necessitate continued treatment 2. current treatment plan must include documentation of diagnosis, discharge planning, individualized goals of the treatment and treatment modalities needed and provided 3. member progress confirms that the presenting or newly defined problems will respond to the current treatment plan 4. daily progress notes, written and signed by the provider, document the treatment received and the members response 5. severe reaction to the medication or need for further monitoring and adjustment of dosage in a controlled setting (documented daily in the progress notes by a physician) 6. clinical evidence that disposition planning, progressive decreases in time spent in the PH program and attempts to discontinue the program have resulted in, or would result in, exacerbation of the psychiatric illness to the degree that would necessitate in patient hospitalization V. Psychiatric Residential Treatment FacilitiesICHP reimburses medically necessary services for psychiatric residential treatment facilit ies (PRTF) with PA processed by Gainwell for fee-for-service and managed care members. See the Behavioral Health Services Module for additional info on documentation requirements and authorization criteria or 405 IAC 5-20-3.1 . VI. Residential SUD TreatmentIHCP provides coverage for short-term, low-intensity and high-intensity residential treatment for OUD and SUD in settings of all sizes, including facilities that qualify as institutes of mental disease (IMDs), when the facility is enrolled with the IHCP as an SUD residential addiction treatment facility. PA is required for all residential SUD stays. Admission criteria for residential stays for OUD or other SUD treatment is based on ASAM Patient Placement Criteria Level s. All documentation needs to support t he ASAM dimensional criteria for the requested level of care. Specific documentation requirements may be submitted on the provider portal, by fax, or by mail with use of the appropriate IN forms. Medical records maintained by psychiatric hospital s must permit determination of thedegree and intensity of the treatment provided in the facility . If a facility determines that a member requires more time than was initially authorized, a PA update request should be s ubmit ted showing that the member has made progress but can be expected to show more progress given more treatment time or that the member has not made progress but has been assessed to have the ability to make progress at the current level of care . Records must also show that member continue t o meet ASAM dimensional criteria for the requested level of care. An additional length of stay can be approved based on documentation of medical necessity . Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.17 Practitioner interaction requirements state that initial evaluations must be completed in person. Follow-up face-to-face evaluations during the members stay may be conducted through telemedicine if necessary. A physician ( eg, psychiatrist), PA , or APRN must see the member face-to-face at least every 7 days during the stay. Ser vices included in payment and reimbursement details are located in the Behavioral Health Services Module . VII. Inpatient Hospital AdmissionsInformation on hospital inpatient admissions can be located in the Inpatient Hospital Services Provider Reference Module , including documentation requirements and additional payment information. PA is required for all Medicaid-covered psychiatric inpatient stays reimbursed under the level-of-care (LOC) payment methodology, as well as substance abuse stays reimbursed under the diagnosis-related group (DRG) methodology. Both reimbursement methodolog ies are described in 405 IAC 1-10.5. E. Conditions of CoverageRetrospective audit shall include postpayment review of the medical record to determine whether the service was medically necessary . F. Related Policies/RulesState and Federal Legislation and Documents A. Community Mental Health Centers; Governmental Units, IND . CODE 12-15-5-21 (2020). B. Reimbursement for Clinical Addiction Counselors; Clinical Supervision Requirement, IND . CODE 12-15-5-16 (2016). C. Reimbursement for Students; Conditions; Policies, IND . CODE 12-15-5-15 (2017). G. Review/Revision HistoryDATE ACTIONDate Issued 04/28/2021 New policy. Approved at Committee.Date Revised 05/11/2022 05/10/202306/ 19 /2024Removed Covid red box and DOB; updated references. Added II.C.4. Updated references. Approved at Committee. Annual review. Added MHPAEA info. Rewrote based on Behavioral Health Services Module from IHCP. Updated F & H. Approved at Committee. Date Effective 11/01/2024 Date Archived H. References1. Behavior Analysts, IND . CODE 25-8.5 (2023). 2. Behavioral Health and Human Services Professionals, IND . CODE 25-23.6 to 11 (2023). Behavioral Health Service Record Documentation Standards-IN MCD-AD-1073 Effective Dat e: 11/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.18 3. Behavioral Health Services Mental Health and Addiction Treatment Provider Reference Manual . Indiana Health Coverage Programs ; 2022. Accessed May 17,2024. www.in.gov 4. Certified Community Behavioral Health Clinics; Implementation; Certification; Requirements; Reimbursement for Eligible Services; Demonstration Program; Rules, IND . CODE 12-15-1.3-25 (2023). 5. Clinical Records. 410 IND . ADMIN . CODE 17-15-1 (2020). 6. Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals, 42 C.F.R. 482 .61 (2020). 7. Coverage for Treatment of Opioid or Alcohol Dependence; Office Requirements; Report Use of Medications to Committee, IND . CODE 12-15-5-13 (2019). 8. Eligible Providers for Supervising Treatment Plan, IND . CODE 12-15-5-14.5 (2020). 9. Expanded Scope of Licensed Behavioral Health Professionals to Certify a Mental Health Diagnosis . Indiana Health Coverage Programs; 2021. IHCP bulletin BT202137. Accessed May 17, 2024. www.in.gov 10. Federal Opioid Use Disorder Treatment Standards, 42 C.F.R. 8.12 (2024). 11. Individualized Mental Health Safety Plan; Requirements, IND . CODE 12-21-5-6 (2021). 12. Inpatient Detoxification, Rehabilitation , and Aftercare for Chemical Dependency, 405 IND . ADMIN . CODE 5-17-5 (2023). 