Payment Policy S ubject: Psychiatric Day Programs P rograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4Me TM Policy CareSource will reimburse participating providers for psychiatric day programs at negotiated per diem rate for the mental health and wellness services provided as part of the day program , as described herein . Definitions None required Provider Reimbursement Guidelines The purpose of this policy is to explain the r eimbursement for providers of psychiatric day facility programs and their component treatments and services as offered to CareSource members . CareSource typically enters into specific negotiated contract s with its providers which establish a defined per diem rate for psychiatric day services. Prior Authorization Prior authorization is required for reimbursement of psychiatric day facility programs. To request prior authorization for these services, please call 1-800-488-0134. During regular business hours, the call will be answered by the CareSource Medical Management Department. If calling after regular business hours, the call will be answered by the CareSource Nurse Triage Line. C overage Psychiatric facility services offered as day (outpatient) programs vary from facility to facility in the scope and content of their services. CareSource considers that all such services a re included in the established per diem rate negotiated with each participating fa cility. However, CareSource will separately reimburse a f acility for the following outpatient hospital and professional services : Speech therapy;Physical therapy;Laboratory ;Radiology ; and,Psychiatrist services.This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Archived These services are not considered to be included in the per diem rate and instead will be reimbursed to the facility in accordance with the fee schedule established at the time of the agreement negotiated and entered into by CareSource and that facility. Related Policies & References OAC Chapter 5160-8- 05, Psychology services provided by licensed psychologists . OAC Chapter 5160-29, Outpatient health facility services. 907 KAR 1:044, Coverage provisions and requirements regarding community mental health center services. State Exceptions NONE Document History This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Archived
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment Policy Subject: Dry Eye Syndrome Testing Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4Me TM Po l i c y Effective February 1, 2014, CareSource will reimburse participating providers for dry eye syndrome testing as set forth in this policy. De f i n i t i o n s Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Dry Eye Syndrome , also known as keratoconjunctivitis sicca, (KCS), keratitis sicca, sicca syndrome, xerophthalmia, or simply, dry eyes, is an eye disease in which tear film evaporation is high or tear production is low, or there is an imbalance in the composition of the patients tears, or eyelid problems, medications, or environmental factors cause a lack of adequate tears, leading the patients eyes to dry out and become inflamed. (from www.mayoclinic.com)Medically necessary services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (from OAC 5160-10-02) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Coverage Microfluidic analysis utilizing an integrated collection and analysis device to measure tear osmolarity (one eye) is a test covered by CareSource, and using the CPT code 83861. The American Academy of Ophthalmology Preferred Practice Pattern guideline for Dry Eye Syndrome specifically recommends tear osmolarity testing for the diagnosis and management of dry eye syndrome. The tear osmolarity test is considered to be a more sensitive method of diagnosing and grading the severity of dry eye compared to corneal and conjunctival staining, tear break-up time, Schirmer test and meibomian gland grading. CareSource acknowledges that this test can only be performed at the point-of-care, as tear fluid is a fragile sample with insufficient volume to allow for collection and transfer to a reference laboratory for analysis, as stated in AMAs CPT Assistant article on the associated CPT code (83861). Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 CareSource will reimburse all participating doctors offices, including optometrists offices,performing a medically necessary tear osmolarity test , provided that the doctors office has been certified as a laboratory under the Clinical Laboratory Improvement Act (CLIA) regulations, and has a CLIA license. Re l a t e d Po l i c ies & Re f e r e n c e s St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y Archived
