ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Non-Invasive Vascular Studies-IN MCD-AD-1120 10/01/2024 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 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 Non-Invasive Vascular Studies-IN MCD-AD-1120Effective Dat e: 10/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 The use of any Doppler device that produces a record but doe s not permit analysis of bidirectional vascular flow or that does not provide a hard copy or printout is part of the physical exam of the vascular system and is not reported separately. V. Noninvasive vascular studies are considered medically necessary when ALL of the following criteria are met: A. The member experiences significant signs/symptoms of arterial or venous disease . B. The information provided by the test is required for medical and/or surgical decision making . C. The test is not redundant to other diagnostic procedures that will be performed . VI. CareSource may request documentation to support medical necessity, including the non-invasive vascular study hard copy or digital copy results.E. Conditions of CoverageNA F. Related Policies/RulesNAG. Review/Revision HistoryDATE ACTIONDate Issued 12/15/2021 Replacing PY-0165. Approved at PGC.Date Revised 12/14/2022 04/24 /2024 Annual review. No changes to content. Updated references. Annual review. Revised D. III. Updated references. Approved at Committee. Date Effective 10/01/2024 Date Archived H. References1. Bertolotto M, Freeman S, Richenberg J, et al. Ultrasound evaluation of varicoce les: systematic literature review and rationale of the ESUR-SPIWGguidelines and recommendations. J . 2020;23(4):487-507. doi:10.1007/s40477-020-00509-z 2. Freeman S, Bertolotto M, Richenberg J, et al. Ultrasound evaluation of varicoceles: guideli nes and recommendations of the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) for detection, classification, and grading. E 2020;30(1):11-25. doi:10.1007/s00330-019 – 06280-y 3. Jedrzejewski G, Wieczorek AP, Osemlak P, et al. The role of ultrasound in the management of undescended testes before and after orchidopexy-an update. M i . 2016;95(51):e5731. doi:10.1097/MD.00000000000 05731 4. Leers SA. Duplex ultrasound. Society for Vascular Surgery. Accessed February 19, 2024. www.vascular.org
ADMINISTRATIVE POLICY STATEMENT Indiana Medicaid Policy Name & Number Date Effective Three-Day Window Payment-IN MCD-AD-1000 09/01/2024 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 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 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 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 Three-Day Window Payment-IN MCD-A D-1000 Effective Date: 09/01/2024 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. SubjectThree-Day Window PaymentB. BackgroundServices provided within 3 days of an inpatient admission or discharge for the same or a related diagnosis are considered part of the admission.C. DefinitionsInpatient Services Services provided while the member is registered as an inpatient in an acute care or psychiatric hospital .Outpatient Services Services provided to a member who is registered with the facility but not registered as an inpatient.D. PolicyI. Three-Day Payment RuleA. Claims submitted for outpatient services that were provided within the 3 calendar days prior to the inpatient admission for the same member may be partially denied if the services are not combined into one claim .1. This only applies when :a. Outpatient services and inpatient admission occur at the same facility ,and b. The same or related diagnosis are considered part of the inpatient admission.2. The outpatient services and inpatient admission must be submitted on 1inpatient claim .3. The dates of the claim should re flect the date of the earliest outpatient service billed not the date of admission.B. If an outpatient claim is paid before the inpatient claim is submitted , the inpatient claim may be denied with Explanation of Benefit ( EOB ) 6516 Outpatient services performed three days prior to inpatient admission. To resolve this denial,providers should void the outpatient claim in history, incorporate the outpatient services into the inpatient claim, and resubmit the corrected inpatient claim.C. If an outp atient claim is submitted after the inpatient claim has been paid, the outpatient claim may be denied with an EOB indicating that the inpatient claim may be adjusted to reflect the outpatient services provided to the patient.D. If both the inpatient and outp atient services are initially paid for the same facility,r etroactive recovery may be initiated for the outpatient services inclusive by the3-day window .E. Physician practices and entities should use modifier PD (diagnostic or related non-diagnostic item or service provided in a wholly owned or operated entity to a member who is admitted as an inpatient within 3 days or 1 day) to identify services subject to the payment window. Three-Day Window Payment-IN MCD-A D-1000 Effective Date: 09/01/2024 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 II. This policy is not applicable when the outpatient and inpatient services are pro vided by different facilities. This policy is also not applicable when the inpatient stay is less than 24 hours. Outpatient services provided within 3 days preceding a less-than-24-h o ur inpatient stay are billed as an outpatient service.E. Conditions of CoverageNAF. Related Policies/RulesNAG. Review/Revision HistoryDATES ACTION Date Issued 10/30/2019 Date Revised 01/15/2021 02/04/2022 05/10 /2023 05/08 /2024 Changed from PY policy , Updated resources Annual review. Editorial changes Annual review. Updated retroactive review process and code recommendations, references, removed definition for same or related procedures. Approved at Committee Review: updated references, approved at Committee Date Effect ive 09/01/2024 Date Archived H. References1. “Inpatient Services” Defined , 405 I ND . A DMIN . CODE 5-2 – 12 ( 202 3 ) .2. “Outpatient Services” Defined , 405 I ND . A DMIN . CODE 5-2 – 1 9 ( 202 3 ) .3. Provider Reference Module Inpatient Hospital Services . Indiana Family & SocialServices Administration ; 2023. ( January 24, 2023 ). Accessed April 12, 2024 .www.in.gov4. Provider Reference Module Outpatient Facility Services . Indiana Family & SocialServices Administration ; 2022. Accessed April 12, 2024 . www.in.govIN-MED-P – 2903120 Issue Date 10/30/2019 Approved OMPP 06/25/2024
