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 Venipuncture and Laboratory Testing-MP-PY-1618 09/01/2025-01/31/2026 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 ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 2 F. Related Policies/Rules ……………………………………………………………………………………………. 2 G. Review/Revision History …………………………………………………………………………………………. 3 H. References …………………………………………………………………………………………………………… 3 Venipuncture and Laboratory Testing-MP-PY-1618 Effective Date: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectVenipuncture and Laboratory TestingB. Background N/A C. Definitions Venipuncture The insertion of a needle for a blood sample collection. D. Policy I. Venipuncture is considered an incidental service when billed on a claim containing laboratory testing with the same place of service, for the same member, on the same date. Therefore, venipuncture is included in the reimbursement for the laboratory test performed and is not separately reimbursable. II. The following CPT codes are considered venipuncture: 36400, 36405, 36406, 34610, 36415, 36591, and 36592. III. CareSource may reimburse CPT code 36400, 36405, 36406, and 36410 when billed with Modifier 59 and/or 22, and appropriate documentation and the medical record reflect a distinct service requiring the skill of a qualified health care professional. IV. CareSource may conduct a post-payment review on claims with venipuncture and no other laboratory testing to ensure compliance. E. Conditions of Coverage Reimbursement policies are designed to assist providers when submitting claims to CareSource and 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. Health care providers and office staff are encouraged to use self-service channels to verify a members eligibility. Reimbursement is dependent upon, 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. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource policies apply to both participating and nonparticipating providers and facilities. F. Related Policies/Rules Modifier 59 Venipuncture and Laboratory Testing-MP-PY-1618 Effective Date: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 Overpayment RecoveryG. Review/Revision HistoryDATE ACTIONDate Issued 05/21/2025 Approved at Committee.Date Revised Date Effective 09/01/2025 Date Archived 01/31/2026 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. ReferencesN/A
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 Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 06/01/2025-01/31/202 6 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 ………………………………………………………………………………………. 6 F. Conditions of Coverage ………………………………………………………………………………………….. 6 G. Related Policies/Rules …………………………………………………………………………………………… 6 H. Review/Revision History …………………………………………………………………………………………. 6 I. References ………………………………………………………………………………………………………….. 6 Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectNeonatal Intensive Care Unit (NICU) Level of CareB. Background This policy aligns with guidance from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) regarding NICU levels of care. This policy provides guidelines for determining the medically appropriate level of care for reimbursement based on available documentation. NICU admissions are reviewed to ensure that services are of an appropriate duration and level of care to promote optimal health outcomes in the most efficient manner. Clinical documentation of an ongoing NICU hospitalization will be reviewed concurrently to substantiate level of care with continued authorization based on the documentation submitted. Reimbursement for the NICU stay will be based on the authorized level of care and determined by the concurrent review process. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have defined and specified the capabilities for each of 4 facility levels of care (ie, a specific unit located in the hospital). These facilities range from a Level I Newborn Observation Unit to a Level IV Regional Neonatal Intensive Care Unit. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification. The Neonatal Intensive Care Unit (NICU) is a critical care area in a facility for newborn babies who need specialized care. The NICU designation requires a combination of advanced technology and a NICU team of licensed professionals. NICU levels of care are based on the complexity of care that a newborn with specified diagnoses and symptoms requires. All four levels of care are represented by a unique revenue code. Any inpatient revenue codes not billed as levels 2-4 will be recognized as a level 1. Level 1=0171 Level 2=0172 Level 3=0173 Level 4=0174 While most infants admitted to the NICU are premature, others are born at term but suffer from medical conditions, such as infections or birth defects. A newborn also could be admitted to the NICU for associated maternal risk factors or complicated deliveries. Although the list of criteria used to determine the NICU levels of care in this policy is not all inclusive, it does provide an overview of the guidelines that are used. C. Definitions Intensity of Care (IOC) The complexity of care that a newborn with specified diagnoses and symptoms requires. Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 Newborn Care Services Services performed from birth to 4 weeks. Neonatal Intensive Care Services (NICU) Critical care services for a newborn. Well Baby Care Services A basic level of care to neonates who are low risk.D. PolicyI. Per federal mandate, newborn members are covered at an inpatient facility for a 2-day stay for vaginal deliveries and a 4-day stay for cesarean sections. These stays will be covered without clinical review (notification may be required) if they are submitted with a normal newborn DRG. II. For any newborn diagnoses/revenue codes/procedures that may be associated with care/treatment outside of routine newborn care (any revenue code 0172, 0173, 0174), authorization is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to provide documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. When a newborn requires a NICU admission or a higher IOC service, an authorization is required. IV. If a complication develops with the mother or baby that necessitates additional hospital days, NICU admission, or non-well-baby service, an authorization should be submitted along with clinical information to support the stay. V. If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to newborn nursery or pediatric level of care, NICU intensity of care will not be assigned regardless of interventions completed during transitional time. VI. Clinical review will determine appropriate IOC utilizing MCG standards. CareSource will adjust IOC reimbursement if clinical documentation does not support the IOC billed. VII. Inpatient admissions may be reviewed to ensure that all services are of an appropriate duration and intensity of care to promote optimal health outcomes. Clinical documentation of an ongoing neonatal hospitalization will be reviewed concurrently to substantiate the level of care and length of stay. A continued authorization will be based on the documentation submitted and alignment with MCG Neonatal Facility Levels of Care and Neonatal Intensity of Care Criteria, as well as CareSource policy. VIII. In order to avoid reimbursement delay or adjustments, providers are encouraged to reference MCG guidelines as well as the clarifications and specific details below. Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 NICULevel Revenue Code Description MCG NICU Intensity of Care Level 1 0171: Newborn Level I Intensity of Care Criteria 1 Routine Care (LOC-010) Neonatal care may be indicated for the physiologically stable infant (eg, no apnea, bradycardia, or unstable temperature) requiring care consisting of 1 or more of the following: Routine newborn care Evaluation and care of neonates with conditions that require inpatient services available at Level I Continued inpatient care during convalescence from condition(s) treated in Level II, Ill or IV while awaiting resolution of specific issues (eg, sustained weight gain, poor PO feeding), or establishment of safe discharge destination and plan Uncomplicated jaundice treated only with phototherapy and requiring infrequent bilirubin checks Absence of parenteral medications Evaluation and management of glucose levels without IV fluids, diagnostic work – up/surveillance, on an otherwise stable neonate where no therapy is initiated Level 2 0172: Newborn Level II Intensity of Care Criteria 2 Continuing Care (LOC – 011) Neonatal care may be indicated for 1 or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen, ( 2L/min), with other co-morbidities stable Administration of intravenous (IV) medications IV Therapy; peripheral or PICC o IV fluids inclusive of hyperalimentation ( 2 L/min of blended oxygen, continuous positive airway pressure (CPAP), NIPPV o conventional ventilation (via endotracheal tube, nasotracheal tube or tracheostomy tube) o high-frequency ventilation long-term (> one week) Presence of chest tubes Umbilical arterial catheter (UAC) for blood draws Active apnea/bradycardic episodes requiring PPV Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia requiring > 5 mg/kg/min or hypoglycemia not responsive to 1 IV dextrose bolus (200 mg/kg or 2 ml/kg of D10W) Total parenteral nutrition or IV fluids to supplement inadequate oral intake (NG or PO) > 50% total nutrition NAS requiring initiation/escalation of medication or inability to wean Hyperbilirubinemia with evidence of hemolysis requiring IVIG or blood transfusion Acute encephalopathy that is moderate to severe and under active investigation or has been investigated and does not meet criteria for therapeutic hypothermia Surgical conditions requiring general anesthesia up to 2 days post-op, if indicated Surgical/Therapies for retinopathy of prematurity (ROP) Seizure activity requiring initiation, supplementation or changing of seizure medications Transfusion of blood products in absence of severe acute etiology or manifestations (eg, transfusion needed