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 3 Payment PolicySubject: Just4Me – Bilateral Procedures Po l i c yCareSource will reimburse for bilateral procedures when the proper modifiers 50, LT, and RT are used. Modifier 50 is not to be utilized if the CPT code description specifies the procedure as bilateral. De f i ni t i o n s”Bilateral procedures ” are defined as surgical operations performed on both the right and left side of a patient’s body during the same operative session requiring separate sterile fields and a separate surgical incision . (from www.cms.gov) “Modifier ” means a reporting indicator used in conjunction with a CPT code to denote that a medical service or procedure that has been performed has been altered by a specific circumstance while remaining unchanged in its definition o r CPT code. (from 907 KAR 3:010) Pr o v i d er R e i m b u r s e m e n t Gu i d e lin e sModifier 50 Modifier 50 is used to report bilateral procedures (procedures described with the same CPT code) that are performed at the same operative session by the same physician on bilateral body structures (identical anatomic sites on opposite sides of the body). The use of modifier 50 is applicable only to services and/or procedures performed on identical anatomic sites or organs (e.g., eyes, ears, kidneys). Modifiers LT and RT may also used to report services render ed on identical anatomic sites; however the use of these modifiers is not interchangeable with use of modifier 50. Modifiers LT and RT should only be used when the bilateral surgery rules do not apply. The bilateral surgery rules apply to procedures with a bilateral indicator of 1, as defined by the Centers for Medicare & Medicaid (CMS). When the fee schedule has a bilateral indicator of 0 or 3, as defined by CMS, use modifiers LT and RT to describe procedures performed on identical anatomic sites. A bilateral procedure is reported on one line using modifier 50. Use a quantity entry of one when modifier 50 is reported. Do not submit two line items to report a bilateral procedure using modifier 50. Modifier 50 should not be used to report diagnostic and radiology facility services. Institutional claims received for an outpatient radiology service appended with modifier 50 will be denied. This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 3 This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 3 of 3 Bilateral IndicatorDefinition Submission Instructions 0 Bilateral surgery payment rules do not apply, do not use modifier 50. Do not submit these procedures with CPT modifier 50. 1Bilateral surgery payment rules apply (150%). Use modifier 50 if bilateral. Units = 1 Submit the procedure on a single detail line with CPT modifier 50 and a quantity of 1. 2Bilateral surgery payment rules do not apply. Already priced as bilateral. Do not use modifier 50. Units = 1 Submit the procedure with a quantity of 1. Do not submit these procedures with CPT modifier 50. 3Bilateral surgery payment rules do not apply. Do not use modifier 50. Units = 1 or 2. Submit the procedure on a single detail line with CPT modifier 50 and a quantity of 2. 9 Bilateral concept does not apply. Do not submit these procedures with CPT modifier 50. Modifiers LT or RTSurgical codes that are considered bilateral codes but are performed unilaterally on only one side of the body should be billed on one line unmodified or on one line with either the LT or the RT modifier indicating the side of the body on which the procedu re was performed. Modifiers LT or RT are required when appropriate to identify: Hospital procedures performed on identical anatomic sites on the right and left sides of the body (e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries). A procedure is performed on only one side. Hospital diagnostic test and radiology services performed on the right and left sides of the body. Surgical codes that are considered bilateral codes but are performed more than once on one or each side of the body and/or b ody part indicated by the code definition must be billed using only the LT and RT modifiers on each line to demonstrate the procedure was performed more than once on one or each side. Although bilateral indicators 0 and 3 can be billed with the LT and RT modifiers, there are some differences between the two indicators; a. Some codes with an indicator of 0 may be performed more than once on a given day. However, even if performed on opposite sides of the body, these services would never be considered bilateral. b. Codes with an indicator of 0 can never be billed with modifier 50. c. Codes with an indicator of 3 can be billed with 50 or LT/RT. These services are generally radiologic and other diagnostic services. d. Codes that have an indicator of 3 that are billed bilaterally receive reimbursement for each code billed. e. Codes that have an indicator of 0 that are billed using LT/RT receive reimbursement for a single code. This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 4 of 3 The CareSource maximum for bilateral procedures is one hundred fifty per cent of the contracted amount allowed for the same procedures performed unilaterally when the code is billed on a single line with the 50 modifier. NOTE: Use of modifiers applies to services/procedures perfor med on the same calendar day. R e l a t e d Po l i c i es & R e f e r e n c e sOAC Chapter 5160-4-22(E) Physician Services, Surgical Services 907 KAR 3.010 Reimbursement for physicians serv ices D o c u m e nt R ev i s i o n Hi s t o r y
