REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Temporary Codes-MP-PY-1413 GA, IN, KY, WV : 05/01/2023 OH: 06/01/2023 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 t he 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 Addi ction 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. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 Temporary Codes-MP-PY-1413Effective Dat e: 05/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectTemporary Codes B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarant ee 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 member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or s ervice that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Temporary codes exist in both CPT and HCPCS manuals and are updated throughout the year. Tcodes (i.e., Category I II codes) are temporary CPT codes for emergingtechnologies, services, and procedures , which support data collection to substantiate widespread use and/or provide documentation for the Food and Drug Administration (FDA) approval process. Many of these code s have not been proven medically necessary and are considered to be experimental or investigational based on a lack of peer-reviewed scientific literature. A variety of temporary HCPCS codes exist . Temporary HCPCS codes may be established by the Centers fo r Medicare and Medicaid Services (CMS) to report drugs, biologicals, devices, and procedures , to identify services and procedures under FDA review or address miscellaneous services, procedures, and supplies . Durable Medical Equipment (DME) Medicare Adminis trative Contractors (MACs) may develop temporary HCPCS codes to report supplies and other products for which a national code has not yet been developed. Temporary HCPC S codes may also be developed by commercial payers to report drugs, services, and supplies. Coverage of these services is under the discretion of local carriers. C. DefinitionsNA D. PolicyI. CareSource con siders temporary codes medically necessary when ALL the following criteria are met: A. Documentation in the medical record supports the use of the code; B. A more specific code is not available to describe the service/procedure; and C. The service provided is within the scope of the members benefit plan. II. CareSource will use current industry standard procedure codes (HCPCS CPT I and Category II codes) throughout the processing systems. HIPAA Transaction & CodeTemporary Codes-MP-PY-1413Effective Dat e: 05/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.Set Rule requires providers use the procedure code(s) tha t are valid at the time the service is provided. III. Providers must use industry standard code sets and must use specific HCPCS CPT I and Category II codes when available unless otherwise directed through the providers contract. IV. If specific codes are not available, unlisted codes require plan preauthorization.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/01/2023 New policyDate Revised Date Effective GA, IN, KY, WV: 05/01/2023 OH: 06/01/2023 Date ArchivedH. References1. 2022 HCPCS Codes Level II. (nd). Temporary Codes for Use with Outpatient Prospective Payment System. Retrieved December 20, 2022 from www.hcpcs.codes . 2. American Academy of Professional Coders (AAPC). (2022). What is HCPCS? Retrieved December 20, 2022 from www.aapc.com . 3. American Medical Association (AMA). (2009). Practice Management Center: Understanding the HIPAA Standard Transactions: The HIPAA Transacti ons and Code Set Rule. Retrieved December 20, 2022 from www.assets.ama-assn.org. 4. Current Procedural Terminology (CPT). 2023 Professional Edition, American Medical Association: Chicago, IL. I. State-Specific InformationA. Georgia 1. Effective: 05/01/2023 B. Indiana 1. Effectiv e: 05/01/2023 C. Kentucky 1. Effect ive: 05/01/2023 D. Ohio 1. Effective: 06/01/2023 Temporary Codes-MP-PY-1413Effective Dat e: 05/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.E. West Virginia1. Effective: 05/01/2023
REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406 05/01/2023 Policy Type REIMBURSEMENT 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 Reimburseme nt 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 t he 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 Addi ction 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 G. References ………………………….. ………………………….. ………………………….. ……………………. 4 Screen ing and Surveillance for Colorectal Cancer-IN MP-PY-0406 Effective Dat e 05/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectScreening and Surveillance for Colorectal Cancer B. BackgroundIn the United States, colorectal cancer (CRC) ranks second to lung cancer as a cause of cancer mortality and is the third most commonly occurring cancer in both men and women with approximately twenty percent (20%) higher incidence rates among African Ameri cans . CRC incidence and mortality rates have declined over previous decades driven by changes in risk factors, early detection of cancer through screening, removal of precancerous polyps with colonoscopy, and advances in surgical /treatment approaches. App ropriate screening reduces colorectal cancer mortality in adults 45 years of age orolder. The benefit of the early detection of and intervention for colorectal cancer declines with age, but it is recommended by both the American College of Gastroenterolog y and the American Society for Gastrointestinal Endoscopy that screening begin at 45 years of age . Individuals 75 years of age and older are recommended to work with a primary care physician to determine if continued screening is appropriate and/or recomme nded. C. Definitions Risk – Agents or situations known to increase development of a condition. Per American Cancer Society guidelines : o Low – Certain f actors are not present , including a personal or family history of colorectal cancer, certain types of polyps, inflammatory bowel disease (e.g., ulcerative colitis, Crohns disease), or radiation to abdomen or pelvic area to treat prior cancer, and/or a confirmed or suspected hereditary co lorectal cancer syndrome (e.g., familial adenomatous polyposis (FAP), or Lynch syndrome) o High or Increased – Any of the factors seen above are present. Colorectal Cancer Screening – Testing for early-stage colorectal cancer and precancerous lesions in asym ptomatic members with an average risk . Surveillance for Colorectal Cancer – Close observation f or members who are at increased or high risk for colorectal cancer. D. PolicyI. Colorectal Cancer Screening A. Prior authorization is not required for par ticipating providers . B. Benefit coverage is for members at least 45 years of age or less than 45 years of age if a t risk for colorectal cancer . C. Screening for colorectal cancer claims must be submitted with one of the following ICD-10 codes: 1. Z12.10 Encoun ter for sc reening for malignant neoplasm of intestinal tract, unspecified . 2. Z12.11 Encounter for screening for malignant neoplasm of colon . 3. Z12.12 Encounter for screening for malignant neoplasm of rectum . 