REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-IN MCD-PY-1366 12/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 59, XE, XP, XS, XU-IN MCD-PY-1366Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 59 , XE, XP, XS, XU B. BackgroundReimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Reimbursement modifiers are 2-character code s that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier inappropriately can result in the deni al of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when 2 Healthcare Common Procedure Coding System(HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management ( E/M ) services, that are not usually reported together, but are appropriate under the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because 2 different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the 2 procedures/surger ies are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established 4 HCPCS modifiersto define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-IN MCD-PY-1366Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 CPT instructions state that m odifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. Modifiers X {EPSU} should be used prior to using modifier 59. II. Modifier X {EPSU} (or 59 , when applicable) may only be used to indicate that adistinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available . Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for sur gical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meets all the following: 1. are performed at different anatomic sites 2. are not ordinarily performed or encountered on the same day 3. cannot be described by 1 of the more specific anatomic NCCI Procedure to Procedure (PTP) -associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1 – T9, LC, LD, RC, LM, RI) B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed during different patient encounters 2. cannot be described by 1 of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91) C. Modifier XE (or 59, when applicable) may also be used when 2 timed procedures are performed during the same encounter but occur 1 after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are either 1. performed at separate anatomic sites Modifier 59, XE, XP, XS, XU-IN MCD-PY-1366Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 2. performed at separate patient encounters on the same date of serviceE. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when all the following apply: 1. diagnostic procedure is the basis for performing the therapeutic procedure 2. occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires 3. provides clearly the information needed to decide whether to proceed with the therapeutic procedure 4. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately. ) F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when all the following apply: 1. diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure 2. occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires 3. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the post-procedure diagnostic procedure is an inherent component or otherwise included (eg, not separately payable) post – procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately. ) E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/Rules Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Modifier 59, XE, XP, XS, XU-IN MCD-PY-1366Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Date Revised 08/02/202307/17 /2024 07/16/2025 Annual review: updated references , approved at Committee Review: updated references, approved at Committee Review: updated references, approved at Committee. Date Effective 12/01/2025 Date Archived H. References1. Claim Submission and Processing . Indiana Health Coverage Programs Provider Reference Module. May 11, 2023. Accessed June 27, 2025 . www.in.gov 2. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 202 5. Accessed June 27, 2025 . www.cms.gov 3. Mechanized Claims Processing and Information Retrieval Systems; Operational, etc., Requirements, 42. U.S.C. 1396b(r) (2024). 4. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services; 202 4. Accessed June 27, 2025 . www.cms.gov 5. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicare and Medicaid Services. Updated April 11, 2025. Accessed June 27, 2025 . www.cms.gov 6. MLN1783722 – Proper Use of Modifiers 59 & -X{EPSU}. US Centers for Medicare & Medicaid Services; 202 4. Accessed June 27, 2025 . www.cms.gov 7. Provider Code Tables . Indiana Health Coverage Programs. October 31, 2023. Accessed June 27, 2025 . www.provider.indianamedicaid.com 8. Transmittal R1422OTN – Publication 100-20 – MM8863 – Specific Modifiers for Distinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Accessed June 27, 2025 . www.cms.gov IN-MED-P-4186870 Issue Date 08/17/2022 Approved OMPP 09/25/2025
REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Modifier 25-IN MCD-PY-1362 12/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 25-IN MCD-PY-1362Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 25 B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a 2-character code that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifier 25 is used to report an Evaluation andManagement (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association (AMA) Current Procedural Terminology (CP T) book defines modifier 2 5 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of mod ifier 25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by aCPT code was performed, the patient’s condition required a medically necessary,significant, and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be rep orted (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses ar e not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. This modifier is not used to report an E/M service that resulted in a decision to perform su rgery. See modifier 57 for a surgical decision . For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier throu gh prepayment and post-payment edit or audit. Using a modifierinappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon Care Sources request. CareSource uses published guidelines from CPTModifier 25-IN MCD-PY-1362Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.C. Definitions American Medical Association (AMA) A professional association of physicians and medical students that maintains the Current Procedural Terminology coding system. Current Procedural Terminology (CPT) Codes that are issue d, updated, and maintained by the AMA that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 25 may be flagged for either a prepayment clinical validation or prepayment medical record coding review .a. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. b. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims s ubmission, this will also result in a claims denial.IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifier 25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier 25, the code may be denied. Modifier 25-IN MCD-PY-1362Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 VI. Appending modifier 25 to an E/M service is considered inappropriate in the following circumstances: A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. B. The E/M service is reported by a qualified professional provider who did not perform the procedure. C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. H. The preventative E/M service is performed at the same time as a preventative care visit (eg, a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preve ntative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation. J. CareSource will not reimburse CPT 99211 when billed with modifier 25. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document.F. Related Policies/RulesModifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022 New PolicyModifier 25-IN MCD-PY-1362Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Date Revised 08/02/202307/17/2024 07/16 /2025 Annual Review: updated references. Approved at Committee Review: updated references, approved at Committee Review: added D.VI.J, updated references, approved at Committee. Date Effective 12/01/2025 Date Archived H. References1. American Medical Association. Reporting CPT modifier 25. CPT Assistance (Online) . 2023;33(11):1-12. Accessed June 19, 2025 . www.ama-assn.org 2. Appropriate use of Modifier 25. American College of Cardiology. Accessed June 19, 2025 . www.acc.org 3. Chaplain S. Are you using Modifier 25 correctly. American Academy of Professional Coders. Published March 25, 2022. Accessed June 19, 2025 . www.aapc.com 4. Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services . Centers for Medicare and Medicaid Services; 202 5. Accessed June 19, 2025 . www.cms.gov 5. Evaluation and Management Services Guide . Centers for Medicare and Medicaid Services; 2024. MLN006764. Accessed June 19, 2025. www.cms.gov 6. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag. 2004;11(9):21-22. Accessed June 19, 2025 . www.aafp.org 7. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services; 2024. Accessed June 19, 2025 . www.cms.gov IN-MED-P-4186812 Issue Date 08/17/2022 Approved OMPP 09/04/2025
REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Urinalysis and Evaluation and Management Services-IN MCD-PY-1606 10/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Urinalysis and Evaluation and Management Services-IN MCD-PY-1606Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectUrinalysis and Evaluation and Management Services B. BackgroundThis policy provides guidance when billing urinalysis laboratory tests in conjunction with Evaluation and Management (E/M) services, on the same day, for the same member, by the same provider. Urinalysis laboratory tests are used to evaluate health and dia gnose medical conditions using the physical, chemical, and microscopic properties of an individuals urine sample. The urine sample is visually examined for color, clarity, and odor. A dipstick is used to examine the chemical properties of the urine sample for its pH, specific gravity, protein, glucose, ketones, bilirubin, urobilinogen, nitrites, and leukocyte esterase. A microscopic exam of urine measures the presence of red blood cells, white blood cells, epithelial cells, casts, crystals, and bacteria. T he results of a urinalysis can help assess kidney function, monitor diabetes mellitus (DM) status, evaluate liver disease, for routine health screening, or alert the health care provider to the possible presence of a urinary tract infection (UTI), proteinu ria, or hematuria. C. Definitions Evaluation and Management ( E/M) Service An interaction with a patient that involves a health care professional evaluating or managing a patients health, which may include office and other outpatient services, hospital inpatient services, consultations, ER visits, nursing facility services, a nd home care services. Outpatient Visit Physicians private office or group practice where members can be evaluated and treated by their provider. Routine Procedures Common procedure (eg, diagnostic test or screen) that is performed in connection with another procedure (eg, collection of a clean-catch urine sample or a throat swab) or is included in a treatment protocol for which a composite payment amount has been esta blished (eg, specific laboratory test performed for an individual receiving dialysis). D. PolicyI. Urinalysis tests (eg, 81002, 81003) are considered routine procedures when performed during an E/M visit in the outpatient setting and are not independently interpretable . When urinalysis tests are conducted in conjunction with an E/M service on the same day, for the same member, by the same provider, the provider will not be reimbursed for the urinalysis tests. Only the E/M service will be reimbursed. E. Conditions of CoverageNA F. Related Policies/RulesNA Urinalysis and Evaluation and Management Services-IN MCD-PY-1606Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 G. Review/Revision HistoryDATE ACTIONDate Issued 05/07/2025 New policy. Approved at Committee.Date Revised Date Effective 10/01/2025 Date Archived H. References1. Evaluation and Management Services. Provider Reference Module. Indiana Health Coverage Programs. Published June 2, 2023. Accessed April 23 , 2025. www.in.gov IN-MED-P-3914132 Issue Date 05 /07/2025 Approved OMPP 07/01/2025
REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Modifiers-IN MCD-PY-1347 10/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Modifiers-IN MCD-PY-1347Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifiers B. BackgroundReimbursement modifiers are a two-digit code that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifiers can be found in the appendices of both Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) manuals. Use of a modifier does not change the code or the codes definition. Examples of mod ifiers use includes: To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same procedure; To indicate that a procedure was performed on the left side, right side, or bilaterally; To report multiple procedures performed during the same session by the same health care provider; To indicate multiple health care professionals participated in the procedure; To indicate a subsequent procedure is due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, use does not guaranteereimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through post-payment audit. Inappropriate use of a modifier can result in a claim denial or incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyIt is the responsibility of the submitting provider to submit accurate documentation of services performed. Providers are expected to use the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided according to the following industry standard guidelines (may not be all-inclusive): National Correct Coding Initiative (NCCI) editing guidelines American Medical Association (AMA) guidelines American Hospital Association (AHA) billing rules Modifiers-IN MCD-PY-1347Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Current Procedural Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS) ICD-10 CM and PCS National Drug Codes (NDC) Diagnosis Related Group (DRG) guidelines CCI table edits State Medicaid Agency The inclusion of a code in a policy does not imply any right to reimbursement or guarantee claims payment. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Indiana Medicaid approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to the individual Indiana Medicaid fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies app ly to bothparticipating and nonparticipating providers and facilities .In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/Rules N/A G. Review/Revision HistoryDATE ACTIONDate Issued 01/01/2020 New policyDate Revised 12/15/2021 10/12/202209/27/202305/07 /2025 Annual review. Removed modifiers, changed background and policy sections to simplify language. New policy number created and converted from PY-0719 due to extensive edits No changes. Update references. Updated references. Approved at Committee. Periodic review. Updates background and references. Approved at Committee. Date Effective 10/01/2025 Date Archived H. References1. Billing 340B Modifiers Under the Hospital Outpatient Prospective Payment System (OPPS). US Centers for Medicare and Medicaid Services. March 3, 2023. Accessed March 26, 2025. www.cms.gov Modifiers-IN MCD-PY-1347Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 2. CPT overview and code approval. American Medical Association. Accessed March 26, 2025. www.ama-assn.org3. Medicare Claims Processing Manual, XII: Physicians/Nonphysician Practitioners. US Centers for Medicare and Medicaid Services. Issued December 19, 2024. Accessed March 26, 2025. www.cms.gov 4. Medicare Claims Processing Manual, XIV: Ambulatory Surgical Centers. US Centers for Medicare and Medicaid Services. March 24, 2023. Accessed March 26, 2025. www.cms.gov IN-MED-P-2484809 Issue Date 01/01/2020 Approved OMPP 06/23/2025
REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Influenza Testing-IN MCD-PY-1548 08/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Influenza Testing-IN MCD-PY-1548Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectInfluenza Testing B. BackgroundInfluenza (flu) is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs. Rapid influenza diagnostic tests (RIDTs) are immunoassays that can identify the presence of influenza A and Bviral nucleoprotein antigens in respiratory specimens and display the result in a qualitative way (positive vs. negative) . Influenza can cause mild to severe illness, and at times can lead to death. Flu symptoms usually come on suddenly . The best way to reduce the risk of flu and its potentially serious complications is by getting vaccinated each year. Having clinical signs and symptoms consistent with influenza increases the reliability of a positive RIDT result. A positive result is most likely a true positive result if the respiratory specimen was collected within 3-4 days of illness during periods of high influenza activity (eg , winter). A n egative result do es not exclude influenza virus infection , and influenza should still be considered in a patient if clinical suspicion is high based upon history, signs, symptoms , and clinical examination. C. Definitions Influenza (Flu) Season Typically, flu activity begins to increase in October and peaks between December and February, although significant activity can last as late as May and begins to increase in October. Rapid Influenza Diagnostic Tests (RIDTs) Immunoassays which d etect the parts of the virus (antigens) that stimulate an immune response , resulting in a positive or negative result . These tests can provide results within approximately 10-15 minutes. D. PolicyI. CareSource considers conventional testing, such