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment PolicySubject: Oxygen Delivery Systems & SuppliesPrograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program,OH M yCare , and OH Just4MeTM Po l i c yEffective January 1, 2014, CareSource provides coverage for the rental of oxygen delivery systems and supplies when a claim meets the criteria outlined in this policy. De f i n i t i o n sCurrent Procedural Terminology ( CPT ) codes are numbers assigned toevery task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org)Healthcare Common Procedure Coding System (HCPCS ) is a set ofhealth care procedure codes based on the American Medical Association’ sCurrent Procedural Terminology (CPT). HCPCS currently includes two leve ls of codes: Level I consists of the American Medical Association ‘s Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prost hetic de vices ,[2] and repre sen t items and suppl ies and no n-physic ian services, not covered by CPT-4 codes (Level I). (from www.wikipedia.org ) Medically necessary services are those health services that are necessary forthe diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (from OAC 5160-10-02) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior AuthorizationCareSource does not require prior authorization for medically necessary oxygen equipment and supplies for its members. ReimbursementCareSource will reimburse providers for the rental of oxygen supply systems and supplies for any member within the following parameters: This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 HCPCSCode Description Limits K0738 Trans fill oxygen system Each : 1 per month per member E1390 Oxygen concentrator, single port E1391 Oxygen concentrator, dual port E1392 Portable oxygen concentrator, rental E0424 Stationary compressed oxygen system, rental E0431 Portable gaseous oxygen system, rental E0434 Portable liquid oxygen system, rental E0439 Stationary liquid oxygen system, rental BillingThe appropriate documentation must be attached to the claim form, or sent separately to CareSource for claims submitted electronically. Re l a t e d Po l i c i e s & Re f e r e n c e sOhio Administrative Code 5160-10-03, Medical supplies and the Medicaid supply list Ohio Administrative Code 5160-10-05, Reimbursement for covered services. Ohio Administrative Code 5160-1-60, Medicaid reimbursement. St a t e Ex c e p t i o n sNONE Do c u m e n t Re v i s i o n Hi s t o r y
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 5 Payment Policy Subject: Just4Me-Family Planning Po l i c y CareSource covers family planning services for members when the services are determined to be necessary for the health and well-being of the member. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for payment will serve as the providers certification of the medical necessity for these services. De f i n i t i o n s Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Family planning services , or Pregnancy prevention/contraceptive management services , are services and supplies provided for the primary purpose of preventing or delaying pregnancy. They include services provided for the prevention of pregnancy, and related supplies. (from OAC 5160-21, Reproductive Health Services.) Infertility is defined as the condition of (i) a presumably healthy woman of childbearing age who has been unable to conceive or (ii) a presumably healthy man who has been unable to produce conception, in either case, after at least one year of trying to do so . (CareSource internal definition) Medically necessary services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (from OAC 5160-10-02) Preconception care means Medicaid-covered preventive medicine services provided prior to a pregnancy for the purpose of achieving optimal outcome of future pregnancies. (from OAC 5160-21, Reproductive Health Services.) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Prior Authorization Members may seek family planning services from any qualified CareSource participating provider without prior authorization. Coverage Family planning services must be furnished under the supervision of a physician or dispensed by a pharmacy for beneficiaries of childbearing age, including minors considered to be sexually active. Family planning services enable beneficiaries to voluntarily choose to prevent initial pregnancy or to limit the number of and spacing of their children. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 5 Covered services include an office visit for a complete exam, pharmaceuticals (including some over the counter [OTC] products), supplies and devices when such services are provided by or under the supervision of a medical doctor, osteopath, or eligible family planning provider. Family planning supplies not furnished by the provider as part of the medical services must be prescribed by a physician and purchased at a pharmacy. Exceptions are condoms and similar supplies which do not require a prescription. Family planning services may include the following. Pregnancy prevention Pregnancy testing Sterilization [Separate CareSource payment policy] Hysterectomies [Separate CareSource payment polic y] Infertility services [not covered] Some of these services can be easily recognized as family planning by the CPT procedure code or drug type code (for example, intrauterine device (IUD) insertion, vasectomy, contraceptive drugs and devices). Other services such as visits, laboratory tests and X-rays are not as readily identifiable as family planning services. Claims Providers are to indicate Family Planning as a diagnosis when billing any of the services listed in this policy that relate to family planning. Providers are to complete the diagnosis code or the appropriate narrative, where applicable. In addition, providers should identify services related to the treatment of complications of family planning. Examples: Surgical procedure such as incision and drainage of pelvic abscess resulting from infection with IUD Office visit and laboratory tests needed because of uterine bleeding while on oral contraceptives Occasionally other services (including hospital, radiology, pharmaceutical, blood and blood derivatives) may be related to family planning or to its complications, and should be properly identified. Non-Comprehensive Family Planning Visits CareSource covers pregnancy prevention/contraceptive management services including evaluation and management (office) visits and consultations for the purpose of: Pregnancy prevention/contraceptive management; Pregnancy examination and testing that includes provision of information about pregnancy prevention; Pregnancy prevention/contraceptive management, including but not limited to fertility awareness and natural family planning .Natural family planning , is the use of fertility awareness-based methods to track ovulation in order to prevent pregnancy. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 3 of 5 Pregnancy determination services when pregnancy testing yields a negative or inconclusive result and provision of information about pregnancy prevention is provided; Medical/surgical services/procedures provided for the purpose of pregnancy prevention/contraceptive management (i.e., injection, fitting, insertion, removal of contraceptive devices); Laboratory tests and procedures provided for the purpose of temporary pregnancy prevention/contraceptive management; Drugs prescribed for the purpose of pregnancy prevention/ contraceptive management; Supplies provided for the purpose of pregnancy prevention/ contraceptive management.Appropriate CPT codes should be used when billing for additional time spent discussing family planning needs with a recipient during routine, non-family planning office visits. Pregnancy prevention/contraceptive management services Providers must include the following information on claims for pregnancy prevention/contraceptive management services: A valid current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) procedure code for each service provided; and An appropriate ICD-9 (before 10/1/2014) or ICD-10 (after 10/1/2014) diagnosis code to indicate an encounter for contraceptive management General contraceptives Condoms are considered medically necessary for men and women in the prevention of pregnancy and to reduce the risk of sexually transmitted disease. Therefore, reimbursement is available for the following codes: Codes Description A4266 diaphragm contraceptive A4267 contraceptive supply condom male A4268 contraceptive supply condom female A4269 contraceptive supply spermicide eg foam gel J7300 Intrauterine copper contraceptive (ParaGard T 380A) J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg (Mirena) IUDs require minimal, yet ongoing , oversight. When members experience active symptoms due to the IUD (e.g., excessive bleeding, cramping, or pelvic inflammatory disease) or need routine IUD surveillance, providers should report E/M codes for those visits as well as the appropriate diagnoses codes for IUD surveillance, current GYN symptoms, or current GYN disease processes. Some physicians also use ultrasound to confirm appropriate placement of an IUD at the time of insertion. When the healthcare provider performs this service, it is not bundled with the insertion codes. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 4 of 5 Evaluation and Management CPT-4 codes, for example 99203 or 99213, may be billed when the member is counseled regarding contraception or is examined to determine the suitability of contraceptive modalities. Implantable Contraceptives: Etonogestrel Etonogestrel, 68 mg contraceptive implant (Implanon, Nexplanon) is billed with code J7307. Implanon must be FDA approved, labeled for use in the United States, and obtained from the single-source distributor. Only providers who have completed a company-sponsored training course and have been assigned a unique Training Identification Number may purchase Implanon. The certificate of training for each provider who inserts the implant must be retained by the provider and is subject to post-audit review. Implanon may be reimbursed when service is performed by on-medical practitioners (NMPs) who have completed the required training. Implanon is not reimbursable to Pharmacy providers. Providers must maintain a written log or electronic record of all Implanon implant systems, including the recipients name, medical record or CareSource number, date of surgery, and lot number of the product, for at least three years from the date of insertion. Records are subject to post-audit reviews. When billing for code J7307 [ Etonogestrel (contraceptive) implant system, including implant and supplies ], providers must attach a copy of the invoice to the claim or document the invoice number and price in the claim. Reimbursement limited to one per recipient, any provider, per 34 months . While the duration of action of Implanon is 36 months, the 34-month limit will permit early removal and insertion of a new implant . Bill in conjunction with the appropriate ICD-9 code (before 10/1/2014) or ICD-10 code (after 10/1/2014). Providers billing code J7307 more than once in 34 months must document the necessity for the repeat implant in the claim. Implantable Contraceptives: Norplant Norplant and related services are reimbursable once per member, per five years. If removal and re-implantation at the same or different incision site is performed prior to five years from the previous implantation, reimbursement is available for the removal only. When a physician inserts an implantable contraceptive, they should use code 11981 [ Insertion, non-biodegradable drug delivery implant ]. Code 11976 [ Removal, implantable contraceptive capsules ] is for use with those members that have the older Norplant capsule systems that need to be removed. For a member who comes to the office to have an implant removed and has a contraceptive rod inserted at the same visit, codes 11976 and 11981 are appropriate; submit the claim as 11976, 11981-51 (Multiple procedures). Note: providers should report the appropriate diagnostic codes for this combination service. When a memberhas a contraceptive rod removed, report 11982 [ Removal of a non-biodegradable drug delivery implant ] or 11983 [Removal with reinsertion of a non-biodegradable drug delivery implant] . [Source: http://www.obgmanagement.com/article_pages.asp?aid=10149 .] ArchivedThis CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 5 of 5 Pregnancy testing CareSource covers pregnancy testing in the physic ians office. Code Description 81025 Pregnancy Test Kits Urine, Qualitative 84703QW Pregnancy Test Urine Instrument Infertility Services (Assisted Reproductive Technology) CareSource does not cover infertility services. Under no circumstances are the following procedures covered: Drugs prescribed in accordance with Chapter 51 60-9 (Pharmacy Services) of the Ohio Administrative Code and/or drugs administered in accordance with Chapter 51 60-4 (Physician Services) of the Ohio Administrative Code; Assisted reproductive technologies (ART); In vitro fertilization; Intrauterine insemination/artificial insemination; and Surgery, including procedures for the reversal of voluntary sterilization. Re l a t e d Po l i c i es & Re f e r e n c e s OAC Rule 5160-21 Preconception Care Services 907 KAR 1:048. Family planning services CareSource Sterilization & Hysterectomy policies Do c u m e n t Hi s t o r y Archived
Payment PolicySubject: Just4Me General Payment Methodology Po l i c y CareSource will pay all Just4Me provider claims based on the general guidelines and decision hierarchies set forth in this policy. De f i n i t i o n sCurrent Procedural Terminology ( CPT ) codes are numbers assigned toevery task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org)RVU , or Relative Value Unit , is a calculator assigned to each CPT codewhich, when multiplied by the conversion factor (CF) and a geographical adjustment (GPCI), creates the compensation level for a particular service. (From www.acro.org/washington) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sWhen paying a Just4Me provider for any claim, CareSource first applies the rate specified fo r the procedure or service as may have been specifically negotiated in