for anemia of prematurity, iatrogenic anemia) Hypotension requiring IV fluid bolus Level 4 0174: Newborn Level IV Intensity of Care Criteria 4 Intensive Care (LOC-013) Includes Level 3 requirements and 1 or more of the following clinical interventions: Perioperative care following surgical repair of severe neonatal conditions, for example: o bowel resection for necrotizing enterocolitis (NEC) o tracheoesophageal fistula or esophageal atresia repair o cardiac surgery excluding PDA ligation o myelomeningocele closure (up to 48 hours post-op) o organ transplant Medically necessary inhaled nitric oxide (iNO) Extracorporeal membrane oxygenation (ECMO) High frequency oscillatory or jet ventilation (initial week) Therapeutic cooling Exchange transfusion (day of procedure) Uncontrolled active seizures despite medications Ongoing cardiovascular support (inotropes, chronotropes, antiarrhythmics) Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 6 E. State-Specific InformationNA F. Conditions of Coverage I. Reimbursement is independent of the location of care and corresponds to the medical treatment provided and level of service the neonate requires. To ensure accurate reimbursement, submitted claims will be reviewed to align with authorized levels of care and/or clinically validate diagnoses, procedures, and other claim information that impact payment. Based on review, the following may occur: Down-code revenue codes to authorized levels of care. Issue a base DRG payment. Adjust claim diagnoses/procedures that are not substantiated in the medical information provided and apply DRG regrouping. Request for complete medical records and/or itemized statements to support the services on the claim may be made. II. 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. G. Related Policies/Rules NA H. Review/Revision History DATE ACTIONDate Issued 09/27/2023 New policy. Approved at Committee.Date Revised 03/12/2025 Annual review, References updated. Approved at Committee. Date Effective 06/01/2025 Date Archived 01/31/202 6 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. About preterm labor and birth. National Institutes of Health. Reviewed May 9, 2023. Severe hemodynamic instability requiring ongoing intravenous fluid/medication support o dialysis o IV sedation that includes paralysis o prostaglandin infusion CPR in the last 24 hours (not inclusive of delivery room resuscitation) Transfusion of blood products in setting of severe acute etiology or manifestation (eg, hemolytic anemia, disseminated intravascular coagulation, hemorrhage) Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 7 Accessed January 30, 2025. www.nichd.nih.gov 2. Admission to NICU. Specification Manual for Joint Commission National Quality Measures . The Joint Commission; 2024. Version 2024B1. Accessed September 1, 2023. www.manual.jointcommission.org 3. Intensity of Care Criteria 1-Routine Care: LOC-010 (ISC GRG). MCG Health. 28th ed. Accessed January 30, 2025. www.careweb.careguidelines.com 4. Intensity of Care Criteria 2-Continuing Care: LOC-011 (ISC GRG). MCG Health. 28th ed. Accessed January 30, 2025. www.careweb.careguidelines.com 5. Intensity of Care Criteria 3-Intermediate Care: LOC-012 (ISC GRG). MCG Health. 28th ed. Accessed January 30, 2025. www.careweb.careguidelines.com 6. Intensity of Care Criteria 4-Intensive Care: LOC-013 (ISC GRG). MCG Health. 27th ed. Accessed January 30, 2025. www.careweb.careguidelines.com 7. Stark AR, Pursley DM, Papile L, et al. Standards for levels of neonatal care: II, III, and IV. Pediatr . 2023;151(6):e2023061957. doi:10.1542/peds.2023-061957
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Interest Payments-MP-PY-1391 04/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to 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: 04/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d. 2A. 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 staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim 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. CareSource follows 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 all otted 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: 04/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d. 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 History DATE ACTIONDate Issued 04/12/2023 New Policy.Date Revised 01/31/2024 01/15/2025 Updated references. Approved at Committee. Updated references. Approved at Committee. Date Effective 04/01/2025 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: 04/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d. 43. Interest rates. Bureau of the Fiscal Service. Updated August 15, 2023. Accessed December 21, 2024. www.fiscal.treasury.gov 4. Prompt Payment Interest Rate; Contract Disputes Act , 88 Fed. Reg. 55,501 (2023). Accessed December 21, 2024 . www. govinfo.gov 5. Prompt Payment of Claims, 42 U.S.C. 1395h(c)(2)(B) (2023 ). 6. Prompt Payment of Claims, 42 U.S.C. 1395u(c)(2)(B) (2023 ). 7. Prompt Payment by MA Organization, 42 C .F .R . 422.520 (2024 ).