4. Z12.13 Encounter for screening for malignant neoplasm of small intestine . D. The following are reimbursed : 1. Highly sensitive fecal immunochemical test (FIT) annually . Screen ing and Surveillance for Colorectal Cancer-IN MP-PY-0406 Effective Dat e 05/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2. Highly sensitive guaiac-based fecal occult blood test (gFOBT) annually .3. Multi-targeted stool DNA test (mt-sDNA) every 3 years . 4. Colonoscopy every 10 years . 5. CT colonography (virtual colonoscopy) every 5 years . 6. Flexible sigmoidoscopy (FSIG) every 5 years . E. A f ollow-up colonoscopy is reimbursed as part of the screening process when a non-colonoscopy test is positive. F. Screening with plasma or serum markers is NOT covered. II. Colonoscopy Surveillance for Colorectal CancerA. Prior authorization is not required for participating providers . B. Surveillance for colorectal cancer claim must be submitted with one of the following ICD-10 codes: 1. Z84.81 Family history of carrier of genetic disease; 2. Z15.89 Genetic susceptibility to other disease ; 3. Z83.71 Family history of colonic polyps ; 4. Z85.038 Personal history of other malignant neoplasm of large intestine; 5. Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus; 6. Z80.0 Family history of malignant neo plasm of digestive organs; 7. Z86.010 Person al history of colonic polyps; or 8. Z92.3 Personal history of irradiation or radiation therapy; or 9. K50 through K52 category codes noninfective enteritis and colitis. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting HCPCS and CPT codes alo ng with appropriate modifiers. Please refer to the individual CMS fee schedule for appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 11/ 01/2017Date Revised 04/28/2020 09/17/202001/12/202202/15/2023 05/10 /2023 Added specific ICD-10 to use for screening and surveillance; added ages; added benefit limits; added definitions Removed definitions and codes ; updated ages , PT modifiers, and frequencies Annual review. Annual review . Removed PT modifier information. Approved at Committee. Date Effective 05/01/2023 Date Archived Screen ing and Surveillance for Colorectal Cancer-IN MP-PY-0406 Effective Dat e 05/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.G. References1. American Cancer Society. When should you start getting screened for colorectal cancer? ( 2021, February 4. Retrieved January 5, 2023 from www.cancer.org. 2. Gupta S, et al . Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. G astrointest Endosc. 2020 Mar;91(3):463-485.e5. 3. Indi ana General Assembly. IC 27-8-14-8.3 Colorectal cancer testing coverage, exception for high deductible health plans. (2021, November 9). Retrieved January 18, 2023 from www.iga.in.gov. 4. Qaseem A, et al. Sc reening for colorectal cancer in asymptomatic average-risk adults: A guidance statement from the American college of physicians. Ann Intern Med. 2019 Nov 5;171(9):643-654. 5. Rex D, Boland C, Dominitz J . Colorectal cancer screening: Recommendations for physicians and patients from the U.S. multi-society task force on colorectal cancer. Gastrointest Endosc. 2017 Jul;86(1):18-33. 6. United States Preventive Services Task Force. Colorectal cancer: Screening. (2021, May 18). Retrieved January 5, 2023 from www.uspreventiveservicestaskforce.org. 7. Wilkins T, McMechan D, Talukder A. Colorectal cancer screening and prevention. Am Fam Physician. 2018 May 15;97(10):658-665..
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date JW Modifier Drug Waste PY-PHARM-0097 01-22-2022Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing lo gic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t 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 lowes t 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 Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Modifier JW Reimbursement Statement INDIANA MARKETPLACE PLANS PY-PHARM-0097 Effective Date: 01-22-2022 2 A. Subject This policy provides guidelines for the documentation and reimbursement of discarded drug wastage from single dose injectable vials. B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use se lf-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 thi s policy does not imply any right to reimbursement or guarantee claims payment. This policy describes documentation requirements and reimbursement guidelines for billing of the discarded portion of drugs and biologicals . Providers shall bill and receive reimbursement for both the dose administered and the unused portion of weight-based or variable dosing injectable drugs that are manufactured and supplied only in single dose or single use format. The discarded portion of single use or single dose vial s must be identified with the JW Modifier as a separate line item from the dose or administered portion. Providers may be reimbursed for the discarded portion s of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropriately reported based on the policy reimbursement guidelines. C. Definitions Modifie r JW refers to the drug amount discarded (wasted) /not administered to any patient. Discarded Wastage or Unused Portion is defined as the amount of a single use/dose vial or other single use/dose package that remains after administering a dose/quantity of a drug or biological. Single Dose Vial is defined as a vial of medication intended for administration by injection or i nfusion that is meant for use in a single patient for a single procedure. These vials are labeled as single-dose or single-vial by the manufacturer and typically, do not contain a preservative. Multi-Dose Vial is defined as a vial of medication intended fo r administration by injection or infusion that contains more than one dose of medication. These vials are labeled as multi-dose by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. Archived Modifier JW Reimbursement Statement INDIANA MARKETPLACE PLANS PY-PHARM-0097 Effective Date: 01-22-2022 3 D. Policy Modif ier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modifier JW. Both details are reimbursable. CareSource will consider reimbursement for: I. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not administered to another patient. CareSource will NOT consider reimbursement for: I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed with out using the most appropriate size vial, or combination of vials, to deliver the administered dose. E. Conditions of Coverage Providers must not use the JW modifier for medications manufactured in a multi-dose vial format. Providers must choose the most appropriate vial size(s) required to prepare a dose to minimize waste of the discarded portion of the injectable vials. Claims considered for reimbursement must not exceed the package size of the vial used for preparation of the dose. Providers must not bill for vial contents overfill. Providers must not use the JW modifier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modifer is only applied to the amount of drug or biologi cal that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modifier. 1. Claim Line #1 HCPCS code for drug administered and the amount admistered to the patient. 2. Claim Line #2 HCPCS code for drug discarded (wasted) with JW modifier appended to indicate waste and the amount discarded (wasted). Note: In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. F. Related Policies/Rules Chapter 17, Section 40.1 of CMS Medicare Claims Processing Manual Pharmacy Reimbursement Modifiers Policy Number PY-071 3 ArchivedModifier JW Reimbursement Statement INDIANA MARKETPLACE PLANS PY-PHARM-0097 Effective Date: 01-22-2022 4 G. Review/Revision History DATE ACTION Date Issued Date Revised Date Effective 01-22-2022 Date Archived H. References 1. https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/downloads/jw-modifier-faqs.pdf 2. https://www.kmap-state-ks.us/Documents/Content/Bulletins/16226%20 – %20General%20 -%20Modifier%20JW.pdf 3. https://www.cms.gov/medicare-coverage-da tabase/view/article.aspx?articleid=55932#:~:text=The%20JW%20modifier%20is%20only,Ch apter%2017%2C%20Section%2040). The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