as rapid influenza diagnostic tests (RIDTs), as lowest cost and should be utilized before any further testing or higher cost tests are performed. II. RIDTs are medically necessary for members (when influenza activity has been documented in the community or geographic area) who present with signs and symptoms of influenza, which may include the following : fever of 100.4 or higher feeling feverish/chills cough sore throat runny or stuffy nose muscle or body aches headaches fatigue (tiredness) Influenza Testing-IN MCD-PY-1548Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 some people may have vomiting and diarrhea, though this is more common in children than adults.III. The lowest cost CPT code for testing must be utilized first to confirm influenza in a patient presenting symptoms: 87804 – Infectious agent antigen detection by immunoassay with direct optical observation; influenza IV. If conventional testing isA. Positive no further testing is medically necessary. B. Negative if the members presenting symptoms support the diagnosis, then molecular diagnostic test (MDT) by polymerase chain reaction (PCR) testing may be medically necessary to confirm the diagnosis. V. Limitations/ExclusionsA. Only 1 RIDT per member per day is reimbursable. B. Only 1 MDT per member per day is reimbursable, if medically necessary . C. Duplicate tests will not be reimbursed. E. Conditions of Coverage NA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 10/23/2024 New policy. Approved at Committee.Date Revised 03/12/2025 Periodic review. Updated V. Limitations/Exclusions for greater clarification. Date Effective 08/01/2025 Date Archived H. References1. Diagnosing flu. Centers for Disease Control. October 3, 2022. Accessed August 26, 2024. www.cdc.gov 2. Flu season . Centers for Disease Control. September 20, 2022. Accessed August 26, 2024. www.cdc.gov 3. Rapid influenza diagnostic tests. Centers for Disease Control. October 25, 2016. Accessed August 26, 2024. www.cdc.gov IN-MED-P-3731675 Issue date 10/23/2024 Approved OMPP 05/02/2025
Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENTINDIANA MEDICAID Policy Name Policy Number Effective Date Standard Medical Billing Guidance PY-PHARM-0124-IN – MCD 01/01/2025 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………… 4 F. Related Policies/Rules …………………………………………………………………………………………….. 5 G. Review/Revision History …………………………………………………………………………………………… 5 H. References …………………………………………………………………………………………………………….. 5 2 A. Subject Standard Medical Billing Guidance Standard Billing Reimbursement Statement INDIANA MEDICAID PY-PHARM-0124-IN-MCD Effective Date: 01/01/2025B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. This reimbursement policy applies to all health care services reported using the CMS1500 Health Insurance Professional Claim Form (a/k/a HCFA), the CMS 1450 Health Insurance Institutional Claim Form (a/k/a UB04) or its electronic equivalent or any successor form. This policy applies to all products, all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Additionally, this policy applies to drugs and biologicals being used for FDA-approved indications or labels. Drugs and biologicals used for indications other than those in the approved labeling may be covered if it is determined that the use is medically accepted, taking into consideration the major drug compendia, authoritative medical literatures and/or accepted standards of medical practice. C. Definitions Indication is defined as a diagnosis, illness, injury, syndrome, condition, or other clinical parameter for which a drug may be given. FDA approved Indication/Label is the official description of a drug product which includes indication (what the drug is used for); who should take it; adverse events (side effects); instructions for uses in pregnancy, children, and other populations; and safety information for the patient. Labels are often found inside drug product packaging. Off-label/Unlabeled use of a drug is defined as a use for a non-FDA approved indication, that is, one that is not listed on the drugs official label/prescribing information. Off-label use is further defined as giving the drug in a way that deviates significantly from the labeled prescribing information for a particular indication. This includes but is not necessarily limited to, dosage, route of administration, duration and frequency of administration, and population to whom the drug would be administered. 3 Standard Billing Reimbursement Statement INDIANA MEDICAID PY-PHARM-0124-IN-MCD Effective Date: 01/01/2025 Unlabeled use of a drug is a use that is not included as an indication on the drug's label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label. Drug compendia, defined as summaries of drug information that are compiled by experts who have reviewed clinical data on drugs. CMS (Center for Medicare and Medicaid Services) recognizes the following compendia: American Medical Association Drug Evaluations (AMA-DE), United States Pharmacopoeia-Drug Information (USP-DI) or its successor publication and American Hospital Formulary Service-Drug Information (AHFS-DI) as authoritative sources for use in the determination of a "medically-accepted indication" of drugs and biologicals used off-label in an anticancer chemotherapeutic regimen. The USP DI is a database of drug information developed by the U.S. Pharmacopoeia but maintained by Micromedex, which contains medically accepted uses for generic and brand name drug products. D. Policy CareSource requires that the use of a drug or biological must be safe and effective and otherwise reasonable and necessary. Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for indications specified on the labeling. Therefore, reimbursement may be provided for the use of an FDA approved drug or biological, if: It was administered on or after the date of the FDAs approval; It is reasonable and necessary for the individual patient; and All other applicable coverage requirements are met. An unlabeled use of a drug is a use that is not included as an indication on the drug's label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label may be covered if it is determined that the use is medically necessary, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. The following guidelines identify three categories in which medications would not be reasonable and necessary according to accepted standards of medical practice. Not for Particular Illness Medications given for a purpose other than the treatment of a particular condition, illness, or injury are not covered (except for certain immunizations.) Route of Administration Not Indicated Medication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. Excessive Medications Medications administered for treatment of a disease which exceed the frequency or duration of dosing indicated by accepted standards of medical practice are not covered. Effective January 1, 1994, off-label, medically accepted indications of Food and Drug Administration (FDA) approved drugs and biologicals used in an anti-neoplastic chemotherapeutic regimen are identified under the indications described below: 4 Standard Billing Reimbursement Statement INDIANA MEDICAID PY-PHARM-0124-IN-MCD Effective Date: 01/01/2025 A regimen is a combination of anti-neoplastic agents clinically recognized for the treatment of a specific type of cancer. Off-label, medically accepted indications are supported in either one or more of the compendia or in peer-reviewed medical literature. E. Conditions of Coverage A medically accepted indication is one of the following: An FDA approved, labeled indication or a use supported in the American Hospital Formulary Service Drug Information (AHFS-DI), NCCN Drugs and Biologics Compendium, Truven Health Analytics Micromedex Drug Dex , Elsevier/Gold Standard Clinical Pharmacology and Wolters Kluwer Lexi-Drugs as the acceptable compendia based on CMS' Change Request 6191 (Compendia as Authoritative Sources for Use in the Determination of a "Medically Accepted Indication" of Drugs and Biologicals Used Off-Label in an Anti-Cancer Chemotherapeutic Regimen); or Articles of Local Coverage Determinations (LCDs) published by CMS. In general, a use is identified by a compendium as medically accepted if the: Indication is a Category 1 or 2A in NCCN, or Class I, Class IIa, or Class IIb in DrugDex; or, Narrative text in AHFS-DI or Clinical Pharmacology is supportive, or Indication is listed in Lexi-Drugs as Use: Off-Label and rated as Evidence Level A A use is not medically accepted by a compendium if the: Indication is a Category 3 in NCCN or a Class III in DrugDex; or, Narrative text in AHFS or Clinical Pharmacology is not supportive, or Indication is listed in Lexi-Drugs as Use: Unsupported If a use is identified as not indicated by CMS or the FDA, or if a use is specifically identified as not indicated in one or more of the compendia listed, or if it is determined, based on peer-reviewed medical literature, that a particular use of a drug is not safe and effective, the off-label use is not supported and the drug will not be covered. Reimbursement is dependent on, but not limited to claims submissions reported using CMS 1500/HCFA, CMS 1450/UB 04 or electronic equivalent, and must include the following: 11-digit NDC (National Drug Code) HCPCS/CPT Code Correct HCPCS units (not NDC units) Correct NDC unit of measure PLEASE NOTE THE FOLLOWING: Providers are responsible for sourcing and submitting accurate codes. Multi-source brands are not accepted without an additional medical necessity review for Dispense as Written (DAW). Medical Necessity for DAW policies can be found at CareSource.com under the applicable markets administrative policies tab. 5 Standard Billing Reimbursement Statement INDIANA MEDICAID PY-PHARM-0124-IN-MCD Effective Date: 01/01/2025 If applicable, individual drug reimbursement information may be found in a drugs Pharmacy Policy. F. Related Policies/Rules G. Review/Revision History DATE ACTIONDate Issued 07/22/2022 Original effective dateDate Revised 12/06/2022 Additions to clarify claims submission requirements, responsibility for sourcing of codes, and MSBs not accepted without additional DAW review. Individual drug reimbursement information may be found in a drugs Pharmacy Policy 01/01/2025 No updates.Date Effective 01/01/2025Date Archived H. References1. Drugs@FDA Glossary of Terms https://www.fda.gov/drugs/drug-approvals-and-databases/drugsfda-glossary-terms 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals 3. United States Federal Food, Drug and Cosmetic Act https://www.fda.gov/regulatory-information/laws-enforced-fda/federal-food-drug-and-cosmetic-act-fdc-actThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. IN-MED-P-3546044; Issued Date: 04/14/2025 OMPP Approval Date: 03/06/2025
REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name Policy Number Effective Date Single Dose Vial Claims Modifiers PY-PHARM-0104 01/01/2025 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 3 D. Policy ……………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………… 4 F. Related Policies/Rules …………………………………………………………………………………………….. 4 G. Review/Revision History …………………………………………………………………………………………… 4 H. References …………………………………………………………………………………………………………….. 