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387 04/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. …. 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 I. References ………………………….. ………………………….. ………………………….. …………………….. 4 Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTranscutaneous Electrical Nerve Stimulation (TENS) B. BackgroundTranscutaneous electrical nerve stimulat ors (TENS) are device s that produce mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the skin. C. Definitions Accessories Reusable items used with a TENS machine, which includes, but is not necessarily limited to, adapters, clips, additional connecting cable for lead wires, carrying pouches, and covers. Supplies Typically disposable items used with a TENS machine, which includes, but is not necessarily limited to , electrodes of any type, lead wires, conductive paste or gel, adhesive, adhesive remover, skin preparation materials, batteries, and battery charger for rechargeable batteries. Transcutaneous Electrical Nerve Stimulation (TENS) The application of mild electrical stimulation to skin electrodes placed over an area of the body experiencing pain, which causes interference with the transmission of pain. TENS requires a stimulator, a type of durable medical equipment (DME). D. PolicyI. TENS units may require medical necessity review. II. CareSource reimburses for TENS units and supplies based on the Centers for Medicare & Medicaid Services (CMS) guidelines.III. TENS units are reimbursed on a 13-month rent to purchase basis, after a successful1-month, non-reimbursable trial period. IV. DocumentationA. The provider of the TENS unit must complete the Certificate of Medical Necessity-Transcutaneous Electrical Nerve Stimulator (TENS) Form , CMS-848. B. For post-operative pain, an attestation must be available for review upon CareSources request, confirming that treatment lasting no longer than 30 days is needed for acute pain following surgery and includes the date of surgery. C. An attestation that the use of a comparable TENS unit for a trial period of at least 30 days produced substantial relief from pain must be completed and available for review upon CareSources request. D. Regarding a TENS unit that was not originally reimbursed by CareSource, documentation to confirm medical necessity must be available for review upon CareSources request before reimbursement is made for supplies or repair. E. The provider must also provide the member with verbal instruction on the use of the TENS unit. Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 F. The provider must maintain written documentation regarding the members instruction on the use of the TENS unit in the members medical record.V. Rental of a TENS unit to treat post-operative pain is limited to a single 30-day period and may not be extended. Modifier RR should be used in this case. VI. Reimbursement for the purchase of a TENS unit may be made if the prescribing provider attests to the medical necessity of continued use of the TENS units (after the successful 1-month, non-reimbursable trial period).VII. SuppliesA. Supplies are not reimbursable during the trial period.B. Supplies are not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase, CareSource covers only 1 unit of supplies (A4595) per month for a 2-lead TENS unit (E0720) or 2 units per month for a 4-lead TENS unit (E0730). D. After a TENS unit has been purchased for an individual, regardless of payment source: 1. Separate payment may be made for necessary supplies, which must be dispensed only when they are needed at a frequency not to exceed once per month. 2. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 3. No separate payment is allowed for individual supply items. E. If a submitted claim does not include a modifier or includes an incorrect or inappropriate modifier, the claim may deny. E. State-Specific InformationNA 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. The following list(s) of codes are provided as a reference. This list may not be all inclusive and is subject to updates.HCPCS CodeDescription E0720 TENS unit, 2-lead, localized stimulation (includes supplies during rental ) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation ( includes supplies during rental ) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead ( for a recipient-owned unit ) Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Modifiers DescriptionRR Rental (use the ‘RR’ modifier when DME is to be rented) NU Purchase of new equipment G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 10/26/2022Date Revised 12/13/2023 12/18 /2024Annual review: updated code list and references. Approved at Committee.Review: updated references, approved at Committee. Date Effective 04/01/2025 Date Archived I. References1. Gibson W, Wand BM, Meads C, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic pain an overview of Cochrane reviews. Cochrane Database Syst Rev . 2019;4:CD011890. doi:10.1002/14651858.CD011890.pub3 2. Johnson MI, Paley CA, Wittkopf PG, et al. Characterising the features of 381 clinical studies evaluating transcutaneous electrical nerve stimulation (TENS) for pain relief: a secondary analysis of the meta-TENS study to improve future research. Medicina (Kaunas) . 2022;58(6):803. doi:10.3390/medicina58060803 3. Local Coverage Article: Transcutaneous Electrical Nerve Stimulators (TENS). Medicare Coverage Database. A52520. Revised January 1, 2023. Accessed December 18 , 2024 . www.cms.gov 4. Local Coverage Determination: Transcutaneous Electrical Nerve Stimulators (TENS). Medicare Coverage Database. L33802. Revised January 1, 2024 . Accessed December 18 , 2024 . www.cms.gov 5. Vance CGT, Dailey DL, Chimenti RL, et al. Using TENS for pain control: update on the state of the evidence. Medicina. 2022;58(10):1332. doi:10.3390/medicina58101332