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 Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center-MP-PY-1407 GA, IN, IA, KY, WV: 03/01/2023-12/31/2024 OH: 04/01/2023-1 2/31/2024 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia b Indiana b Iowa b Kentucky b Ohio b West Virginia Table of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 4 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 6 G. Review/Revision History …………………………………………………………………………………………. 6 H. References …………………………………………………………………………………………………………… 6 I. State-Specific Information ………………………………………………………………………………………. 7 Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center-MP-PY-1407 Effective Date: 03/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectDental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center B. Background Reimbursement policies are designed to assist providers submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Most dental care can be provided in a traditional dental office setting with local anesthesia and if medically necessary, a continuum of behavior guidance strategies, ranging from simple communicative techniques to nitrous oxide, enteral or parenteral sedation. Monitored anesthesia care or sedation (minimal, moderate, or deep) may be a requirement of some patients including those with challenges related to age, behavior or developmental disabilities, medical status, intellectual limitations or other special needs. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require as a medical necessity, general anesthesia in a healthcare facility such as an ambulatory surgical center or outpatient hospital facility. 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-A hospital is 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 to additional regulations beyond basic hospital conditions of participation. o Inpatient Hospital-A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. o Off Campus Outpatient Hospital-A portion of an off-campus hospital provider-based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. o On Campus Outpatient Hospital-A portion of a hospitals main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center-MP-PY-1407 Effective Date: 03/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. o Short Procedure Unit (SPU ) – A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic or medical services. Medically Necessary-The health insurance exchange, defines medically necessary services as health care services or supplies that are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. As outlined by the Centers for Medicare & Medicaid Services (CMS), medically necessary services or supplies: o Are proper and needed for the diagnosis or treatment of a medical condition; o Are provided for the diagnosis, direct care, and treatment of a medical condition; and o Meet the standards of good medical practice in the local area and are not mainly for the convenience of the patient or the physician. 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. 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 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. Monitored Anesthesia Care (MAC) – Does not describe the continuum of depth of sedation; rather it describes 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. 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 assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. 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 positive 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 initially intended. Individuals administering moderate sedation/analgesia (conscious sedation) should be able to rescue patients who enter a state of deep sedation/analgesia,Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center-MP-PY-1407 Effective Date: 03/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. while those administering deep sedation/analgesia should be able to rescue patients who enter a state of general anesthesia. Rescue of 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.D. Policy Most dental care and/or oral surgery is effectively provided in an office setting. However, some members may have a qualifying condition that requires the procedure be provided in a hospital setting or ambulatory surgical center under general anesthesia. The purpose of this document is to provide reimbursement and billing guidance for facility related services when dental procedures are rendered in a hospital or ambulatory surgical center (ASC) place of service (POS) under general anesthesia. Hospital inpatient or outpatient facility services and ASC facility services for the provision of dental care under general anesthesia are addressed in this policy, not dental care or oral surgery in an office setting. Professional dental services are covered only to the extent that the member has dental benefits and guidelines for dental services are provided in the delegated dental vendors Dental Office Reference and Policy Manual. CareSource policy notes the intent of hospital, outpatient, and ASC facility requests is the medical necessity of general anesthesia services to perform dental procedures on a member. Requests with the goal of no, minimal, moderate, or deep sedation services, will only be considered in extenuating circumstances mandated by systemic disease for which the patient is under current medical management and which increases the probability of complications, such as respiratory illness, cardiac conditions, or bleeding disorders. Medical record and physician attested letter would be required with authorization requests. 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 service is a Health Insurance 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. I. Dental Prior Authorization Process A. A prior authorization is required for all dental services performed in a hospital inpatient or outpatient facility or a ambulatory surgery center facility. B. Dental services authorization for an outpatient/ASC setting: 1. Requests for dental services under general anesthesia are submitted to DentaQuest Dental Utilization Review. Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center-MP-PY-1407 Effective Date: 03/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2. DentaQuest reviews for appropriate medical necessity requirements (listed in the DentaQuest Dental Office Reference Manual) for general anesthesia or for IV sedation in the outpatient hospital or ASC setting. 3. If service request does not meet medical necessity criteria, the Notice of Adverse Benefit Determination (Denial Notice) is issued by DentaQuest. 4. If dental procedure(s) and the general anesthesia/sedation in the outpatient hospital or ambulatory surgery center are approved, DentaQuest will send an automated approval letter to the requesting dentist and this can be viewed in the DentaQuest provider portal. C. Facility authorization process 1. Upon approval, DentaQuest Participating Providers are required to administer services at CareSource participating hospitals/facilities. Upon receipt of approval from DentaQuest, the provider should use the information below for facility authorization as applicable. 2. For facility administrative pre-certification, the (hospital or ASC facility) may: a. Submit the request on the CareSource Provider Portal at CareSource.com >Login >Provider Portal; or b. Request a Facility Certification by calling CareSource directly at: CareSource: 800.488.0134 and select option to Request an Authorization (if immediate precertification needs). NOTE: The request should include the facility services requested, the Dental Authorization Approval Letter and the dental authorization number. 3. CareSource Medical Utilization Management team will complete ALL of the following: a. Verify that facility is in network; b. Review the dental pre-determination letter (PDL) or authorization; c. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted that require PA; and d. Fax a Facility Approval to the hospital/ASC which can also be viewed in CareSource Provider portal. NOTE: 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.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual 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 Center POS (24) Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center-MP-PY-1407 Effective Date: 03/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. o Use CPT code 41899 as the facility fee codeWill be paid according to CareSource contract and the Medicare Physician Fee S chedule (PFS).Dental-related facility charges must be billed on an institutional claim (UB – 04 c laim 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 PhysicianFee Schedule (PFS). All associated professional services, such as radiology and anesthesia, a s we ll as ancillary services related to the dental services, must be billed on a pr ofessional claim (CMS-1500 claim form or electronic equivalent).I npatient Hospital Facility POS (21)o All services as well as any additional Room and Board fees would have to be pr e-certified and receive medical necessity review. Services are subject t o benef it provisions and criteria for dental hospital admissions for both adult and pedi atric members is in accordance with CareSource and Dental BenefitsAdministrator clinical guidelines.Dental/Oral Surgery Professional Services o The scope of this policy is limited to medical plan coverage of the facility and/or general anesthesia services provided in conjunction with dental treatment, and not the dental or oral surgery services. For information on dental benefits, pleas e c onsult the DentaQuest Office Reference Manual for clinical guidelines, policies,and procedures. F. Related Policies/Rules NA G. Review/Revision History DATE ACTION Date Issued 11/30/2022 Date Revised Date Effective GA, IN, IA, KY, WV: 03/01/2023 OH: 04/01/2023 Date Archived GA, IN, IA, KY, WV 12/31/2024 OH: 12/31/2024This 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.References 1.American Academy of Pediatric Dentistry. Oral Health Policies and R ecommendations (The Reference Manual of Pediatric Dentistry). (2021-2022).Retrieved January 28, 2022 from www.aapd.org.2. C enters for Medicare and Medicaid Services. Ambulatory Surgical Centers. RetrievedJanuary 28, 2022 from www.cms.gov. Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center-MP-PY-1407 Effective Date: 03/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3. Centers for Medicare and Medicaid Services. Hospitals . Retrieved January 28, 2022 from www.cms.gov. 4. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. (2019, October 23). Retrieved January 28, 2022 from www.asahq.org.I. State-Specific Information A. Georgia 1. Effective: 03/01/2023 B. Indiana 1. Effective: 03/01/2023 C. Iowa 1. Effective: 03/01/2023 D. Kentucky 1. Effective: 03/01/2023 E. Ohio 1. Effective: 04/01/2023 F. West Virginia 1. Effective: 03/01/2023
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387 IN, GA, WV, KY: 02/01/2023 OH: 03/01/2023 Policy Type REIMBURSEMENT 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, benefit s 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 p rocedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or supplie s that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or sig nificant 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 incl ude 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 Reim bursement 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 co ntract (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 mod ify 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. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387Effective Dat e: 02/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectTranscutaneous Electrical Nerve Stimulation (TENS) B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These pr oprietary 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 t he claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCP CS code(s) for the product or service that is being provided. Theinclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Transcutaneous electrical nerve stimulation (TENS) is a device that produces a mildelectrical stimulation that causes interferences with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the members skin.C. Definitions 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). Accessories Reusable items used with a TENS machine, which may include 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, whic h 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. D. PolicyI. TENS units may require medi cal 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 t rial period. IV. Documentation Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387Effective Dat e: 02/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. 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 CareSo urces 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 subs tantial 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. F. The provider must maintain written documentation regarding the members instruction on the use of t he 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 reimbursab le 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 of 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 cl aim may deny. E. 