ADMINISTRATIVE POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Trading Partners-IN MCD-AD-0082 10/01/2024 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 sta ndards, 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 witho ut which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the 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 Man uals, 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 Evi dence 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 Covera ge) 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 limitati ons 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
ADMINISTRATIV E POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Continuity of Care-IN MCD-AD-0743 07/01/2024 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 techno logy assessment guidelines, other medical management industry 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 th e diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These se rvices meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Eviden ce 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 ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Continuity of Care-IN MCD-AD-0743Effective Dat e: 07/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectContinuity of Care B. BackgroundContinuity of care (COC) comprises a series of separate health care services so that treatment remains coherent, unified over time, and consistent with a members health care needs and preferences. To ensure that care is not disrupted, COC becomes a bridge of coverage, allowing members to transition to CareSources provider network. Newly enrolled members can continue to receive services by an out-of-network provider when an established relationship exists with that provider, and/or the member will be recei ving services for which a prior authorization was received from another payer. Existing members may also utilize COC when a participating provider or acute care hospital terminates an agreement with CareSource. COC promotes safety and effective healthcare to transitioning members. C. Definitions Acute Conditio n A medical or behavioral health (BH) condition that involves a sudden onset of symptoms due to an illness, injury or other medical problem requir ing prompt medical attention and with a limited durati on. Chronic Conditio n A medical or BH condition due to a disease, illness, or other medical problem that is complex in nature , persists wit hout cure and/ or worsens over an ex tended period or requires ongoing tr eatment to maintain remission o r prevent deterioration . In-Network (Network) Provide r Any provider, group of providers, or entity that has a network provider agreement with CareSource or a subcontractor and receives Medicaid funding directly or indirectly to order, refer , or render covered services . Level-of-Care (LOC ) The outcome of the measure of an individuals care needs , includ ing nursing home or institutional placement ne ed s of an individual. Out-of-Network Provider Any provider , group of providers, or entity not directly or indirectly employed by or does not have a provider agreement with CareSource or any of its subcontractors. Primary Car e All health care and laboratory services furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/ gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes the service. [42 CFR 438.2]. Primary Medical Provider (PMP) Also called a Primary Care Physician (PC P) , a PCP or other licensed health practitioner practicing in accordance with state law who is responsible for providing preventive and primary health care to patients , initiating referrals for specialist care , and maintaining the continuity of patient car e. At a minimum, providers allowed to serve as PMPs must include physicians, physician assistants, and advanced practice registered nurses. Specialis t A Board-eligible or certified physician who declares him /her self as a specialist and practices a specific medical specialty. For the purposes of this Continuity of Care-IN MCD-AD-0743Effective Dat e: 07/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 definition, Board-eligible means a physician who meets all the requirements for certification but has not tested for or has not been issued certification. Terminal Illnes s 6-month or less life expectancy if the illness runs a normal course. Transition of Car e A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. D. PolicyI. CareSource supports COC to ensure that consistent healthcare services are delivered through proper coordination combined with information sharing among providers to enhance a patient focused approach. Requests will be accepted from a member, a members representative, or a provider on behalf of a member. CareSource follows Indiana Health Coverage Programs ( IHCP ) requirements to facilitate the exchange of member-specific data and ensure facilitiation of care among all stages to enrollment or termination completion. All transitions of care between healthcare settings will be handled according to IHCP requirements, including care coordination guidance, discharge planning, and followup with providers/member s, particularly regarding outpatient followup after inpatient discharge. Critical continuity of care areas include, but are not limited to: A. members receiving HIV, Hepatitis Cand/or behavioral health services, especially when a PA was received from a previous payer B. pregnant members C. members transitioning into the Hoosier Healthwise or HIP program from traditional fee-for-service or into HIP from Hoosier Healthwise D. members transitioning between managed care entities, particularly during an inpatient stay E. members