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 04/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents Table of Contents ……………………………………………………………………………………………………….. 1 A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 Effective Date: 04/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d. 2A. SubjectLeft Ventricular Assist Device (LVAD) Supplies B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant ee claims payment. A left ventricular assist device ( LVAD) is a surgically implanted battery-operated, mechanical pump, which helps the left ventricle (main pumping chamber of the heart) pump blood to the rest of the body. It is a treatment for a weakened heart or end stage heart failure. LVADs can be used as: Bridge-to-transplant therapy: A life-saving therapy for patients awaiting a heart transplant. Patients use the LVAD until a heart becomes available. In some cases, the LVAD is able to restore the failing heart, eliminating the need for a transplant. Destination therapy: Some patients are not candidates for heart transplants. In this case, patients can receive long-term treatment using an LVAD, which can prolong and improve patients’ lives. C. Definitions Heart Failure A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently causing symptoms to occur throughout the body. Left-sided heart failure occurs when the heart loses its ability to pump blood preventing organs from receiving enough oxygen. The condition can lead to complications that include right-sided heart failure and organ damage. Ventricular Assist Device (VAD) A surgically attached device to one or both intact ventricles used to assist or augment the ability of a damaged or weakened native heart to pump blood. Improvement in the performance of the native heart may allow the device to be removed. D. Policy I. Dressings and supplies A. CareSource considers reimbursement for LVAD dressings a covered service when all the following criteria are met: 1. The initial dressings supplied under the bundled in-patient benefit at the facility where the LVAD was implanted are expended. Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 Effective Date: 04/01/2025 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d. 32. Dressings necessary for the effective use of a LVAD must be billed using the appropriate supply code . B. LVAD dressings are a disposable supply and , therefore , a purchase-only item . C. Supplies billed with miscellaneous code E1399 will be denied if a more appropriate code is available. II. The following codes are not all inclusive but provide a general reference of unlisted/miscellaneous codes that are generally used incorrectly.Code Description E1399 Durable medical equipment, miscellaneous Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device III. Batteries A. Batteries for LVADs should be billed using the following codes: 1. Q0503: Battery for pneumatic ventricular assist device, replacement only, each. 2. Q0506: Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only B. Batteries billed with miscellaneous code E1399 will be denied. C. A rechargeable battery may be approved with a spare for uninterrupted use. IV. Warranty CareSource may request warranty information regarding the DME item or supply. If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the prior authorization. V. Prior authorization submitted with unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration during review: A. a complete description of the item (including, as applicable, the manufacturer, model or style, and size), a list of all bundled components, and an itemization of all charges B. any other information requested by CareSource VI. Non-covered services A. monitoring of LVADs B. multiple battery packs beyond the pair required for continuous useE. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Codes in this policy reflect Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 Effective Date: 04/01/2025 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d. 4those found in CMS Transmittal 10837 for National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs). A. All unlisted or miscellaneous codes defined within this policy are subject to medical necessity review and prior authorization. B. Prior authorization is not a guarantee of payment. C. Claims must include an invoice. D. CareSource may verify the use of any code through post-payment audit. E. If a more appropriate code is discovered, CareSource may request recoupment.F. Related Policies/Rules Unlisted and Miscellaneous Codes G. Review/Revision History DATE ACTIONDate Issued 12/13/2023 New Policy, approved at Committee.Date Revised 12/18/2024 Added Unlisted and Miscellaneous Codes to section F. Updated references. Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. Artificial Hearts and Related Devices, Including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy. Medicare Coverage Database; 2020. Decision Memo CAG-00453N . Centers for Medicare & Medicaid Services. Accessed November 11, 2024. www.cms.gov 2. Heart failure. National Heart, Blood and Lung Institute. Accessed November 11, 2024. www.nhlbi.nih.gov 3. Left ventricular assist devices (LVADs) . Cleveland Clinic. Accessed November 11, 2024. www.my.clevelandclinic.org 4. NCD-Ventricular Assist Devices (VADs) (20.9.1). Centers for Medicare & Medicaid Services. Accessed November 11, 2024. www.cms.gov
