REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Influenza Testing-IN MP-PY-1539 02/01/2025 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 MP-PY-1539Effective Dat e: 02/01/2025The 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 lowe st 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 MP-PY-1539Effective Dat e: 02/01/2025The 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 test per member per day is reimbursable. B. Duplicate tests will not be reimbursed. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 10/23/2024 New policy. Approved at Committee.Date Revised Date Effective 02/01/2025 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
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, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, 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 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.REIMBURSEMENT POLICY STATEMENT Marketplace Policy Name & Number Date Effective Reimbursement of Advanced Practice Behavioral Health Providers – IN MP-PY-1542 01/01/2025-10/31/2025 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents 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 of Advanced Practice Behavioral Health Providers-IN MP-PY-1542 Effective Date: 01/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectReimbursement of Advanced Practice Behavioral Health ProvidersB. Background The Omnibus Budget Reconciliation Act of 1989 allowed coverage for clinical social worker services under Medicare Part B. In an effort to expand access to behavioral health (BH) services, address the acute shortage of BH professionals, and advance health equity, Section 4121(FF) of the Consolidated Appropriations Act, 2023 (CAA, 2023), established a new Medicare benefit category for Marriage and Family Therapist (MFT) and Mental Health Counselor (MHC) services furnished by and directly billed by MFTs and MHCs. Payment for MFT and MHC services, diagnosis and treatment of BH issues, under Part Bof the Medicare program began January 1, 2024. Per 42 CFR 410.54(a)(3), an MHC must be licensed or certified as an MHC, clinical professional counselor, professional counselor, addiction counselor, or alcohol and drug counselor by the state in which the services are performed. Individuals who meet all the applicable statutory and regulatory qualifications to be an MHC, even though the applicable state may license or certify the individual under a different title, may enroll as an MHC. This list of mental health professional titles will vary by state. Medicare recognizes licenses obtained through the interstate license compact pathway as valid, full licenses for the purposes of meeting federal license requirements. Some non-physician practitioner (NPP) compacts allow the NPP to work in a compact member state, other than the home state, without going through the normal licensure process in the remote state. NPPs working under such a compact must meet both the licensure requirements outlined in the primary state of residence and those established by the compact laws of the interstate compact states. MFTs and MHCs have also been added to the list of practitioners who can furnish Medicare telehealth services. During the COVID-19 public health emergency (PHE), the Centers for Medicare and Medicaid Services (CMS) used emergency waiver and other regulatory authorities so providers could deliver more services to patients via telehealth. Section 4113 of the CAA, 2023 extended many of these flexibilities through December 31, 2024 and made some of them permanent. Services furnished by an MFT and MHC are also covered when furnished in a rural health clinic and federally qualified health center. This policy is provided as a courtesy only to address payment for the new benefit category. CMS provides additional information on how to become a Medicare provider, billing and payment instructions for this benefit category, telehealth services, and other applicable technical information. Any information provided by a relevant government or state body supersedes the information in this policy. Reimbursement of Advanced Practice Behavioral Health Providers-IN MP-PY-1542 Effective Date: 01/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 C. Definitions Marriage and Family Therapist (MFT) Criteria established by CMS to enroll as an eligible provider includes the following: o possess a master's or doctor's degree which qualifies for licensure or certification as an MFT pursuant to state law of the state in which the individual furnishes the services defined as MFT services o completed at least 2 years or 3,000 hours of post masters degree clinical supervised experience in MFT in an appropriate setting such as a hospital, skilled nursing facility (SNF), private practice, or clinic o licensed or certified as a MFT by the state in which the professional performs the services Mental Health Counselor (MHC) Criteria established by CMS to enroll as an eligible provider, including addiction and alcohol and drug counselors, includes o possess a master's or doctor's degree which qualifies for licensure or certification as an MHC, clinical professional counselor, or professional counselor under the state law of the state in which the professional furnishes the services defined as MCH services o completed at least 2 years or 3,000 hours of post masters degree clinical supervised experience in MHC in an appropriate setting such as a hospital, SNF, private practice, or clinic o licensed or certified as an MHC, clinical professional counselor or professional counselor by the state in which the services are providedD. Policy I. CMS began applying mid-level reductions to MFTs and MHCs as of January 1, 2024. CareSource follows Medicare policy and reimbursement rules for this benefit category enrolled in Medicare to provide these services. II. CareSource will pay MFT/MHCs for services at 75% of the amount reimbursed under the Medicare Physician Fee Schedule (PFS). Reduction of reimbursement applies to the following Indiana-recognized state licenses: A. Licensed Clinical Addiction Counselors B. Licensed Chemical Dependency Counselors C. Licensed Marriage and Family Therapists D. Licensed Mental Health Counselors III. This billing benefit category cannot be used for the following: A. MFT/MHC services to clients under a partial hospitalization program (PHP) or intensive outpatient program (IOP) by a hospital outpatient department or community mental health center (CMHC) B. MFT services provided to skilled nursing facility (SNF) residents on or after January 1, 2024 from consolidated billing C. MFT/MHC services to an inpatient of a Medicare-participating hospital Reimbursement of Advanced Practice Behavioral Health Providers-IN MP-PY-1542 Effective Date: 01/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 E. Conditions of CoverageClaims with dates of service prior to January 1, 2024 are not be payable.F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 09/25/2024 New policy. Approved at Committee.Date Revised Date Effective 01/01/2025 Date Archived 10/31/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H. References1. Centers for Medicare and Medicaid Services. Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs) , Center for Program Integrity; 2024. Accessed August 23, 2024. www.cms.gov 2. Centers for Medicare and Medicaid Services. Medicare Clarifies Recognition of Interstate License Compact Pathways, Medicare Learning Network; 2021. MLN Matters #SE20008. Accessed August 23, 2024. www.cms.gov 3. Centers for Medicare and Medicaid Services. Medicare and Mental Health Coverage, Medicare Learning Network; 2024. MLN Booklet #1986542. Accessed August 23, 2024. www.cms.gov 4. Consolidated Appropriations Act, Sections 4113 and 4121(FF) (2023). 5. Marriage and Family Therapist Services, 42 C.F.R. 410.53 (2023). 6. Mental Health Counselor Services, 42 C.F.R. 410.54 (2023). 7. Payment for Physicians Services, 42 U.S.C. 1395, section 1848(g)(4)(A) (2018). 8. Rules. Indiana Professional Licensing Agency. Accessed September 9, 2024. www.in.gov 9. Telehealth Services and Prescriptions, I ND . C ODE 25-1- 9.5 (2024)
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407 01/01/2025 Kentucky inactive as of 01/01/202 6 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407Effective Dat e: 01/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDental Services Rendered in a Hospital or Ambulatory Surgery Center B. BackgroundThe decision to perform dental care in a particular place of service is based on a wide variety of factors, including the age and special health care needs (physical, intellectual, and developmental disabilities or chronic medical conditions) of the individual, in addition to the type, number, and complexity of procedures planned. These factors also determine the type of anesthesia used during the procedure. Most dental care can be provided in a dental office setting with local anesthesia or local anesthesia supplemented with non-pharmacological behavior guidance (basic toadvanced techniques) and/or pharmacological options. Basic non-pharmacological behavior guidance includes communication guidance, positive pre-visit imagery, direct observation, tell-show-do, ask-tell-ask, voice control, non-verbal communication, positive reinforcement and descriptive praise, distraction, and desensitization. Pharmacological options may include nitrous oxide, oral conscious sedation and intravenous (IV) sedation (mild, moderate, or deep), or monitored general anesthesia by trained certified individuals in each level of sedation dentistry. As noted by the American Academy of Pe diatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require the use of general anesthesia as medically necessary in a healthcare facility, such as an ambulatory surgica l center, hospital operating room, or short procedure unit (SPU). C. Definitions Ambulatory Surgical Center (ASC) A distinct entity that operates exclusively to furnish outpatient surgical services to patients who do not require hospitalization and are typically discharged less than 24 hours following admission. Hospital An institution primarily engaged in providing, by or under the supervision of physicians, diagnostic and therapeutic services or rehabilitation services. Critical access hospitals are certified under separate standards. Psychiatric hospitals are subject t o additional regulations beyond basic hospital conditions of participation. Monitored Anesthesia Care (MAC) A specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Sedation Continuum When patients undergo procedural sedation/analgesia, a sedation continuum is entered. Several levels have been formally defined along this continuum, as follows: o Minimal Sedation (Anxiolysis) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. o Moderate Sedation (Analgesia) (Conscious Sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407Effective Dat e: 01/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.o Deep Sedation (Analgesia) A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require a ssistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. o General Anesthesia A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and p ositive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Note: Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initia lly intended. Individuals administering moderate sedation should be able to rescue patients who enter a state of deep sedation, while those administering deep sedation should be able to rescue patients who enter a state of general anesthesia. Rescue o f a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper than intended level of sedation , such as hypoventilation, hypoxia, and hypotension and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation. Short Procedure Unit (SPU ) A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic , or medical services. D. PolicyThis policy is intended to provide guidance on the process for obtaining authorization and reimbursement for dental services performed in a place of service (ASC or hospital OR/SPU) and reimbursement for related facility charges (eg, operating room, anesthesia, medical consults). Dental services are only covered in a hospital setting when the nature of the surgery or the condition of the patient precludes performing the procedure in the dentists office or other non-hospital outpatient setting and the inpatient or outpatient servic e is a HealthInsurance Marketplace covered service. As such, it would exclude any diagnostic or preventive dental services delivered in a hospital setting, if these services cannot be performed in office.Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407Effective Dat e: 01/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 I. Dental Prior Authorization ProcessA. Prior authorization is required for all dental services performed in a hospital inpatient or outpatient facility or ambulatory surgery center facility. B. Dental services authorization for an outpatient/ASC setting 1. Requests for dental services should be handled through the members dental plan . Claims submitted for professional dental services should be submitted using the appropriate CDT codes and applicable ADA form. 2. If the member does not have a stand-alone dental plan, the member will be responsible for the costs of the dental services. C. Facility process Facility service claims should be submitted to CareSource using the applicable claim form (eg, CMS-1500, UB-04). E. State-Specific InformationNA F. Conditions of Coverage The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarantee payment for it. 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 information is provided as a reference. This list may not be all inclusive and is subject to updates. Outpatient Hospital Facility (SPU) POS (19, 22); Ambulatory Surgical CenterPOS (24) o Use CPT code G0330 as the facility fee code Will be paid according to CareSource contract and the Medicare Physician Fee Schedule ( PFS). 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 Will be paid according to CareSource contract and the Medicare PFS. 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). 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 in accordance with clinical guidelines. Dental/Oral Surgery Professional Services Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407Effective Dat e: 01/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 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, and not the dental or oral surgery services.G. Related Policies/RulesNAH. Review/Revision HistoryDATE ACTIONDate Issued 11/30/2022Date Revised 08/28/2024 Annual review: updated background, reorganized definitions, removed facility PA process and DentaQuest information, updated references. Approved at Committee. Date Effective 01/01/2025 Date Archived I. References1. Ambulatory Surgical Centers. Centers for Medicare and Medicaid Services. Updated September 6, 2022. Accessed July 12, 2024. www.cms.gov 2. American Academy of Pediatric Dentistry. Management of dental patients with special health care needs. Reference Manual of Pediatr Den t. 202 3-2024:337-344. Accessed June 13, 2024. www.aapd.org 3. American Academy of Pediatric Dentistry. Policy on hospitalization and operating room access for oral care of infants, children, adolescents, and individuals with special health care needs. Reference Manual of Pediatr Den t. 202 3-2024:169-170. Accessed June 13, 2024. www.aapd.org 4. American Academy of Pediatric Dentistry. Policy on third-party reimbursement for management of patients with special health care needs. Reference Manual of Pediatr Den t. 202 3-2024:181-184. Accessed June 13, 2024. www.aapd.org 5. Committee on Quality Management and Departmental Administration. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. October 23, 2019. Accessed July 12, 2024. www.asahq.org 6. Hospitals. Centers for Medicare and Medicaid Services. Updated September 6, 2023. Accessed July 13, 2024 . www.cms.gov
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, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, 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 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.REIMBURSEMENT POLICY STATEMENT Marketplace Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-MP-PY-1367 10/01/2024-09/30/2025 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. State-Specific Information ………………………………………………………………………………………. 4 F. Conditions of Coverage ………………………………………………………………………………………….. 5 G. Related Policies/Rules ……………………………………………………………………………………………. 5 H. Review/Revision History …………………………………………………………………………………………. 5 I. References …………………………………………………………………………………………………………… 5 Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 59, XE, XP, XS, XUB. Background Reimbursement 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-digit codes 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. 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 through prepayment and post-payment audit. Using a modifier inappropriately 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 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. 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/surgeries 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 four HCPCS modifiers to 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-MP-PY-1367 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT instructions state that modifier 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. DefinitionsCurrent 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 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. Policy I. 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 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment 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 submission, 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. Modifiers X {EPSU} should be used prior to using modifier 59. VI. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that a distinct 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. Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet 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 2. performed at separate patient encounters on the same date of service E. 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 requires3. 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. State-Specific Information NA Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 F. 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 applies to both participating 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.G. Related Policies/Rules Modifier 25 Modifiers H. Review/Revision History DATE ACTION Date Issued 08/17/2022 Date Revised 08/02/2023 07/17/2024 Annual review: updated references. Approved at Committee Review: updated references, approved at Committee Date Effective 10/01/2024 Date Archived 09/30/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. I. References1. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 2024. Accessed July 1, 2024. www.cms.gov 2. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services; 2024. Accessed July 1, 2024. www.cms.gov 3. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicare and Medicaid Services. Updated September 6, 2023. Accessed July 1, 2024. www.cms.gov 4. MLN1783722-Proper Use of Modifiers 59 & – X{EPSU}. US Centers for Medicare & Medicaid Services; 2024. Accessed July 1, 2024. www.cms.gov 5. Transmittal R1422OTN-Publication 100-20-MM8863-Specific Modifiers for Distinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Accessed July 1, 2024. www.cms.gov