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. Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387Effective Dat e: 02/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.The following list(s) of codes are provided as a reference. This list may not be all inclusive and is subject to updates.HCPCS Code Description 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) A4557 Lead wires (e.g., apnea monitor), per pair Modifiers Description RR Rental (use the ‘RR’ modifier when DME is to be rented) NU Purchase of new equipment F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 10/26/2022Date Revised Date Effective GA, IN, KY, WV: 02/01/2023 OH: 03/01/2023 Date ArchivedH. References1. Gibson W, Wand BM, Meads C, Catley MJ, OConnell NE. Transcutaneous electrical nerve stimulation (TENS) for chronic pain an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2019 April; 4(4):CD011890. Retrieved August 8, 2022 from www.ncbi.nlm.nih.gov. 2. Johnson MI, Paley CA, Wittk opf PG, Mulvey MR, Jones G. 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 J une; 58(6):803. Retrieved August 8, 2022 from www.ncbi.nlm.nih.gov . 3. Vance CGT, Dailey DL, et al. Using TENS for pain control: the state of the evidence. Pain Manag. 2015 May; 4(3):197-209. Retrieved August 8, 2022 from www.ncbi.nlm.nih.gov. I. State-Specific InformationA. Georgia 1. Effective: 02/01/2023 B. Indiana 1. Effective: 02/01/2023 C. Kentucky 1. Effect ive: 02/01/2023 D. Ohio 1. Effective: 03/01/2023 Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387Effective Dat e: 02/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.B. West Virginia1. Effective: 02/01/2023
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Overpayment Recovery-MP-PY-1393 IN, GA, WV, KY: 01/01/2023 OH: 03/01/2023 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 requir ements, 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 servi ce, 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 ar e 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 o f 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 memb er 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 Polic y 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. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 Overpayment Recovery-MP-PY-1393 Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectOverpayment Recovery B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. H ealth 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 se rvice that is being provided. Theinclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Retrospective review of claims paid to providers assist CareSource with ensuring accuracy in the payment process. C areSource will request voluntary repayment fromproviders when an overpayment is identified.Fraud, waste and abuse investigations are an exception to this policy. In these investigations, the look back period may go beyond 2 years.C. Definitions Claims Adjustment Adjustment is defined as a claim that was previously paid and is being updated for one of the following reasons: o Denied as a zero payment, o a partial payment, o a reduced payment, o a penalty applied, o an additional payment or o a supplemental pa yment. Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the member. Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. Explanation of Payment (EOP) The EOP or contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Forwarding Balance (FB) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past claim has been adjusted to a different dollar amount and that funds are owed t o CareSource. Overpayment Recovery-MP-PY-1393 Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved. Improper Payment A payment that should not have been made or an overpayment was made. Examples include, but are not limited to: o Payments made for an ineligible member; o Ineligible service payments; o Payments made for a service not re ceived; and o Duplicate payments. Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 CFR. o A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Provider Level Balancing (PLB) Adjustments to the total check/remit amount occur in the PLB segment of the remit. The PLB can e ither decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment (BPR, which means total payment within the EOP). Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. D. PolicyI. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider: A. The name and pat ient account number of the member to whom the service(s) were provided; B. The date(s) of services provided; C. The amount of overpayment; D. The reason for the recoupment; and E. That the provider has appeal rights. II. Overpayment RecoveriesA. Lookback period is 24 months from the claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. III. Coordination of Benefit RecoveriesA. Lookback period is 12 months from claim paid date. B. Advanced no tification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to correct ed claims being submitted within original claim timely filing guidelines. Overpayment Recovery-MP-PY-1393 Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.IV. Retro Active Eligibility RecoveriesA. Lookback period is 24 months from claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normaltimely filing limits apply to corrected claims being submitted within original claim timely filing guidelines.V. Management of Claim Credit Balances. A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on aproviders record. This m ay result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move aproviders record into a negative balance in which funds would be owed toCareSource.1. This information will be displayed on the EOP in the PLB section.B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is notconsidered to be an overp ayment recovery and does not fall under the terms of this policy.1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 whenadjusted, instead of the $2 difference.b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D. IV.2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adju stment with the $2 reduced payment is subject to the guidelinesoutlines in section D.I D. IV.b. The reduced payment will trigger a 30-day advanced notification with the details related to the claim and overpayment.C. Reconciliation of negative bal ance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has beenoffset, unless otherwise negotiated.D. Providers are notified of negative balances through (EOPs) and 835s. 1. Providers are expected to use this information to reconcile and maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances.E. Notification of negative balances and reconciliation of negative balances may not occur concurrently.1. Providers are expected to maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances when they occur.VI. In the event of any conflict between this policy and any written agreement between the provide r and CareSource, that written agreement will be the governing Overpayment Recovery-MP-PY-1393 Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.document.E. 