REIMBURSEMENT POLICY 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 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 Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 01/01/2025-12/31/2025 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. State-Specific Information ………………………………………………………………………………………. 4 F. Conditions of Coverage ………………………………………………………………………………………….. 4 G. Related Policies/Rules ……………………………………………………………………………………………. 4 H. Review/Revision History …………………………………………………………………………………………. 4 I. References …………………………………………………………………………………………………………… 5 Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 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. SubjectPre-Exposure Prophylaxis (PrEP) Preventive ServicesB. Background An estimated 1.2 million individuals in the United States are human immunodeficiency virus positive (HIV+), with an estimated 30,635 new infections in 2020. Though treatable, HIV infection is incurable and associated with significant health complications. Effective strategies to prevent HIV infection remain a key public health priority. To prevent the spread of HIV, the Centers for Disease Control and Prevention (CDC) recommends the use of antiretroviral pre-exposure prophylaxis (PrEP) in sexually active individuals who are at high risk of HIV exposure as well as individuals who use drugs intravenously. Studies have shown that PrEP significantly reduces the transmission of HIV to persons who are currently HIV -. The Federal Patient Protection and Preventive Care Act of 2010 requires insurance plans cover preventive medicine services with a recommendation of A or Bby the U.S. Preventive Services Task Force (USPSTF). The USPSTF assigns one of five letter grades (A, B, C, D, or I) which describes the strength of a recommendation and communicates its importance to providers. Grade A The USPSTF recommends the service; there is high certainty that the net benefit is substantial. Grade BThe USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Grade CThe USPSTF recommends selectively offering or providing the service to individual patients based on professional judgement and patient preferences. There is at least moderate certainty that the net benefit is small. Grade DThe USPSTF recommends against the service; there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Grade I The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of the service. The USPSTF recommends clinicians prescribe PrEP with effective antiretroviral therapy to individuals who are at increased risk of HIV acquisition to decrease the risk of acquiring HIV infection (Grade A). To achieve the benefit of PrEP, it is important for individuals to receive counseling about antiretroviral medication adherence, safer sex practices, and regular testing for HIV and other related infections. Prior to receiving a prescription for PrEP, individuals may require counseling and laboratory testing to evaluate the need for PrEP as well as establish a baseline health status. As PrEP is only effective with medication adherence, follow-up appointments with or without laboratory testing are often necessary. As of October 1, 2023, ICD-10 code Z29.81 (encounter for HIV pre-exposure prophylaxis) is available for providers to use on medical claims. Insurance plans are not required to provide coverage for these preventive services when delivered by out-of-network providers. Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 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 Pre-Exposure Prophyaxis (PrEP) Antiretroviral medication that helps prevent individuals from acquiring HIV. USPSTF An independent, volunteer panel of national experts that makes evidence-based recommendations about clinical preventive services.D. Policy I. CareSource will provide PrEP and related services to members who qualify as high risk, following USPSTF guidelines for the prevention of HIV. These services are classified as preventive with no cost share. Please refer to the most recently published USPSTF guideline for clarification of high risk and current coverage recommendations. II. CareSource covers the following without cost-sharing when associated with PreP: A. FDA-approved PrEP antiretroviral medications B. baseline and monitoring services, including 1. HIV testing 2. hepatitis Band Ctesting 3. creatinine testing and calculated estimated creatine clearance (eCrCI) or glomerular filtration rate (eGFR) 4. pregnancy testing (as appropriate) 5. sexually transmitted infection (STI) screening and counseling 6. adherence counseling C. office visits associated with PrEP III. The following code set has been provided for informational purposes only. These codes may be used to identify a service as part of PrEP preventive services. In order for a service in Section II to be identified as part of PrEP preventive services and cost sharing to be waived, providers need to follow the below coding steps: A. Use ICD-10 code Z29.81 on the claim, or B. Use ICD-10 code Z20.6 or Z11.4, and at least one of the other below codes