REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406 05/01/2022 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 methodolo gy, 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 ser vices include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new mo rbidity, 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 co nvenience 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 pol icies 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 an d applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Screening andSurveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 05/01/2022 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. 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 a re not a guarantee of payment. Reimbursement for claim s may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staf f are encouraged to use self-service channels to verify member eligibility. The evidence is convincing that appropriate screening reduces colorectal cancer mortality in adults 50-75 years of age. The benefit of early detection of and intervention for color ectal cancer declines after 75 years of age . African Americans have been shown to have higher colorectal cancer rates of incidence , and it is recommended by both the American College of Gastroenterology and the American Society for Gastrointestinal Endosco py that screening begin at 45 years of age. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant ee claims payment. C. Definitions Colorectal Cancer Screening – Detects early stage colorectal cancer and precancerous lesions in asymptomatic members with an average risk of colorectal cancer. Surveillance for Colorectal Cancer Close observation f or mem bers who are at increase d or high risk for colorectal cancer. Average risk – Per American Cancer Society Guidelines, members who are at average risk for colorectal cancer do not have the following : o Personal history of colorectal cancer or certain types of polyps; o Family history of colorectal cancer; o Personal history of inflammatory bowel disease (i.e. ulcerative colitis or Crohns disease); o A confirmed or suspected hereditary colorectal cancer syndrome (i.e. familial adenomatous polyposis or Lynch syndrom e); or o Personal history of getting radiation to abdomen or pelvic area to treat prior cancer. Increased or high risk – Per American Cancer Society Guidelines, members who are at increased or high risk for colorectal cancer include the following : o Strong family history of colorectal cancer or certain types of polyps; o Personal history of colorectal cancer or certain types of polyps; o Personal history of inflammatory bowel disease (i.e. ulcerative colitis or Crohns disease); Screening andSurveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 05/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.o Family history of a hereditary colorectal cancer syndrome such as familial; adenomatous polyposis (FAP) or Lynch syndrome (also known as hereditary non-pol yposis colon cancer or HNPCC); or o Personal history of radiation to the abdomen or pelvic area to treat a prior cancer. D. Policy I. 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 forty-five years of age if a t risk for colorectal cancer , according to most recent published guidelines of American Cancer Society . C. Screening for colorectal cancer claims must be submitted with one of the following ICD-10 codes: 1. Z12.10 Encounter for sc reening for malignant neoplasm of intestinal tract, unspe cified 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 sensit ive fecal immunochemical test (FIT) annually 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. Flexibl e sigmoidoscopy (FSIG) every 5 years E. A follow-up colonoscopy is reimbursed as part of the screening process when a noncolonoscopy test is positive. F. Screening with plasma or serum markers is NOT covered. G. PT modifier is used when the colorectal cancer screening test was converted to a diagnostic test or other procedure. II. Colonoscopy Surveillance for Colorectal CancerA. Prior authorization is not required for par ticipating 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 neoplasm 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. Screening andSurveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 05/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.C. PT modifier is used when the colorectal cancer screening test was converted to a diagnostic test or other procedure. E. Condition s of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes alo ng with appropriate modifiers. Please refer to the individual CMS fee schedule for appropriate codes. F. Related Policies/Rules Evidence of Coverag e and Health Insurance Contract Indiana G. Review/Revision History DATE ACTIONDate Issued 11/ 01/2017Date Revised 04/28/2020 09/17/202001/12/2022Added 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. Date Effective 05/01/202 2 Date Archived H. References 1. Centers for Medicare and Medicaid Services. (2021, January 19). Billing and Coding: Colorectal Cancer Screening – Medical Policy Article. Retrieved December 16, 2021 from www.cms.gov. 2. Centers for Medicare and Medicaid Services. (2020, April 20). Informati on on Essential Health Benefits (EHB) Benchmark Plans. Retrieved December 16, 2021 from www.cms.gov. 3. Doubeni, C. (2021, December 07). Tests for screening for colorectal cancer. Retrieved December 16, 2021 from www.u ptodate.com . 