4 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Single Dose Vial Claims Modifiers Indiana Medicaid PY-PHARM-0104 Effective Date: 01/01/2025 2 A. SubjectThis policy provides guidance for claims billing documentation and reimbursement of single dose injectable vials. B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. This policy describes documentation requirements and reimbursement guidelines for billing of the administered and discarded portion(s) of drugs and biologicals. Providers shall bill and receive reimbursement for both the dose administered and the unused portion of weight-based or variable dosing injectable drugs that are manufactured and supplied only in single dose or single use format. The JW modifier is required to be reported on a claim to report the amount of drug that is discarded and eligible for payment and should be used only for claims that bill single-dose container drugs. The discarded portion of single use or single dose vials must be identified with the JW Modifier as a separate line item from the dose or administered portion. Providers may be reimbursed for the discarded portions of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropriately reported based on the policy reimbursement guidelines. As of July 1, 2023, providers and suppliers are required to report the JZ modifier on all claims that bill for drugs from single-dose containers when there are no discarded amounts. The JZ modifier is reported on a claim to attest that no amount of drug was discarded and should only be used for claims that bill for single-dose container drugs. Claims containing drug administered from multi-dose vials are not subject to this requirement. Under this policy, all claims for separately payable single dose format injectable drugs must include either a JW modifier or a JZ modifier after 7-1-2023 in order to be reimbursed. Single Dose Vial Claims Modifiers Indiana Medicaid PY-PHARM-0104 Effective Date: 01/01/2025 3 MODIFIER SHORT DESCRIPTOR LONG DESCRIPTORJW Discarded portion of drug not administered Drug amount discarded/not administered to any patient JZ All drug administered none discarded Zero drug amount discarded/not administered to any patient C. DefinitionsModifier JW refers to the drug amount discarded (wasted)/not administered to any patient. Modifer JZrefers to zero drug amount discarded/not administered to any patient.Discarded Wastage or Unused Portion is defined as the amount of a single use/dose vial or other single use/dose package that remains after administering a dose/quantity of a drug or biological. Single Dose Vial i s defined as a vial of medication intended for administration by injection or infusion that is meant for use in a single patient for a sing le procedure. These vials are labeled as single-dose or single-vial by the manufacturer and typically do not contain a preservative. Multi-Dose Vial is defined as a vial of medication intended for administration by injection or infusion that contains more than one dose of medication. These vials are labeled as multi-dose by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria.D. Policy Modifier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modifier JW. Both details are reimbursable. CareSource will consider reimbursement for: I. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not administered to another patient. CareSource will NOT consider reimbursement for: I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. NOTE: The JZ modifier is required when there are no discarded amounts of a single-dose container drug for which the JW modifier would be required if there were discarded Single Dose Vial Claims Modifiers Indiana Medicaid PY-PHARM-0104 Effective Date: 01/01/2025 4 amounts. The JZ modifier is required to attest that there were no discarded amounts, and no JW modifier amount is reported.E. Conditions of Coverage Providers must not use the JW modifier for medications manufactured in a multi-dose vial format. Providers must choose the most appropriate vial size(s) required to prepar e a dose to minimize waste of the discarded portion of the injectable vials. Claims considered for reimbursement must not exceed the package size of the vial used for preparation of the dose. Providers must not bill for vial contents overfill. Providers must not use the JW modifier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modifer is only applied to the amount of drug or biological that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modifier. 1. Claim Line #1 HCPCS code for drug administered and the amount admistered to the patient. 2. Claim Line #2 HCPCS code for drug discarded (wasted) with JW modifier appended to indicate waste and the amount discarded (wasted). The JZ Modifier is applied when zero amounts of a single-dose container drug is discarded. F. Related Policies/Rules Chapter 17, Section 40.1 of CMS Medicare Claims Processing Manual G. Review/Revision History DATE ACTIONDate Issued 01-22-2023 Original effective dateDate Revised 08-25-2023 Updated policy to include JZ modifier. Updated policy name and references. 10-11-2024 Annual review. No changes.Date Effective 01-01-2025Date Archived H. References1. Billing and Coding: JW and JZ Modifier Billing Guidelines Article-Billing and Coding: JW and JZ Modifier Billing Guidelines (A55932) (cms.gov)2. New JZ Claims Modifer for Certain Medicare Part BDrugs https://www.cms.gov/files/document/mm13056-new-jz-claims-modifier-certain-medicare-part-b- drugs.pdf3. Discarded Drugs and Biologicals JW Modifier and JZ Modifier Policy FAQs. jw-modifier-faqs.pdf (cms.gov) The Reimbursement Policy Statement detailed above has received due consideration as defined in theReimbursement Policy Statement Policy and is approved.Single Dose Vial Claims Modifiers Indiana Medicaid PY-PHARM-0104 Effective Date: 01/01/2025 5 IN-MED-P -354604 5; Issued Date: 04/14/2025 OMPP Approval Date: 03/06/2025
REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Interest Payments-IN MCD-PY-1325 06/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of 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 Interest Payments-IN MCD-PY-1325 Effective Date: 06/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Interest Pay ments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care pr oviders and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim The result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A claim with no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and additional elements, or revisions to data elements, of which the provider has knowledge. Original Claim The initial , complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by State and/or f ederal regulation defining timeliness and interest requirements. D. Policy I. CareSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations ( IC 12.15.21.3 ). II. Payment of interest on original claims is made when CareSource fails to adjudicate original claims within the applicable state and federal prompt pay timeframes on clean claims. III. Payment of interest on adjusted claims starts on the date the provider disputes the original payment with CareSource. IV. CareSource considers interest payment on claims that were not paid accurately on prior processing attempts. If CareSource had the information to pay the claim correctly on a previous payment but failed to do so, CareSource will pay the claim Interest Payments-IN MCD-PY-1325 Effective Date: 06/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.3within the allotted timeframe from Prompt Pay and i nterest regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe. V. CareSource only pays interest on claim payment s that are occurring under prompt pay regulations. A contractual adjustment of a claim is not subject to state and federal regulations for interest payment. VI. CareSource performs regular reviews of our paid claims to correct claim payment. A. Reviews can include items , such as retroactive eligibility updates, authorization updates, coordination of benefits (COB) updates, and fee schedule updates. B. Reviews include proactive measures to correct claim payment when it has been determined that a systemic issue paid claims incorrectly. C. Claims are not subject to interest payment s when CareSource takes proactive measures to pay claims correctly . E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 03/31/2021 New PolicyDate Revised 04/27/2022 04/12/2023 01/31/2024 01/15/2025 No changes; Updated references . Updated references . Approved at Committee. Updated references . Approved at Committee. Updated references. Approved at Committee . Date Effective 06/01/2025 Date Archived H. References 1. Interest, 41 U.S.C. 7109 (2024 ). 2. Interest Penalties, 31 U.S.C. 3902 (2024 ). 3. Interest rates. Bureau of the Fiscal Service. Updated August 15, 2024 . Accessed December 3, 2024. www.fiscal.treasury.gov 4. Payment or Denial of Claims; Interest, IND . CODE 27-13-36.2-4 (2024 ). 4. Prompt Payment Interest Rate; Contract Disputes Act, 88 Fed. Reg. 55,501 (Aug. 15, 2023). Accessed December 3, 2024 . www.govinfo.gov 5. Prompt Payment of Claims, 42 U.S.C. 1395h(c)(2)(B) (2024 ). 6. Prompt Payment of Claims, 42 U.S.C. 1395u(c)(2)(B) (2024 ). 7. Prompt Payment by MA Organization, 42 C.F.R. 422.520 (2024) .Interest Payments-IN MCD-PY-1325 Effective Date: 06/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.48. Required Rules, I ND . CODE 12-15-21-3 (2023 ). IN-MED-P-3566165 Issue Date 03/31/2021 Approved OMPP 03/ 21/2025
Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENTINDIANA MEDICAID Policy Name Policy Number Effective Date 340B Drug Pricing PY-PHARM-0087 02/24/2025 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ……………………………………………………………………………………………. 4 F. Related Policies/Rules …………………………………………………………………………………………….. 4 G. Review/Revision History …………………………………………………………………………………………… 4 H. References …………………………………………………………………………………………………………….. 4 2 A. Subject 340B Drug Pricing 340B Drug Pricing INDIANA MEDICAID PY-PHARM-0087 Effective Date: 02/24/2025B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. The 340B Drug Pricing Program is a federal program, which limits the cost of covered outpatient drugs to eligible health care organizations and covered entities. The purpose of the program was to enable covered entities to stretch scarce federal resources as far as possible, reach more eligible patients and provide more comprehensive services. This policy describes the claim submission requirements for outpatient pharmacy and provider administered drugs. C. Definitions 340B Covered Entity (CE) A facility that is eligible to purchase drugs through the 340B Program and appears on the HRSA Office of Pharmacy Affairs Information System (OPAIS). 340B Drug Discount Program (340B) Section 340B of the Public Health Service (PHS) Act (1992) that requires drug manufactures participating in the Medicaid Drug Rebate Program to sign a pharmaceutical pricing agreement (PPA) with the Secretary of Health and Human Services. Actual Acquisition Cost The actual prices paid to acquire drug products sold by a specific manufacturer. Care Management Organization (CMO) Organizations, such as CareSource, contracted by the Georgia Department of Community Health to coordinate services for Medicaid members. Contract Pharmacy A pharmacy contracted with a Covered Entity to dispense 340B medications purchased by the Covered Entity. Current Procedural Terminology (CPT) A medical code set maintained by the American Medical Association to describe and bill for medical, surgical, and diagnostic services. Fee-for-Service (FFS) Claims billed directly to Indiana Medicaid for prescriptions and physician administered drugs provided to FFS members. 