on the claim. ICD-10CodeCode Description Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z11.4 Encounter for screening for human immunodeficiency virus [HIV] Z11.59 Encounter for screening for other viral diseases Z11.8 Encounter for screening for other infectious and parasitic diseases Z11.9 Encounter for screening for infectious and parasitic diseases, unspecified Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV] Z20.828 Contact with and (suspected) exposure to other viral communicable diseases Z20.89 Contact with and (suspected) exposure to other communicable diseases Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 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 Z20.9 Contact with and (suspected) exposure to unspecified communicable diseaseZ29.89 Encounter for other specified prophylactic measuresZ32.00 Encounter for pregnancy test, result unknown Z32.01 Encounter for pregnancy test, result positive Z32.02 Encounter for pregnancy test, result negative Z51.81 Encounter for therapeutic drug level monitoring Z70.0 Counseling related to sexual attitude Z70.1 Counseling related to patients sexual behavior and orientation Z70.3 Counseling related to combined concerns regarding sexual attitude, behavior and orientation Z71.7 Human immunodeficiency virus [HIV] counseling Z72.51 High risk heterosexual behavior Z72.52 High risk homosexual behavior Z72.53 High risk bisexual behavior Z72.89 Other problems related to lifestyle Z77.21 Contact with and (suspected) exposure to potentially hazardous body fluids Z77.9 Other contact with and (suspected) exposures hazardous to health Z79.899 Other long term (current) drug therapy W46.0XXA Contact with hypodermic needle, initial encounter W46.0XXD Contact with hypodermic needle, subsequent encounter W46.1XXA Contact with contaminated hypodermic needle, initial encounter W46.1XXD Contact with contaminated hypodermic needle, subsequent encounter IV. Exclusions Claims received from the emergency department would not generally qualify as PrEP preventive services.E. State-Specific InformationNA F. Conditions of Coverage NA G. Related Policies/Rules NA H. Review/Revision History DATE ACTION Date Issued 09/27/2023 New Policy. Approved at Committee. Date Revised 10/09/2024 Review: updated references. Approved at Committee. Date Effective 01/01/2025 Date Archived 12/31/2025 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. Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 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. 5 I. References1. Assistant Secretary for Public Affairs. About the Affordable Care Act. United States Dept of Health and Human Services. Reviewed March 17, 2022. Accessed September 11, 2024. www.hhs.gov 2. Billing Coding Guide for HIV Prevention. National Alliance of State & Territorial AIDS Directors; 2016. Accessed September 11, 2024. www.nastad.org 3. Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas, 2021. Accessed September 11, 2024. www.cdc.gov 4. Centers for Medicare and Medicaid Services. FAQs about Affordable Care Act implementation part 54. July 28, 2022. Accessed September 11, 2024. www.cms.gov 5. Coverage of Preventive Health Services, 29 C.F.R. 2590.715-2713 (2023). 6. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention. About HIV. Centers for Disease Control and Prevention. Reviewed January 24, 2024. Accessed September 11, 2024. www.cdc.gov 7. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention. About PrEP. Centers for Disease Control and Prevention. Reviewed May 6, 2024. Accessed September 11, 2024. www.cdc.gov 8. Krakower D, Mayer KH. HIV pre-exposure prophylaxis. UpToDate. Updated October 12, 2023. Accessed September 11, 2024. www.uptodate.com 9. Mayer KH, Molina JM, Thompson MA, et al. Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER): primary results from a randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial. Lancet . 2020;396(10246):239-254. doi:10.1016/S0140-6736(20)31065-5 10. Patient Protection and Affordable Care Act, 42 U.S.C. 18001-18122 (2024). 11. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2021 Update: Clinical Providers Supplement. Centers for Disease Control and Prevention; 2021. Accessed September 11, 2024. www.cdc.gov 12. Pre-Exposure Prophylaxis for the Prevention of HIV Infection: A Systematic Review for the U.S. Preventive Services Task Force. December 2022. Accessed September 11, 2024. www.uspreventiveservicestaskforce.org 13. Task force at a glance. United States Preventive Services Task Force. Accessed September 11, 2024. www.uspreventiveservicestaskforce.org 14. U.S. Preventive Services Task Force. Preexposure prophylaxis to prevent acquisition of HIV: US Preventive Services Task Force recommendation statement. JAMA. 2023;330(8):736-745. doi:10.1001/jama.2023.14461 15. U.S. Preventive Services Task Force. Grade Definitions. June 2018. Accessed September 11, 2024. www.uspreventiveservicestaskforce.org 16. US Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2021 Update: A Clinical Practice Guideline. US Centers for Disease Control and Prevention; 2021. Accessed September 11, 2024. www.cdc.gov 17. What does FDA regulate? United States Food and Drug Administration. Reviewed March 29, 2024. Accessed September 11, 2024. www.fda.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective 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
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