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. F. Related Policies/RulesCareSource Marketplace Provider Manual CareSource Provider Agreement, ARTICLE V. CLAIMS AND PAYMENTS G. Review/Revision HistoryDATE ACTIONDate Issued 10/2 6/2022 New policyDate Revised Date Effective GA, IN, KY, WV: 01/01/2023 OH: 03/01/2023 Date ArchivedH. References1. Center of Medicare & Medicaid Services. (2008, September 29). Limitation on Recoupment (935) for Provider, Physicians and Suppliers Overpayments. Retrieved 10/14/2022 from www.cms.gov I. State-Specific InformationA. Georgia 1. Effective: 01/01/2023 a. Georgia Code (2021). Title 33 Insurance Chapter 20A – Managed Health Care Plans Article 3 – Managed Health Care Plans 33-20A-62. Payment. Retrieved 10/14/2022 from www.law.justia.com B. Indiana 1. Effective: 01/01/2023 a. Indiana General Assembly. (2022). IC 27-13-36.2-8 Claim payment errors. Retrieved 10/14/ 2022, 2022from www.iga.in.gov b. Indiana General Assembly. (2022). IC 27-13-36.2-9 Claim overpayment adjustment. Retrieved 10/14/ 2022, 2022 from www.iga.in.gov C. Kentucky 1. Effective: 01/01/2023 a. Kentucky Revised Statutes. (2000, July 14 (last updated on 10/18/2022 )). 304.17A-708 Resolution of payment errors retroactive denial of claims — conditions. Retrieved 10/18/2022 from www.apps.legislature.ky.gov b. Kentucky Revised Statues. (2002, July 15 (last updated on 10/18/2022) ). 304.17A-714 Collection of claim overpayments dispute resolution. Retrieved 10/18/ 202 2 from www.apps.legislature.ky.gov D. Ohio 1. Effective: 03/01/2023 Overpayment Recovery-MP-PY-1393 Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.a. Ohio Revised Code. (2002, July 24). 3901.38 Payments considered final overpayment. Retrieved 10/14/2022 from www.codes.ohio.gov E. West Virginia 1. Effective: 01/01/2023 a. West Virginia Code. (2022). 33-25A-23a. Civil penalty imposed by commissioner. Retrieved 10/14/2022 from www.code.wvlegislature.gov b. West Virginia Code. (2022). 33-45-1. Definitions. Retrieved 10/14/2022 from www.code.wvlegislature.gov c. West Virginia Code. (2022). 33-45-2. Minimum fair business standards contract provisions required; processing and payment of health care services; provider claims; commissioner’s jurisdiction. Retrieved 10/14/2022 from www.code.wvlegislature.gov
REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Payment to Out of Network Providers-IN MP-PY-1341 01/01/2023 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, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of func tion, 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. Thi s 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 contra ct (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 s ervices 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 Payment to Out of Network Providers-IN MP-PY-1341 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectPayment to Out of Network Providers B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify a 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 beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. This policy is intended to define the reimbursement rate for claims received fromproviders who are not contracted (out of network) providers with CareSource.C. Definitions Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. Emergency Medical Condition An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm. D. PolicyServices provided by out-of-network providers are not covered under Marketplace Plans and require prior authorization however, exceptions exist. For those situati ons where CareSource is required to provide out-of-network coverage and the reimbursement methodology is not defined, CareSources standard reimbursement will be as follows: I. Preauthorized, medically necessary services rendered to CareSource members by out-of-network providers will be reimbursed at: A. Durable Medical Equipment (DME) – 60% of the Medicare rate; B. Orthotics/Prosthetics – 60% of the Medicare rate; C. All Applied Behavior Analysis (ABA) services that require prior authorization – 60% of the CareSou rce established ABA fee schedule ; D. Skille d Nursing Facility (SNF) – 60% of the Medicare allowable rate; E. Labs not related to Covid testing – 60% of the Medi care rate; F. All other services will be reimbursed at 60% of the Medicare rate (see exclusion list below in section IV.). II. In the event of emergency services and unanticipated out of network care,CareSource will adhere to the Federal No Surprises Act, January 1, 2022 . A. No prior authorization is required for emergency services. Payment to Out of Network Providers-IN MP-PY-1341 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.B. Reimburseme nt rates for out of network services will be paid per the I ndianaHouse Bill 1004 at the usual and customary established rate. C. Emergency health care services , not otherwise subject to the No Surprises Act , will be reimbursed based on state regulations . III. In the event of any conflict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document.IV. Exclusions : the following will be reimbursed at 100% of the Medicare rate :A. Provider types whose rei mbursement methodology is mandated by state/federalregulation/statute or rule or directive. B. Prior authorized hospital-based services stay . C. Avastin drug services. D. Covid testing l abs . E. Dermatology services. F. Home health services . G. Hospice . H. Private Duty Nursing (PDN) . I. All services in a Federally Qualified Health Center (FQHC), Rural Health Clinics (RHC) and Indian Health Clinics . E. Conditions of Coverage Reimbursement is depende nt 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. F. Related Policies/Rules Evidence of Coverage and Health Insurance Contrac t Indiana G. Review/Revision History DATE ACTIONDate Issued 01/19/2022 New policyDate Revised 10/26/2022 Updated D.I. rates. Updated D. IV. Exclusions. Updated references. Date Effective 01/01/2023 Date Archived H. References 1. B. Fuchs, J. Hoadley. January 19, 2021. Summary of the No Surprises Act. January 1, 2021. Retrieved 09 /15/202 2 from www.commonwealthfund.org. 2. IN Code 27-1-45-8 (2020). Out of Network Practitioner Providing Services at in Network Facility; Reimbursement; Notice; Explanation of Costs if Exceeds Estimate; Emergency Rules. Retrieved on 09 /15/202 2 from www.law.justia.com. Payment to Out of Network Providers-IN MP-PY-1341 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3. IN Code 12-15-12 (202 0). Managed Care. Retrieved on 09 /15/202 2 from www.law.justia.com. 4. IN Code 25-1-9-23 (2020). In Network Practitioner Charges; Good Faith Estimates; Requirements; Reimbursement of Out of Network Practitioners; Notice; Explanation of Costs Exceeding Est imate; Exemption; Rules. Retrieved on 09 /15/202 2 from www.law.justia.com. 5. Indiana General Assembly 2020 Session. House Bill 1004. Retrieved on 09 /15/202 2 from www.iga.in.gov. 6. No Surprises Act of the 2021 Consolidated Appropriations Act. Pub. L. No. 1 16-260, 134 Stat. 1182, Division BB, 109. Retrieved 09 /15/202 2 from www.congress.gov.