3 340B Drug Pricing INDIANA MEDICAID PY-PHARM-0087 Effective Date: 02/24/2025 Healthcare Common Procedure Coding System (HCPCS) A set of health care procedure codes based on CPT. Health Resources and Services Administration (HRSA) The primary federal agency responsible for administering the 340B program. National Council for Prescription Drug Programs (NCPDP) the standards organization that creates the standard format through which pharmacy claims are submitted to a Pharmacy Benefit Manager (PBM). National Drug Code (NDC) A drug product that is identified and reported using a unique, three-segment number, which serves as a universal product identifier for the specific drug. Pharmacy Benefit Manager (PBM) The entity that processes retail pharmacy or PBM benefit claims for CareSource. Provider Administered Drugs Drugs administered directly by a health care provider to a patient. D. Policy I. Pharmacies Allowed to Bill 340B Claims A. Only Covered Entities that elected to dispense 340B medications to Medicaid members on the HRSA Medicaid Exclusion File may bill 340B claims. B. Contract pharmacies that are in the CareSource pharmacy network are permitted to bill for 340B purchased drugs. II. Retail Pharmacy (Point-of-Sale) 340B Claims A. In addition to the NDC and other fields consistently submitted to the PBM for payment, all 340B Covered Entities must identify 340B claims using either of the two below NCPDP Telecommunication Standard D.0 fields: Submission Clarification Code 20 submitted in field 420-DK Basis of Cost Determination Code 08 submitted in field 423-DN B. When submitting 340B claims, providers are permitted, but not required to, submit Basis of Cost Determination Code 08. Providers electing to identify 340B claims using this field must also submit their 340B acquisition code in the Submitted Ingredient Cost field 409-D9. C. For drugs not purchased at 340B rates, do not include either of the 340B identifiers listed above. III. Provider Administered 340B Drug Claims A. In addition to the HCPCS/CPT code, NDC, and other fields consistently submitted for claims payment, 340B Covered Entities should submit the claim on a CMS 1500 or UB-04 claim form with the either of the following modifiers: JG Drug or biological acquired with 340B drug pricing program discount TB Drug or biological acquired with 340B drug pricing program discount, reported for information purposes 4 340B Drug Pricing INDIANA MEDICAID PY-PHARM-0087 Effective Date: 02/24/2025 IV. Auditing and Monitoring A. To ensure compliance with 340B billing requirements, CareSource will monitor both 340B and non-340B claim submissions to identify potential 340B claims. Should we identify a claim we believe is 340B, we will inform the provider of the potential billing error and ask for validation, as well as correction. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting the appropriate and applicable drug-related codes (HCPCS, CPT, NDC) along with appropriate 340B claim fields, if applicable. F. Related Policies/Rules None applicable G. Review/Revision History DATE ACTION Date Issued 05/13/2021 Date Revised 03/14/2024 Updated contract pharmacies in the CareSource pharmacy network billing permittance language. Updated references links. Date Effective 02/24/2025 Date Archived H. References 1. Indiana Health Coverage Programs Provider Reference Module Pharmacy Services. Published March 31, 2023 https:// www.in.gov/medicaid/providers/files/modules/pharmacy-services.pdf 2. Indiana Health Coverage Programs Provider Reference Module Injections, Vaccines, and Other Physician Adminstered Drugs. Published August 3, 2023 https:// www.in.gov/medicaid/providers/files/modules/injections-vaccines-and-other-physician-administered-drugs.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.IN-MED-P-3546052 ; Issued Date: 02/24/2025 OMPP Approval Date: 02/24/2025
REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Dental Services Rendered in an Outpatient Facility or Ambulatory Surgery Center-IN MCD-PY-1304 11/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Dental Services Rendered in an Outpatient Facility or Ambulatory Surgery Center-IN MCD-PY-1304Effective Dat e: 11/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 3. The facility request should include the facility services requested (ie, operating room charges, anesthesia) , the Dental Authorization Approval Letter, and the dental authorization number. 4. CareSource Medical Utilization Management team will complete ALL of the following: a. Verify that facility is in network . b. Review the dental pre-determination letter (PDL) or authorization . c. Complete the administrative approval for facility fee and anesthesia. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted . HCPCS code G0330 only requires administrative review . d. Fax a Facility Approval to the hospital/ASC which can also be viewed in the CareSource Provider Portal . E. Conditions of CoverageFacility Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates : 0078 Outpatient Hospital Facility (SPU) POS (19, 22); Ambulatory Surgical Center POS (24) o Use HCPCS code G0330 as facility fee code 0083 Will be paid according to CareSource contract and IHCP fee schedule. For a list of revenue codes reimbursed, as well as outpatient payment information for relevant codes, see the Revenue Codes tab of the Outpatient Fee Schedule accessible from the IHCP Fee Schedules page at in.gov/Medicaid/providers . 0083 Dental-related facility charges must be billed on an institutional claim (UB-04 claim form, Portal institutional claim, 837I transaction). o Use CPT 00170 for anesthesia for intraoral treatments, including biopsy 0083 Will be paid according to CareSource contract and IHCP fee schedule . 0083 All associated professional services, such as radiology and anesthesia, as well as ancillary services related to the dental services, must be billed on a professional claim (CMS-1500 claim form or electronic equivalent). 0078 Inpatient Hospital Facility POS (21) o All services as well as any additional room and board fees would have to be pre – certified and receive medical necessity review. Services are subject to benefit provisions , and criteria for dental hospital admissions for both adult and pediatric members is i n accordance with 405 IND . ADMIN . CODE 5-33 . 0078 Dental/Oral Surgery Professional Services o The scope of this policy is limited to medical plan coverage of the facility and/or general anesthesia services provided in conjunction with dental treatment, not the dental or oral surgery services. For i nformation on dental benefits, please consult the CareSource Office Reference Manual for clinical guidelines, policies , and procedures , and the provider contracted fee schedule .
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