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, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, 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 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.REIMBURSEMENT POLICY STATEMENT Marketplace Policy Name & Number Date Effective Modifier 25-MP-PY-1363 10/01/2024-09/30/2025 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. State-Specific Information ………………………………………………………………………………………. 4 F. Conditions of Coverage ………………………………………………………………………………………….. 4 G. Related Policies/Rules ……………………………………………………………………………………………. 4 H. Review/Revision History …………………………………………………………………………………………. 4 I. References …………………………………………………………………………………………………………… 5 Modifier 25-MP-PY-1363 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 25B. Background Reimbursement 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-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. Modifier 25 is used to report an Evaluation and Management (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 (CPT) book defines modifier 25 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 modifier 25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT 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 reported (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 are 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 surgery. 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 through prepayment and post-payment edit or audit. Using a modifier inappropriately 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 CareSources request. CareSource uses published guidelines from Modifier 25-MP-PY-1363 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.C. DefinitionsAmerican 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 issued, 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 submission, 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. VI. Appending modifier 25 to an E/M service is considered inappropriate in the following circumstances: Modifier 25-MP-PY-1363 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 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 other than the qualified professional provider who performed 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 preventative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation.E. State-Specific InformationNA F. Conditions of Coverage Reimbursement 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 applies to both participating 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. G. Related Policies/RulesModifier 59, XE, XP, XS, XU Modifiers policy H. Review/Revision History DATE ACTION Date Issued 07/20/2022 New Policy Modifier 25-MP-PY-1363 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 Date Revised 08/02/202307/17/2024 Annual Review: updated references. Approved at Committee Review: updated references, approved at Committee Date Effective 10/01/2024 Date Archived 09/30/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. I. References1. American Medical Association. Reporting CPT modifier 25. CPT Assistant (Online). 2023;33(11):1-12. Accessed July 8, 2024. www.ama-assn.org 2. Appropriate use of modifier 25. American College of Cardiology. Accessed July 8, 2024. www.acc.org 3. Chaplain S. Are you using Modifier 25 correctly. American Academy of Professional Coders. Published March 25, 2022. Accessed July 8, 2024. www.aapc.com 4. Chapter 1 General Correct Coding Policies for Medicare National Correct Coding Initiative Policy Manual . Centers for Medicare and Medicaid Services; 2024. Accessed July 8, 2024. www.cms.gov 5. Felger TA, Felger M. Understanding when to use modifier-25. Fam Pract Manag. 2004;11(9):21-22. Accessed July 8, 2024. www.aafp.org 6. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services; 2024. Accessed July 8, 2024. www.cms.gov
REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406 07/01/2024 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-standa rd claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, 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 no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards 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. Medica lly 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., Evidenc e 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 (MHP AEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectScreening and Surveillance for Colorectal Cancer B. BackgroundIn the United States, colorectal cancer (CRC) ranks second to lung cancer as a cause of cancer mortality and is the third most commonly occurring cancer in both men and women with approximately 20% higher incidence rates among African Americans. CRC incide nce and mortality rates have declined over previous decades driven by changes in risk factors, early detection of cancer through screening, removal of precancerous polyps with colonoscopy, and advances in surgical/treatment approaches. Appropriate screening reduces colorectal cancer mortality in adults 45 years of age or older. The benefit of the early detection of and intervention for colorectal cancer declineswith age, but it is recommended by both the American College of Gastroenterol ogy and the American Society for Gastrointestinal Endoscopy that screening begin at 45 years of age . Individuals 75 years of age and older are recommended to work with a primary care physician to determine if continued screening is appropriate and/or recom mended. C. Definitions Risk Agents or situations known to increase development of a condition. Per American Cancer Society guidelines : o Low Certain f actors are not present , including a personal or family history of colorectal cancer, certain types of polyps, inflammatory bowel disease (eg, ulcerative colitis, Crohns disease), or