REIMBURSEMENT POLICY STATEMENT Marketplace Policy Name & Number Date Effective Modifiers-MP-PY-1392 IN, GA, WV, KY: 01/01/2023-12/31/2023 OH: 02/01/2023-12/31/2023 Policy Type REIMBURSEMENT 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. Conditions of Coverage ………………………………………………………………………………………….. 3 F. Related Policies/Rules ……………………………………………………………………………………………. 3 G. Review/Revision History …………………………………………………………………………………………. 3 H. References …………………………………………………………………………………………………………… 3 I. State-Specific Information ………………………………………………………………………………………. 4 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 di sease, 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 an y 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 ref er to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Modifiers-MP-PY-1392 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectModifiers B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for 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 offic e staff are encouraged to use self-service channels to verify a members eligibility. Reimbursement modifiers are a two-digit code that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifiers can be found in the appendices of both Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) manuals. Use of a modifier does not change the code or the codes definition. Examples of modifiers use includes: To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same procedure; To indicate that a procedure was performed on the left side, right side, or bilaterally; To report multiple procedures performed during the same session by the same health care provider; To indicate multiple health care professionals participated in the procedure; To indicate a subsequent procedure is due to a complication of the initial procedure.Although CareSource accepts the use of modifiers, use does not 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 pos t-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.C. Definition sCurrent Procedural Terminology (CPT) – Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) – Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier-Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. Modifiers-MP-PY-1392 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. D. PolicyIt is the responsibility of the submitting provider to submit accurate documentation of services performed. Providers are expected to use the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided according to the following industry standard guidelines (may not be all-inclusive): National Correct Coding Initiative (NCCI) editing guidelines; American Medical Association (AMA) guidelines; American Hospital Association (AHA) billing rules; Current Procedural Terminology (CPT); Healthcare Common Procedure Coding System (HCPCS); ICD-10 CM and PCS; National Drug Codes (NDC); Diagnosis Related Group (DRG) guidelines; and CCI table edits. The inclusion of a code in a policy does not imply any right to reimbursement or guarantee claims payment. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to the individual CMS 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. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTION Date Issued 10/12/2022 New policy Date Revised Date Effective GA, IN, KY, WV: 01/01/2023 OH: 02/01/2023 Date Archived GA, IN, KY, WV: 12/31/2023OH: 12/31/202 3 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 form al documented Policy. Modifiers-MP-PY-1392 Effective Date: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. H. References1. Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved 09/30/2022 from www.cms.gov 2. CPT overview and code approval. (2022, September 30). Retrieved 09/30/2022 from www.ama-assn.org 3. Medicare Claims Processing Manual Chapter 12-Physicians/Nonphysician Practitioners. (2022, March 4). Retrieved 09/30/2022 from www.cms.gov 4. Medicare Claims Processing Manual Chapter 14-Ambulatory Surgical Centers. (2017, December 22). Retrieved 09/30/2022 from www.cms.gov 5. Modifiers Recognized by Ohio Medicaid. (2022, January 28). Retrieved 09/30/2022 from www.medicaid.ohio.gov 6. Optum360 EncoderProForPayers.com-Login. (2022, September 30) Retrieved 09/30/2022 from www.encoderprofp.com I. State-Specific InformationA. Georgia 1. Effective: 01/01/2023 B. Indiana 1. Effective: 01/01/2023 C. Kentucky 1. Effective: 01/01/2023 D. Ohio 1. Effective: 02/01/2023 E. West Virginia 1. Effective: 01/01/2023
REIMBURSEMENT POLICY ST AT EM ENTMarketplace Policy Name & Number Date Effective Em ergenc y Departm ent Serv ic es Lev eling f or Fac ility Claim s-MP-PY-1386 IN, GA, KY, WV: 01/01/2023 OH: 02/01/2023 Policy TypeREIMBURSEMENT This policy applies to the follow ing Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..2 E. Conditions of Co ve r age ………………………………………………………………………………………..2 F. Related Policies/Rules ………………………………………………………………………………………….2 G. Review/Revision History ……………………………………………………………………………………….3 H. Ref er en ce s …………………………………………………………………………………………………………3 I. State-Specif ic Inf or mat io n ……………………………………………………………………………………..3 Reimbursement Po licie s prepared by CareSource a nd its a ffilia te s a re intended to provide a general reference regarding b illin 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, 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 limite d to, those health ca re services or supplies that are proper and necessary for the diagnosis or treatment of disease, illn e ss, 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 in c lude 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 co n flict between th is Policy and the plan contract (i.e., Evidence of Coverage), then the plan cont ract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy 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 limita tio n s that a re le ss favorable than the limita tio n s that apply to medical conditions as covered under this policy. Emerg en c y Dep artmen t Serv i c es Lev el i n g fo r Facility Claims-MP-PY-1386 Effec ti v e Date: 01/01/2023 Effec ti v e Date OH: 02/01/2023 Th e REIMBURSEMENT Policy Statemen t d etai l ed abo v e h as rec ei ved due c o ns id eratio n as defi n ed in th e REIMBURSEMENT Policy Statemen t Po l i c y an d i s approved. A. Subjec tEmergency Department Services Leveling for Facility Claims B. Bac k groundEmergency department (ED) services are generally provided when a medical condition requires immediate action, such as an injury or sudden illness. Data f rom the National Center f or Health Statistics indicates there are 130 million emergency department visits in the United States per year. The policy describes appropriate levels of reimbursement f or f acility services in relat ion to the levels of complexity or severity rendered in the ED. The Centers f or Me dic ar e & Medicaid Services ( CMS) provider guidelines to hospitals to direct the f orm of general guidelines to be used in f acility coding f or ED services. The volume an d intensity of f acility resources utilized by the physician to provide patient c ar e is identif ied by the f acility code. Prof essional codes are based on the intensity and complexity of provider perf ormed work. C. Def initions Emergency Services-An emergency medical condition within the capability of the emergency department of a hospital, including ancillary services routinely av ailab le to evaluate such emergency medical condition. Health Care Facility-A hospital or long-t e rm c ar e f acility. Other healthcare f acilities include associated sites, such