13. Inpatient Hospital Services Provider Reference Module . Indiana Health Coverage Programs ; 2023. Accessed May 17, 2024. www.in.gov 14. Inpatient Psychiatric Services for Individuals Under Age 21 in Psychiatric Facilities or Programs, 42 C.F.R. 441.150 to 441.184 (2024). 15. Intensive Outpatient Treatment Program, IND . CODE 12-15-5-20 (2020). 16. Legal Recognition of Electronic Records, Electronic Signatures, and Electronic Contracts, IND . CODE 26-2-8-106 (2022). 17. Medical Records, 405 IND . ADMIN . CODE 1-1.4-2 (2023). 18. Medically Necessary Service Defined, 405 IND . ADMIN . CODE 5-2-17 (2023). 19. Mental Health Services, 405 IND . ADMIN . CODE 5-20-1 to 8 (2023). 20. Minimum Standards for the Provision o f Services by Opioid Treatment Facilities and Programs, 440 IND . ADMIN . CODE 10-1 to 4 (2023). 21. Prior Authorization, 405 IND . ADMIN . CODE 5-3-1 to 14 ( 2023). 22. Private Secure Facilities, 465 IND . ADMIN . CODE 2-11-1 to 89 (2023). 23. Psychologists, IND . CODE 25-33 (2023). 24. Recovery Audits; Development, Review, and Certification of Plans of Treatment, IND . CODE 12-15-13.5-6 (2020). IN-MED-P 3096862 Issue Date 04/28/2021 OMPP Approved 08/14/2024
ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Pain Management Providers-IN MCD-AD-1099 11/01/2024 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the E vidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Cove rage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limita tions that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. Re ferences ………………………….. ………………………….. ………………………….. ……………………. 3 Pain Management Providers-IN MCD-AD-1099Effective Dat e: 11/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectPain Management Providers B. BackgroundPractitioners who have obtained additional education/certification to practice in the field of pain medicine are able to help members manage and treat pain . C. Definitions American Board of Medical Specialties (ABMS) An organization of medical specialty boards with shared goals and standards related to the certification of medical specialists, including initial specialty and subspecialty certification, as well as maintenan ce of certification throughout the physicians career. American Board of Pain Medicine (ABPM) An organization that administers a psychometrically-developed and practice-related examination in the field of Pain Medicine to qualified candidates. Physicians who have successfully completed the ABPM credentialing process and examination will be issued certificates as specialists in the field of Pain Medicine and designated as Diplomates of the American Board of Pain Medicine. American Osteopathic Association ( AOA) An organization of osteopathic specialty boards with shared goals and standards related to the certification of osteopathic specialties. Certification includes primary certification, certification of special or added qualifications and osteopathic c ontinuous certification. Pain Management The medical discipline concerned with the diagnosis and treatment of the entire range of painful disorders. D. PolicyI. All the following criteria must be met for physicians to achieve successful credentialing as pain management specialists: A. Successful completion of residency in a pertinent residency program such as neurology neurosurgery physical medicine and rehabilitation anesthesiology B. Board certification in 1 of the above specialties, as recognized by ABMS, AOA, or ABPM . C. Successful completion of fellowship training in pain medicine or anesthesiology certification in pain management . D. Additional board certification in Pain Management by 1 of the following pathwa ys is preferred: 1. American Board of Anesthesiology, subspecialty in Pain Medicine 2. American Board of Physical Medicine and Rehabilitation, subspecialty in Pain Medicine 3. American Board of Psychiatry and Neurology, subspecialty in Pain Medicine Pain Management Providers-IN MCD-AD-1099Effective Dat e: 11/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 4. American Osteopathic Board of Anesthesiology, certification of added qualifications in Pain Management5. American Osteopathic Board of Neuromusculoskeletal Medicine, certification of added qualifications in Pain Management 6. American Osteopathic Board of Physi cal Medicine and Rehabilitation, certification of added qualifications in Pain Management 7. American Board of Pain Medicine (not an ABMS or AOA specialty) E. Physician is enrolled with the State in the appropriate type and specialty to provide care for Medic aid members. II. Physicians board certified in 1 of the above specialties , but without additional pain management fellowship training or certification (anesthesia route) , will not be credentialed in pain management. III. Primary care physicians and specialists other than those listed above will not be credentialed as pain management physicians. Physicians who receive additional training in pain management and intend to have a non-interventional pain management practice will not be credentialed or listed as pain management physicians but will be privileged to perform pain management a s part of general medical practice depending on current level of training and experience. IV. All physicians who do not meet requirements I .A-I.C will be reviewed at thecredentialing committee for further consideration.E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 05/12/2021 New policyDate Revised 05/25/2022 07/ 19 /2023 06/05 /2024 Annual Review: updated policy to match internal criteria Annual review: updated references. Approved at Committee. Annual review: updated references, approved at Committee. Date Effective 11/01/2024 Date Archived H. References1. ABMS Guide to Medical Specialt ies . American Board of Medical Specialties ; 202 4. Accessed May 20, 20 24 . www.abms.org 2. Certification and American Board of Pain Medicine MOC Examinations. American Board of Pain Medicine. Accessed May 20, 2024 . www.abpm.org Pain Management Providers-IN MCD-AD-1099Effective Dat e: 11/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 3. Specialties and Subspecialties. American Osteopathic Association (AOA) BoardCertification . Accessed May 20, 2024 . www.certification.osteopathic.org IN-MED-P-3012339 Issue date 05/12/2021 OMPP Approved 08/13/2024
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