radiation to abdomen or pelvic area to treat prior cancer, and/or a confirmed or suspected hereditary colo rectal cancer syndrome (eg, familial adenomatous polyposis (FAP), or Lynch syndrome) . o High or Increased Any of the factors seen above are present. Colorectal Cancer Screening Testing for early-stage colorectal cancer and precancerous lesions in asympto matic members with an average risk . Surveillance for Colorectal Cancer Close observation f or members who are at increased or high risk for colorectal cancer. D. PolicyI. Colorectal Cancer Screening A. Prior authorization is not required for par ticipating providers . B. Benefit coverage is for members at least 45 years of age or less than 45 years of age if a t risk for colorectal cancer . C. Screening for colorectal cancer claims must be submitted with one of the following ICD-10 codes: 1. Z12.10 Encounter for sc reening for malignant neoplasm of intestinal tract, unspecified 2. Z12.11 Encounter for screening for malignant neoplasm of colon 3. Z12.12 Encounter for screening for malignant neoplasm of rectum 4. Z12.13 Encounter for screening for malignant neoplasm of small intestine Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. The following are reimbursed :1. Highly sensitive fecal immunochemical test (FIT) annually 2. Highly sensitive guaiac-based fecal occult blood test (gFOBT) annually 3. Multi-targeted stool DNA test (mt-sDNA) annually 4. Colonoscopy every 10 years 5. CT colonography (virtual colonoscopy) every 5 years 6. Flexible sigmoidoscopy (FSIG) every 5 years E. A follow-up colonoscopy is reimbursed as part of the screening process when a non-colonoscopy test is positive . F. Screening with plasma or serum markers is NOT covered . II. Colonoscopy Surveillance for Colorectal CancerA. Prior authorization is not required for participating providers . B. Surveillance for colorectal cancer claim must be submitted with one of the following ICD-10 codes: 1. Z84.81 Family history of carrier of genetic diseas e 2. Z15.89 Genetic susceptibility to other disease 3. Z83.71 Family history of colonic polyps 4. Z85.038 Personal history of other malignant neoplasm of large intestine 5. Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus 6. Z80.0 Family history of malignant neoplasm of digestive organs 7. Z86.010 Pe rson al history of colonic polyps 8. Z92.3 Personal history of irradiation or radiation therapy 9. K50 through K52 category codes Noninfective enteritis and colitis E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting HCPCS an d CPT codes alo ng with appropriate modifiers. Please refer to the individual CMS fee schedule for appropriate codes. F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 11/ 01/2017Date Revised 04/28/2020 09/17/202001/12/202202/15/2023 05/10 /2023 Added specific ICD-10 to use for screening and surveillance; added ages; added benefit limits; added definitions Removed definitions and codes ; updated ages , PT modifiers, and frequencies Annual review. Annual review . Removed PT modifier information. Appro ved at Committee. Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 09/ 27 /202303/27/2024Updated frequency for stool DNA testing. Approved at Committee.Annual review , references updated. Approved at Committee Date Effective 07/01/2024 Date Archived H. References1. American Cancer Society guideline for colorectal cancer screening. Revised November 17 , 2020 . Accessed February 8, 2024. www.cancer.org 2. Cancer Intervention and Surveillance Modeling Network Colorectal Cancer Working Group. Colorectal Cancer Screening: An U pdated Decision Analysis for the U.S. Preventive Services Task Force . Agency for Healthcare Research and Quality; 2021. AHRQ Publication No 20-05271-EF-2. Accessed February 14, 2024. www.ncbi.nlm.nih.gov 3. Coverage for Colorectal Cancer Screening; Exception for Grandfathered Health Plans , IND . CODE 27-8-14 .8-3 (202 3). 4. Gupta S, Lieberman D, Anderson JC, et al . Recommendations for follow-up after colonoscopy and polypectomy: a consensus update b y the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc . 2020;91(3):463-485.e5. doi :10.1053/j.gastro.2019.10.026 5. Qaseem A, Harrod CS, Crandall CJ, Wilt TJ . Screening for colorectal cancer in asymptomatic average-risk adults: a gui dance statement from the American college of physicians (version 2) . Ann Intern Med . 20 23 ;17 6(8):1017-1144 . doi:10.7326/M23-0779 6. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA . 2021;325(19):1965-1977. doi: 10.1001/jama.2021.6238 7. Wilkins T, McMechan D, Talukder A. Colorectal cancer screening and prevention. Am Fam Physician . 2018;97(10):658-665. Accessed February 12, 2024. www.aafp.org
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, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, 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 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. REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Overpayment Recovery-MP-PY-1393 05/01/2024 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 3 E. State-Specific Information ………………………………………………………………………………………. 5 F. Conditions of Coverage ………………………………………………………………………………………….. 5 G. Related Policies/Rules ……………………………………………………………………………………………. 5 H. Review/Revision History …………………………………………………………………………………………. 5 I. References …………………………………………………………………………………………………………… 5 Overpayment Recovery-MP-PY-1393 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectOverpayment RecoveryB. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Retrospective review of claims paid to providers assist CareSource with ensuring accuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified. Fraud, waste and abuse investigations are an exception to this policy. In these investigations, the look back period may go beyond 2 years. C. Definitions Claims Adjustment Adjustment is defined as a claim that was previously adjudicated and is being updated for one of the following reasons: o denied as a zero payment o a partial payment o a reduced payment o a penalty applied o an additional payment o a supplemental payment Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the member. Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. Explanation of Payment (EOP) The EOP or contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Forwarding Balance (FB) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past Overpayment Recovery-MP-PY-1393 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 claim has been adjusted to a different dollar amount and that funds are owed to CareSource. Improper Payment A payment that should not have been made or an overpayment was made. Examples include, but are not limited to: o payments made for an ineligible member o ineligible service payments o payments made for a service not received o duplicate payments Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 CFR. o A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Provider Level Balancing (PLB) Adjustments to the total check/remit amount occur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment (BPR, which means total payment within the EOP). Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits.D. PolicyI. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider: A. the name and patient account number of the member to whom the service(s) were provided B. the date(s) of services provided C. the amount of overpayment D. the reason for the recoupment E. that the provider has appeal rights II. Overpayment Recoveries A. Lookback period is 24 months from the claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. III. Coordination of Benefit Recoveries A. Lookback period is 12 months from claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal Overpayment Recovery-MP-PY-1393 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Retro Active Eligibility Recoveries A. Lookback period is 24 months from claim paid date. B. Advanced notification will occur 30 days in advance of recovery. V. Management of Claim Credit Balances. A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. This information will be displayed on the EOP in the PLB section. B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $2 difference. b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D. IV. 2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D. IV. b. The reduced payment will trigger a 30-day advanced notification with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. D. Providers are notified of negative balances through EOPs and 835s. Providers are expected to use this information to reconcile and maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances.E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. Providers are expected to maintain their AR to account for the reconciliation of negative balances when they occur. VI. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document.Overpayment Recovery-MP-PY-1393 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 E. State-Specific Information1. Georgia a. Payment, GA. C ODE 33-20A-62 (2022). 2. Indiana a. Claim Payment Errors, I ND . C ODE 27-13-36.2-8 (2022). b. Claim Overpayment Adjustment, IND . C ODE 27-13-36.2-9 (2022). 3. Kentucky a. Resolution of Payment Errors Retroactive Denial of Claims Conditions, K Y. R EV . S TAT . 304.17A-708 (2024). b. Collection of Claim Overpayments Dispute Resolution, K Y. R EV . S TAT . 304.17A-714 (2024). 4. Ohio a. Payments Considered Final Overpayment, O HIO REV . C ODE ANN . 3901.388 (2002). 5. West Virginia a. Civil Penalty Imposed by Commissioner, W. V A. C ODE R. 33-25A-23a (2022). b. Definitions, W. V A. C ODE R. 33-45-1 (2022). c. Minimum Fair Business Standards Contract Provisions Required; Processing and Payment of Health Care Services; Provider Claims; Commissioner's Jurisdiction, W. V A. C ODE R. 33-45-2 (2022). F. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. G. Related Policies/Rules CareSource Marketplace Provider Manual CareSource Provider Agreement, Article V. Claims and Payments H. Review/Revision History DATE ACTIONDate Issued 10/26/2022 New policyDate Revised 02/14/2024 Annual review. Removed IV.C. Updated references. Approved at Committee. Date Effective 05/01/2024 Date Archived I. References1. Limitation on Recoupment (935) for Provider, Physicians and Suppliers Overpayments . Center of Medicare & Medicaid Services; 2008. Reviewed 2020. Accessed January 29, 2024. www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Interest Payments-MP-PY-1391 05/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regardin g 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, Reimbur sement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, 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 ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. State-Specific Information ………………………………………………………………………………………. 3 F. Conditions of Coverage …………………………………………………………………………………………. 3 G. Related Policies/Rules …………………………………………………………………………………………… 3 H. Review/Revision History ………………………………………………………………………………………… 3 I. References ………………………………………………………………………………………………………….. 3Interest Payments-MP-PY-1391 Effective Date: 05/01/2024 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. SubjectInterest Payments 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 providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provi ded. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim has 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 Federal regulation defining timeliness and interest requirements . D. Policy I. CareSource strictly adhere to all regulatory guidelines relating to interest. We follow the guidelines outlined in Prompt Payment regulations. (42 C .F .R . 422.520) II. Payment of interest is made when CareSource fails to pay the claim within the applicable state and federal prompt pay timeframes on clean claims. III. 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 within the allotted timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe. IV. CareSource only pays interest on claim payments that are occurring under prompt pay regulations. A contractual adjustment of a claim is not subject to state and Interest Payments-MP-PY-1391 Effective Date: 05/01/2024 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d. 3federal regulations for interest payment. CareSource performs regular audits to correct claim payment. A. Audits on retroactive eligibility updates, authorization updates, coordination of benefits (COB) updates, and fee schedule updates. B. Audits include proactive measures to correct claim payment when it has been determined that a systemic issue has paid claims incorrectly. C. Claims are not subject to interest payment when CareSource takes proactive measures to pay claims correctly .E. State-Specific Information A. Georgia 1. Definitions; Prompt Pay Requirements; Penalties , G A. CODE ANN . 