that providers contract. However, If the contract doesnt specify terms for reimbursement, then CareSource pays the provider at 100% of the Medicare set cost/price for the specific p rocedure or service. Codes not covered on Medicare Fee Schedules, but which do have RVU values will be reimbursed at the amount calculated by multiplying the RVU (relative value unit assigned to that CPT code) x the conversion factor. Codes not covered on Medicare Fee Schedules and which do not haveRVU values, but which are covered on Medicaid Fee Schedules will be reimbursed at 135% of the Medicaid rate for the specific procedure or service. Unlisted codes will be reimbursed at 35% of billed charges. All other services will be reimbursed at 35% of billed charges. Re l a t e d Po l i c i es & Re f e r e n c e sNONE D o c u m e n t Re v i s i o n Hi s t o r y This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 1
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing.Page 1 of 2 Payment Policy Subject: Just4Me-Preventive Services and Sick Visit on Same Date of Service Po l i c y CareSource will reimburse participating providers as outlined in this policy whena preventive services visit or exam and a sick visit are performed on the same date of service for a CareSource member. De f i n i t i o n s Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org)Preventive Services are exams and screenings to check for health problems,with the intention to prevent any problem discovered from becoming worse.Preventive services may include, but are not limited to, physical checkups,hearing, vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations.Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age, but are especially important for children under the age of 21. (CareSource internal definition) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Preventive medicine exam codes 99381-99385 and 99391-99395 should be billed with the appropriate ICD-9 diagnosis codes (if before 10/1/2014) or ICD-10diagnosis codes (after 10/1/2014). When a provider conducts a preventive medicine service or exam at the time of an acute care visit, Evaluation &Management CPT codes 99201-99204 or 99212-99214 may be submitted alongwith the appropriate ICD-9 or ICD-10 code, indicating the reason for the acute care visit, as a secondary diagnosis.Care Source will reimburse the provider for the preventive medicine CPT code at100% of the allowed amount, and will reimburse the provider for the acute careCPT code at 50% of the allowed amount. Please see the examples provided on the next page of this policy. Archived This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing.Page 2 of 2 Correct Billing Example (this example is pre-10/1/2014, using ICD-9 ) Date of Service Procedure Code Diagnosis Code Billed Amount Allowed Amount 01/15/2014 99392 V20.0 $150.00 $52.97 (100%) 01/15/2014 99213 462 $100.00 $20.19 (50%) Incorrect Billing Example(this example is pre-10/1/2014, using ICD-9 ) Date of Service Procedure Code Diagnosis Code Billed Amount Allowed Amount 01/15/2014 99392 V20.0 $150.00 $52.97 (100%) 01/15/2014 99213 V20.0 $100.00 $0.00 Re l a t e d Po l i c i e s & Re f e r e n c e s Do c u m e n t Re v i s i o n Hi s t o r y Archived
T his Ca r e So ur ce Ma na gem ent Gr o u p Proprietary po lic y is not a g u ar an tee of pa yme nt. Pa ym ent s may be subject to limitations and/or q u ali fic ati on s and wi ll be d et er mi ned wh e n t he c laim is r ec ei ved fo r p ro cess in g. Page 1 of 2 Payment Policy Subject: Just4M e Abortion-Archived 3/31/2021 Po l i c y CareSourc e will c ov er abortions f or eligible CareSourc e m em bers under stric t f ederal guidelines, whic h require that the lif e of the m other would be endanger e d if the f etus were c arried to term , or if the m other was a v ic tim of rape or inc est. Abortions are not c ov ered if used f or f am ily planning purposes.D e f i n i t i o n s 42 C.F.R. 441.201, Title 42-Public Health def ines the standards under whic h abortion proc edures c an be perf orm ed f or f ederally f unded health c are.A therapeutic abortion is the term ination of a pregnanc y where f etal heart ton e s are present at the ti m e of the abortiv e proc edure. The term ination of a pregnanc y m ay be induc ed m edic ally (prostaglandin suppositories, etc .) or surgic ally (dilati o n and c urettage, etc .). This inc ludes the deliv ery of a non-v iable (inc apable of liv in g outside the uterus) but liv e f etus, if labor was augm ented by pitoc in drip, lam inar i a suppository , etc .(f rom nc dhhs .gov ) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Prior Authorization Prior authorization is required f or the adm inistration of an abortion proc edure to v alidate m edic al nec essity per f ederal regulations. The c onsent f orm m ust be subm itted with the request f or authorization.Reimbursement Reim bursem ent is av ailable f or abortions only when the abortion is required to be c ov ered under f ederal law subjec t to lim itations and restric tions set out in 42 CFR Subpart CSec .50.301, 50.302, 50.303, 50.304, 50.306, 42 CFR 441.200 Sec 441.200, 441.201, 441.202, 441. 