as pharmacies and outpatient laboratories. Assisted living f acilities, senior living f acilities, prisons, or group homes are not included. Facility Resources-Resources u s ed to provide health c ar e an d services, including but not limited to materials, personnel, f acilities, and f unds.D. Polic yI. CareSource policy rei mburses ED services if services billed ar e supported by documentation. II. Billing requires the f ollowing conditions be me t : A. Emergency department services ar e billed in accordance with the appropriate He alt h c ar e Co mmo n Procedure Coding System (HCPCS)/Current Pr o c e dural Terminology (CPT) codes. B. The primary diagnosis billed agrees with the emergency department r e ported level of care. C. CareSource will consider the level of resources owned or covered by the f ac i lity to properly treat the patient.E. Conditions of Cov erageNAF. Related Polic ies/RulesMedical Necessity Determinations Emerg en c y Dep artmen t Serv i c es Lev el i n g fo r Facility Claims-MP-PY-1386 Effec ti v e Date: 01/01/2023 Effec ti v e Date OH: 02/01/2023 Th e REIMBURSEMENT Policy Statemen t d etai l ed abo v e h as rec ei ved due c o ns id eratio n as defi n ed in th e REIMBURSEMENT Policy Statemen t Po l i c y an d i s approved. G. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 10/04/2022Date Revised Date Effective GA, IN, KY, WV: 01/01/2023 OH: 02/01/2023 Date ArchivedH. Ref erenc es 1. American College of Emergency Physicians. ED f acility level coding guidelines. Ame r ic an College of Emergency Physicians. Retrieved September 1, 2022 f r o m www.acep.org. 2. Centers f or Disease Control an d Prevention. Defining He alt h c ar e Facilities and He alt h c ar e-associated Legionnaires’ Disease. Retrieved August 26, 2022 f rom https://w ww.cdc.gov. 3. Centers f or Disease Control an d Prevention: Nat io n al Center f or Health Statistics. Emergency Department Visits. Retrieved July 15, 2022 f rom www.cdc.gov 4. Centers f or Medicare and Medicaid Services. Medicare Claims Processing Manual Chapter 12-Physicians/Nonphysician Practitioners. Retrieved September 1, 2022 f r o m www.cms.gov. 5. Racmonitor. Dif f erentiating between p r of e s s ion al an d f acility ED coding. ( Feb 12, 2020). Retrieved on August 25, 2022 f rom https://racmonitor.com.I. State-Spec if ic Inf orm ationA. Georgia 1. Ef f ective: 01/01/2023 B. Indiana 1. Ef f ective: 01/01/2023 C. Kentucky 1. Ef f ective: 01/01/2023 D. Ohio 1. Ef f ective: 02/01/2023 E. West Virginia 1. Ef f ective: 01/01/2023
REIMBURSEMENT POLICY STATEMENT Marketplace Policy Name & Number Date Effective Durable Medical Equipment (DME) Modifiers – MP-PY-1368 IN, GA, WV, KY: 12/01/2022-12/31/2023 OH: 01/01/2023-12/31/2023 Policy Type REIMBURSEMENT 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. Conditions of Coverage ………………………………………………………………………………………….. 3 F. Related Policies/Rules ……………………………………………………………………………………………. 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 4 I. State-Specific Information ………………………………………………………………………………………. 4 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. Th ese 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) w ill 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. Durable Medical Equipment (DME) Modifiers-MP-PY-1368 Effective Date: 12/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectDurable Medical Equipment (DME) Modifiers B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS 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.Modifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additional information, to the code description, of the product or service. Using a modifier inappropriately can re sult in the denial of a claim or an incorrect reimbursement for a product or service.The purpose of this policy is to simplify and standardize the use of modifiers, when billing for rented, purchased, or rent to purchase DME equipment. There are many modifiers that can be used when billing DME. This policy addresses the rental modifier RR and the new equipment purchase modifier NU. CareSource expects providers to use the modifiers stated in this policy to increase efficiency and timely reimbursement. Any other appropriate modifier per national or state billing standards can be appended to a DME item along with the modifiers addressed in this policy (LT, RT, etc.). The modifiers addressed in this policy is not an all-inclusive list and providers should adhere to national and state billing guidelines for modifier usage for all other modifiers not addressed within this policy.C. DefinitionsDurable Medical Equipment (DME) equipment and supplies ordered by a health care provider for everyday or extended use. Healthcare Common Procedure Coding System (HCPCS) codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. Durable Medical Equipment (DME) Modifiers-MP-PY-1368 Effective Date: 12/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. D. PolicyI. This policy outlines the use of DME modifiers for the rental and/or purchase of Durable Medical Equipment (DME). II. DME items can be: A. Purchased; B. Rented; or C. Rented on a short-term basis and then purchased at the end of the rental period.III. DME items must be billed with appropriate HCPCS codes along with appropriate modifiers when applicable: A. Purchase Modifier-NU: 1. CareSource requires that Modifier NU is appended to all claims for the purchase of DME equipment. B. Rental Modifier-RR: 1. CareSource requires that Modifier RR is appended to all claims for the rental period of DME equipment. a. The combined total reimbursement for rental and subsequent purchase of a DME item cannot exceed the maximum fee. b. At the end of the rent to purchase period, the DME becomes the property of the member. C. Disposable supplies do not require a modifier.IV. Modifiers that are not to be used for claims submission for DME equipment: A. LL-Lease/rental B. NR-New when rented C. RB-Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement parts are new equipment)V. CareSource considers a replacement part as a new equipment purchase and modifier NU should be used instead of modifier RB.VI. DME items that are submitted for reimbursement without a modifier are considered a purchase. If the DME item was intended to be a rental and the modifier RR was left off the claim in error, CareSource may verify the use of any modifier through post payment audit and proper reimbursement adjustment will occur. All information regarding the use of these modifiers must be made available upon CareSources request.E. Conditions of CoverageModifier Description RR Rental (use the RR modifier when DME is to be rented) NU Purchase New Equipment (use the NU modifier when DME is to be purchased) Durable Medical Equipment (DME) Modifiers-MP-PY-1368 Effective Date: 12/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTION Date Issued 09/14/2022 New policy Date Revised Date Effective GA, IN, KY, WV: 12/01/2022 OH: 01/01/2023 Date Archived GA, IN, KY, WV:12/31/2023 OH: 12/31/2023This Policy is no longer active and has been archived. Please note that there could be other Policies that may have s ome of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H. References1. Durable Medical Equipment (DME). (n.d.). Retrieved on 09/06/2022 from www.healthcare.gov. I. State-Specific InformationA. Georgia 1. Effective: 12/01/2022 B. Indiana 1. Effective: 12/01/2022 C. Kentucky 1. Effective: 12/01/2022 D. Ohio 1. Effective: 01/01/2023 E. West Virginia 1. Effective: 12/01/2022
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