33-24-59.14 (2023). B. Indiana 1. Payment or Denial of Claims; Interest, I ND . CODE 27-13-36.2-4 (2023). 2. Required Rules, I ND . CODE 12-15-21-3 (2023). C. Kentucky 1. Payment of Interest for Failing to Pay, Denying, or Settling a Clean Claim as Required, K Y. REV . STAT . ANN . 304.17A-730 (2023) . D. Ohio 1. Computation of I nterest, O HIO REV . CODE ANN . 3901.389 (2002). E. West Virginia 1. Minimum Fair Business Standards Contract Provisions Required; Processing and Payment of Health Care Services; Provider Claims; Commissioner's Jurisdiction , W. VA. CODE 33-45-2 (2022).F. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes . G. Related Policies/Rules NA H. Review/Revision Histo ry DATE ACTIONDate Issued 04/12/2023 New Policy.Date Revised 01/31/2024 Updated references. Approved at Committee. Date Effective 05/01/2024 Date Archived I. References1. Interest, 41 U.S.C. 7109 (2022). 2. Interest Penalties, 31 U.S.C. 3902 (2023). Interest Payments-MP-PY-1391 Effective Date: 05/01/2024 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. 43. Interest rates. Bureau of the Fiscal Service. Updated August 15, 2023. Accessed December 21, 2023. www.fiscal.treasury.gov 4. Prompt Payment Interest Rate; Contract Disputes Act , 88 Fed. Reg. 55,501 (Aug. 15, 2023). Accessed December 21, 2023. www. govinfo.gov 5. Prompt Payment of Claims, 42 U.S.C. 1395h(c)(2)(B) (2021). 6. Prompt Payment of Claims, 42 U.S.C. 1395u(c)(2)(B) (2021). 7. Prompt Payment by MA Organization, 42 C .F .R . 422.520 (2022) .
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Temporary Codes-MP-PY-1413 04/01/2024 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 requirement s, 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 no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of fun ction, 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 contr act (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 an y limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Temporary Codes-MP-PY-1413Effective Dat e: 04/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTemporary Codes B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claim s may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staf f are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is beingprovided. The inc lusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Temporary codes exist in both CPT and HCPCS manuals and are updated throughout the year. Tcodes (ie, Category III codes) are temporary CPT codes for em ergingtechnologies, services, and procedures , which support data collection to substantiate widespread use and/or provide documentation for the Food and Drug Administration (FDA) approval process. Many of these codes have not been proven medically necessa ry and are considered to be experimental or investigational based on a lack of peer-reviewed scientific literature. A variety of temporary HCPCS codes exist . Temporary HCPCS codes may be established by the Centers for Medicare and Medicaid Services (CMS) t o report drugs, biologicals, devices, and procedures , to identify services and procedures under FDA review or address miscellaneous services, procedures, and supplies . Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) may develop t emporary HCPCS codes to report supplies and other products for which a national code has not yet been developed. Temporary HCPC S codes may also be developed by commercial payers to report drugs, services, and supplies. Coverage of these services is under t he discretion of local carriers. C. DefinitionsNA D. PolicyI. CareSource con siders temporary codes medically necessary when ALL the following criteria are met: A. Documentation in the medical record supports the use of the code . B. A more specific code is not available to describe the service/procedure . C. The service provided is within the scope of the members benefit plan. II. CareSource will use current industry standard procedure codes (HCPCS CPT I and Category II codes) throughout the processing systems. HIPAA Transaction & CodeTemporary Codes-MP-PY-1413Effective Dat e: 04/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Set Rule requires providers use the procedure code(s) that are valid at the time the service is provided.III. Providers must use industry standard code sets and must use specific HCPCS CPT I and Category II codes when available unless otherwise directed through the providers contract. IV. If specific codes are not available, unlisted codes require plan preauthorization.E. State-Specific Information NA F. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. G. Related Policies/RulesNA H. Review/Revision Histo ryDATE ACTIONDate Issued 02/01/2023 New policyDate Revised 01/17/2024 Annual rev iew: updated references, approved at Committee. Date Effective 04/01/2024 Date Archived I. References1. American Academy of Professional Coders. What is HCPCS? Accessed January 2, 2024. www.aapc.com 2. CPT Professional 2024 . American Medical Association; 2024. 3. HCPCS Codes Temporary Codes for Use with Outpatient Prospective Payment System. Accesse d January 2, 2024. www.hcpcs.codes 4. Understanding the HIPAA standard transactions: The HIPAA Transactions and Code Set rule. American Medical Association. Accessed January 2, 2024. www.assets.ama-assn.org