203, 441.206, 441.207, 441.208, 405 . All appropriate doc um entation m ust be attac hed to the c laim and to c laim s f or direc tly related serv ic es bef ore CareSourc e c an reim burse f or any c laim . CareSourc e will reim burse f or drugs or dev ic es to prev ent im plantation of the f ertilized ov um , and f or m edic al proc edures f or the term ination of an ec topic pregnanc y . The requirem ents stated below do not apply to those abortions that are treatm ents f or incom plete, m issed, or septic abortions. Reim bursem ent f or abortion serv ic es, other than those identif ied abov e, is restric ted to the f ollowing c irc um stanc es when the appropriate c ertif ic ation is m ade: Instanc es in whic h the wom an suf f ers f rom a phy sic al dis order, phy sic a l injury , or phy sic al illness, inc luding a lif e-endangering phy sic al c onditio n c aused by or arising f rom the pregnanc y itself , that would, as c ertif ied by aT his Ca r e So ur ce Ma na gem ent Gr o u p Proprietary po lic y is not a g u ar an tee of pa yme nt. Pa ym ent s may be subject to limitations and/or q u ali fic ati on s and wi ll be d et er mi ned wh e n t he c laim is r ec ei ved fo r p ro cess in g. Page 2 of 2 phy sic ian, plac e the wom an in danger of death unless an abortion is perf orm ed; or Instanc es in whic h the pregnanc y was the result of an ac t of rape and th e patient, the patients legal guardian or the person who m ade the report to the law enf orc em ent agenc y , c ertif ies in writing that a report was f iled, prio r to the perf orm anc e of the abortion, with a law enf orc em ent agenc y hav in g the requisite jurisdic tion, unless the patient was phy sic ally unable to c om ply with the reporting requirem ent and that f ac t is c ertif ied by the phy sic ia n perf orm ing the abortion; orInstanc es in whic h the pregnanc y was the result of an ac t of inc est and the patient, the patients legal guardian or the person who m ade the repor t c ertif ies in writing that a report was f iled, prior to the perf orm anc e of th e abortion, with either a law enf orc em ent agenc y hav ing the requis i t e jurisdic tion, or, in the c ase of a m inor, with a c ounty c hildre n serv ic es , unless the patient was phy sic ally unable to c om ply with the reporti n g requirem ent and that f ac t is c ertif ied by the phy sic ian perf orm ing th e abortion.Certification Bef ore reim bursem ent f or an abortion c an be m ade, the phy sic ian perf orm ing th e abortion m ust c ertif y that one of the three c irc um stanc es outline abov e ha s oc c urred. The c ertif ic ation m ust be m ade on the appropriate state-spec if i c c ertif ic ation f orm . All c ertif ic ations m ust c ontain the nam e and address of th e patient. The c ertif ic ation f orm m ust be properly ex ec uted and subm itted to CareSourc e, inc luding appropriate signatures. Claim s f or pay m ent will be deni e d if the required c onsent is not attac hed or if i nc om plete or inac c urate doc um entati o n is subm itted. Reim bursem ent will not be m ade f or assoc iated serv ic es suc h as anesthes i a , laboratory tests, or hospital serv ic es if the abortion serv ic e itself c annot be reim bursed. Re l a te d Pol ic i es & Re f er e n c e s 42 C.F.R. [Code of Federal Regulations] 441, Subpart Eor Subpart FOAC Chapter 5160-17 Abortions 907 KAR 1:054. Prim ary c are c enter and f ederally-qualif ied health c enter serv ic es KRS [Kentuc k y Rev ised Statutes] 205.010(3), 205.510(5), and 212.275(3) National Coalition (NC) Div ision of Medic al Assis anc e-Medic aid and Healt h Choic e-Clinic al Cov erage Polic y No.: 1E-2 – Therapeutic and Non-therapeu t i c Abortions (Rev ised Date: Marc h 1, 2012)D o c u m e n t Re v i s i o n Hi s t o r yDate Archived 03 /31/202 1 This Po lic y is no lo nger ac tiv e and has been arc hiv ed . Please no te that there c ould be o ther Po lic ies that may hav e s ome of the s ame r ules inc o rp orated and CareSource res erves the rig ht to f o llow CMS/State/NCCI g uidelines without a formal d o c umented Policy .
Payment Policy Subject: Biofeedback Services Po l i c y CareSource will not cover biofeedback services. Re l a t e d Po l i c i es & Re f e r e n c e s OAC Chapter 5160-4-28(G) , Physician Services, Noncovered services. KAR Rule 3:005 Section 4-10(m) Services not covered. St a t e Ex c e p t i o n s KY Do c u m e n t Hi s t o r y 10/31/2013 OAC Rule renumbered from 5101:3-4-28(K), per Legislative Service Commission Guidelines. Thi s CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 1Archived
© Copyright CareSource 2025. All rights reserved.
System Details