transitioning between IHCP programs, particularly when a HIP member becomes preg nant or disabled F. members exiting the Hoosier Healthwise or HIP program to receive excluded services G. members transitioning to a new PMP H. members transitioning to private insurance, Marketplace coverage, or no coverage I. members transitioning between HIP plans II. COC services will be provided when ONE of the following occurs:A. Newly enrolled, CareSource members may qualify for COC coverage in the following circumstances: 1. The member chooses to receive care from an out of network provider. Coverage will be extended as follows: a. eligibility for 180 days if the provider was providing treatment prior to enrollment . b. eligibility during the 30-day transition period . Continuity of Care-IN MCD-AD-0743Effective Dat e: 07/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 c. pregnant women in the 3rd trimester throughout prenatal, delivery , and postpartum periods or women with a history of high risk pregnancy who want to see a treating provider from a previous high risk pregnancy . 2. The member is or will be receiving services for which a prior authorization (PA) was received from another payer. Services will be pro vided for 180 days. The date of member enrollment for purposes of the PA time frames begins on the date CareSource receives the members fully eligible file from the State. Authorization extends to any service o r procedure previously authorized, including, but not limited to, the following: a. surgeries and therapies b. home health c. physician services B. Terminations of contractual relationships between CareSource an d providers, provider groups, or entities will result in changes to provider network status. Termination requests will be reviewed when a health partner is terminated from the CareSource network , and that termination was not related to a fraud or quality of care issue . S ervices will be provided for 60 days . C. Inpatient stays will be handled in the following manner: 1. For r eimbursement s based on diagnos is-related group (DRG) methodology, the admitting managed care entity ( MCE ) is responsible for the entire inpatient stay through member discharge or ineligibility for medicaid , including the hospital DRG payment and any outlier payments (without a capitation payment). If the member is transitioning from the admitting MCE to anoth er MCE or traditional Medicaid, the admitting MCE will provide care coordination, including coordination of discharge plans, with the receiving MCE or inpatient provider, as applicable. 2. For reimbursement based on a level-of-care (LOC) methodology, the adm itting MCE is responsible for the days during which the member is enrolled with the MCE and the transition of care coordination for the remainder of the stay. The admitting MCE is financially responsible for the per diem payments and any outlier payments ( without capitation payment) associated with the days the member remains enrolled with the admitting MCE. If the member is transitioning from the admitting MCE to another MCE or to traditional Medicaid, the receiving MCE or traditional Medicaid program is r esponsible for the per diem payments associated with the days the member is enrolled with the receiving MCE or in traditional Medicaid until the member is discharged from the hospital or eligibility for Medicaid terminates. The admitting MCE is responsible for the transition of care coordination with the receiving MCE or the inpatient provider, as applicable . III. To coordinate care and facilitate transition , COC services will be provided for 180calendar days , including out of network provider s, but the following may be subject to a medical necessity review : A. tra nsportation on a scheduled basis B. physical therapy, speech therapy, occupational therapy and rehabilitation therapy Continuity of Care-IN MCD-AD-0743Effective Dat e: 07/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 C. inpatient and outpatient behavioral health careD. inpatient substance abuse treatment E. long term care, including nursing homes, skilled nursing facilities, psychiatric residential treatment facilities , and other facilities that provide long term non – acute care . F. post-emergency care (covered 30 days without a medical necessity review after member sees an out of network provider in an emergency department) G. home health services H. specialized medical care requir ing ongoing care from specialist s I. specialized durable medical equipment , including ventilators and other respiratory assistance equipment E. Conditions of CoverageIf a n out of networ k provider s services meet medical necessity and the COC policy, CareSource will work to obtain a single case agreement (SCA) document. F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATES ACTIONDate Issued 04/01/2020Date Revised 08/17/2022 02/14/2024 Updated in line with UM P&P. Editorial revisions. Annual review. Definitions updated to contract. Added contract language to D.I., added D.II.C. Updated F. and G. Approved at Committee. Date Effective 07/01/2024 Date Archived H. References1. CareSource Indiana Medicaid Provider Manual . CareSource; 2023. Accessed January 31, 2024. www.caresource.com 2. Continuation of Care Provisions, IND . CODE 27-13-36-6 (1998). 3. Continuity of Care and Referrals when Specialty Care Warranted, IND . CODE 27 – 13-37-3 (1998). 4. Healt hy Indiana Plan Policies and Procedures Manual . Indiana Health Coverage Programs. Revised January 24, 2024. Accessed January 31, 2024. www.in.gov 5. Managed Care, 42 C.F.R. 438 (2024). 6. Problems with Continuity of Care, Reporting, IND . CODE 12-24-12-4 (1994). 7. Speci al Rules for Ambulance Services, Emergency and Urgently Needed Services, and Maintenance and Post-Stabilization Care Services, 42 C.F.R. 422.113 (2024). 8. Standards for Continuity of Care, IND . CODE 27-13-36-11 (1998). 9. State Plans for Medical Assistance , 42. U.S.C. 1396a(e)(5) (2024). IN-MED-P-2691373 Issue date 04/01/2020 OMPP Approved 03/25/2024
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