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, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, 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 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. REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 03/01/2024 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 4 F. Related Policies/Rules ……………………………………………………………………………………………. 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 5 Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Date: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 26 and TC: Professional and Technical ComponentB. 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 providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. According to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), a modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. It may also provide more information about a service such as it was performed more than once, unusual events occurred, or it was performed by more than one physician and/or in more than one location. The Current Procedural Terminology (CPT) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency. CPT codes are also used for administrative management purposes such as claims processing and developing guidelines for medical care review. Some procedure coding, described by a single CPT code, is comprised of two distinct portions: a professional component (26) and a technical component (TC). When the professional component of one such procedure is performed separately, the specific service performed by the physician may be identified by adding CPT modifier 26. In this scenario, the facility provides the technical component of a service/procedure, billing the same procedure code with modifier TC. In this way the components of the service can be separately billed by the provider and facility. C. Definitions Global Procedure/Service-Represents both the professional and technical component as a complete procedure or service, identified by reporting the procedure without modifier 26 or TC. Modifier 26 (Professional Component) – Used to indicate when a physician or other qualified health care professional renders the supervision and interpretation portion of a service or procedure and the preparation of a written report. Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Date: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 Modifier TC (Technical Component) Used to indicate the technical personnel, equipment, supplies, and institutional charges of a service or procedure.D. PolicyI. CareSource expects providers and facilities to adhere to national coding guidelines and standards when utilizing modifiers. II. Modifier 26 A. The professional component is outlined as a physicians service, which may include technician supervision, interpretation of results, and a written and signed report. B. To claim only the professional portion of a service, CPT instructs professionals (or providers) to append modifier 26 to the appropriate CPT code. C. Modifier 26 is also be used to bill for the professional component portion of a test when the provider utilizes equipment owned by a hospital/facility. III. Modifier TC A. The technical component includes the provision of all equipment, supplies, personnel, and costs related to the performance of the procedure. B. The payment for the technical component portion also includes the practice expense and the malpractice expense. C. To claim only the technical portion of a service, append modifier TC Technical component to the appropriate CPT code. D. Fees for the technical component are generally reimbursed to the facility or practice that provides or pays for the supplies, equipment, and/or clinical staff (technicians). E. Hospitals are typically exempt from appending modifier TC because it is assumed that the hospital is billing for the technical component portion of any onsite service. IV. Global procedure/service A. The global procedure is when the same physician or other qualified health care professional performed both the professional component and technical component of that service. This may be the case if an X-ray of a broken bone is taken in the orthopedic surgeons office. B. A global service is identified by reporting the eligible code without modifier 26 or TC. In such cases, the provider is reimbursed for the equipment, supplies, and technical support, as well as the interpretation of the results and the report. C. When reporting a global service, no modifiers are necessary to receive payment for both components of the service. V. Exclusions A. Do not append modifier 26 if there is a dedicated code to describe only the professional/physician component of a given service (eg, 93010 Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Date: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). B. Do not append modifier TC if there is a dedicated code to describe the technical component, for example, 93005 electrocardiogram: tracing only, without interpretation and report. C. CareSource does not allow reimbursement for use of modifier 26 or modifier TC when: 1. It is reported with an Evaluation and Management (E&M) code. 2. There is a separate standalone code that describes the professional component only, technical component only or global test only of a selected diagnostic test. VI. Duplicate billing A. When one provider reports a global procedure and a different provider reports the same procedure with a professional (26) or technical (TC) component modifier for the same patient on the same date of service, the first charge approved by CareSource will be eligible for reimbursement and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. B. When one provider reports a procedure with a professional (26) and a different provider reports a global procedure for the same patient on the same date of service, the first charge approved by CareSource will be eligible for reimbursement and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. C. When one provider reports a procedure with a technical (TC) component modifier and a different provider reports a global procedure for the same patient on the same date of service, the first charge approved by CareSource will be eligible for reimbursement and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. VII. CareSource may request documentation for post-payment review of claims submitted with modifier 26 or modifier TC. If documentation is not provided, CareSource may recoup previously paid claim.E. Conditions of CoverageNA F. Related Policies/Rules Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation G. Review/Revision History DATE ACTIONDate Issued 11/29/2023 New policy. Approved at Committee.Date Revised Date Effective 03/01/2024 Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Date: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 Date ArchivedH.References1. CPT overview and code approval. American Medical Association. Accessed November 6, 2023. www.ama-assn.org 2. Medicare Claims Processing Manual Chapter 23-Fee Schedule Administration and Coding Requirements . Centers for Medicare and Medicaid Services. Revised June 2, 2023. Accessed November 6, 2023. www.cms.gov
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