4. EncoderPro. (n.d.). ICD10 CM Guidelines. Retrieved January 12, 2022 from www.encoderprofp.com. 5. Indiana General Assembly. (2021, November 09). IC 27-8-14-8.3 Colorectal cancer testing coverage, exception for high deductible health plans. Retrie ved December 16, 2021 from www.iga.in.gov. 6. Qaseem, A., Crandall, C. J., Mustafa, R. A., Hicks, L. A., & Wilt, T. J. (2019, November 5). Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement from the American College of P hysicians. Retrieved December 16, 2021 from www.annals.org. 7. Rex, D., et. al . (2017). Colorectal cancer screening: Recommendations for physicians. Gastrointestinal Endoscopy, 86(1), 18 33. Retrieved December 16, 2021 from www.asge.org/. 8. Samir, G, et.al. (20 20). Recommendations for follow-up after colonoscopy and polypectomy: A concensus update by the United States Multi-Society Task Force Screening andSurveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 05/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.on Colorectal Cancer (American Society for Gastrointestinal Endoscopy, AGA Institute and The American College of Gastroen terology). Retrieved January 12,2022 from www.giejounal.org. 9. Wilkins, T., Mcmechan, D., Talukder, A. (2018, May 15). Colorectal Cancer Screening and Prevention. Retrieved December 16, 2021 from https://www.aafp.org. 10. Wolf, A., et. al. (2018). Colorectal c ancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. Retrieved December 16, 2021 from www.onlinelibrary.wiley.com. 11. United States Code of Federal Regulations. (2021, September 27). 156.110 EHB-benchmark plan sta ndards. Retrieved December 16, 2021 from www.govregs.com . 12. United States Preventive Services Task Force (2016, June 15). Colorectal Cancer: Screening. Retrieved December 16 , 202 1 from www.uspreventiveservicestaskforce.org .
REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Robotic-Assisted Surgery IN MP PY-0956 05/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as 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 Contents 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 ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3Robotic-Assisted Surgery IN MP PY-0956 Effective Date: 05/01/2022 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTPo lic y St ate m ent Po lic y a nd is a pp rove d.A. SubjectRobotic-Assisted Surgery 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. 4Health care providers and their office sta ff 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. Robot-assisted surgery involves the use of a robot and computer technology under the direction and guidance of a surgeon. These surgeries are minimally invasive procedures using robotic devices designed to access surgical locations through smaller incisions or ports. There surgeries are generally performed using a workstation console containing remote controls for the surgical instruments as well as a compute r equipped with a three-dimensional magnified video monitor of the surgical site through use of miniature cameras. The primary difference between robotic and conventional laparoscopic procedures is that the surgical instruments are manipulated indirectly t hrough computer controls rather than manually by the surgeon. The robotic controls allow the surgical tools to emulate the movement of the surgeon performing cuts, clamps and suturing in a similar fashion as would be done in an open procedure. Examples of robotic surgical systems include the da Vinci Surgical System (Intuitive Surgical, Inc.) and the ZEUS Robotic Surgical System (Computer Motion, Inc.) C. Definitions Robotic Assisted Surgery-is defined as the performance of operative procedures with t he assistance of robotic technology. D. Policy I. Robotic-Assisted Surgery, HCPCS S2900, is included in the primary surgical procedure and not separately reimbursable. II. Modifier 22 (increased procedural services): 1. Should be used only to report complications or complexities during the surgical procedure that are unrelated to the use of the robotic system, such as increased intensity, increased time, increased difficulty of procedures, or severity of patients condition.Robotic-Assisted Surgery IN MP PY-0956 Effective Date: 05/01/2022 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTPo lic y St ate m ent Po lic y a nd is a pp rove d.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the (CMS) fee schedule for appropriate codes. F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 02/01/2020 New PolicyDate Revised 01/19/2022 No changes; updated references Date Effective 05/01/2022 Date Archived H. References 1. Robotic surgery. Medline Plus Web site. (May 2013) . Retrieved December 28, 2021 from www.nlm.nih.gov . 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services; Retrieved December 28, 2021 from www.cms.gov. 3. Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets . Retrieved December 28, 2021 from www.cms.gov . 4. Daniel M. Herron, MD. A consensus Document on Robotic Surgery. Prepared by the SAGES-MIRA Robotic Surgery Consensus group. Position Papers/ Statement published on 11/2007. Retrieved December 28, 2021 from www.sages.org . 5. Estes, Stephanie Jet al. Best Practices for Robotic Surgery Programs. JSLS : Journal of the Society of Laparoendoscopic Surgeons vol. 21,2 (2017): e2016.00102. Retrieved December 28, 2021 from www.nlm.nih.gov . 6. U.S. Food and Drug Administration. Computer-Assisted Surgical Systems (Aug. 20, 2021). Retrieved December 28, 2021 from www.fda.govThis guideline contains custom content that has been modifi ed from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC.
REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Modifiers-IN MP-PY-1348 03/01/2022 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 no t limited to, those health care services or suppli es 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 si gnificant 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 inc 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 Rei mbursement 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 c ontract (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 mo dify 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 li mitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. .. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ….. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …….. 3 H. References ………………………….. ………………………….. ………………………….. ………………………. 4 Modifiers-IN MP-PY-1348Effective Date: 03/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe 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. R eimbursement 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 pro viders and office 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 andother 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 bilate rally; 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 init ial procedure. Although CareSource accepts the use of modifiers, use does not guaranteereimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any mod ifier through post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources req uest. C. Definitions Current Procedural Terminology (CPT) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common P rocedure 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-IN MP-PY-1348Effective Date: 03/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe 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 Termin ology (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 th e 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. Un less otherwise noted within the policy, our policies apply to bothparticipating and nonparticipating providers and facilities .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 N/A G. Review/Revision HistoryDATE ACTIONDate Issued 08 /01/2019 New policyDate Revised 12/15/2021 Annual review. Removed modifiers, changed background and policy sections to simplify language . New policy number created and converted from PY-0713 due to extensive edits Date Effective 03/01/2022 Date Archived Modifiers-IN MP-PY-1348Effective Date: 03/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.H. References 1. Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved November 17, 2021 from www.cms.gov. 2. CPT overview and code approval. (2019, March 22). Retrieved November 17, 2021 from www.ama-assn.org. 3. Med icare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners. (2018, November 30). Retrieved November 17, 2021 from www.cms.gov . 4. Medicare Claims Processing Manual Chapter 14 – Ambulatory Surgical Centers. (2017, December 22). Retrieved November 17, 2021 from www.cms.gov. 5. Optum360 EncoderProForPayers.com – Login. (2019, February 18). Retrieved November 17, 2021 from www.encoderprofp.com.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Overpayment Recovery PY-111 4 01/01/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims e diting logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the 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. CSMG Co. 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.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. 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 Overpayment RecoveryINDIANA MARKETPLACEPY-111 4 Effective Date: 01/01/2022 2 A. SubjectOverpayment Recovery 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 a nd/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 sel f-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. 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. CareSource will request voluntary repayment fromproviders when an o verpayment is identified .Fraud, waste and abuse investigations are an exception to this policy. In theseinvestigations, 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, a partial payment, a reduced payment, a penalty applied, an additional payment or a supplemental payment. 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 pre viously paid is updated to a denied status as a zero payment or results in a reduced payment. EOP The EOP or Explanation of Payment contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Coordin ation 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. Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. 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; Overpayment RecoveryINDIANA MARKETPLACEPY-111 4 Effective Date: 01/01/2022 3 o Ineligible service payments;o Payments made for a service not received; and o Duplicate payments. Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. PLB (Provider Level Balancing) Adjustments to the total check / remit amount occ ur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment (BPR, which means total p ayment within the EOP). 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 indicate s that a past claim has been adjusted to a different dollar amount and that funds are owed to CareSource. D. Policy I. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider : A. The name and patient account number of the member to whom the service (s) were provided ; B. The date(s) of services provided ; C. The amount of overpayment ; D. The reason for the recoupment ; and E. That the provider has a ppeal rights . II. Overpayment R ecoveriesA. 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 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 subm itted within original claim timely filing guidelines. 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 . Overpayment RecoveryINDIANA MARKETPLACEPY-111 4 Effective Date: 01/01/2022 4 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. V. Management of Claim Credit Balan ces.A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decrea ses in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. 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 not considered to be an overpaymen t recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $ 2 difference. b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D. IV. 2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D. IV. b. The reduced payment will trigger a 30-day advanced notification with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through cl aims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. D. Providers are notified of negative balances through (EOPs) and 835s. 1. Providers are expected to use this information to reconci le 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 provider and CareSource, that written agreement will be the governing document.Overpayment RecoveryINDIANA MARKETPLACEPY-111 4 Effective Date: 01/01/2022 5 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/Rules CareSource Marketplace Provider Manual CareSource Provider Agreement, ARTICLE V. CLAIMS AND PAYMENTS G. Review/Revision History DATE ACTIONDate Issued 04/29/2020 New policyDate Revised 10/13/2021 Updated definitions. Added D. V. and D. VI. Updated references. Approved at PGC. Date Effective 01/01/2022 Date Archived H. References 1. Indiana General Assembly. (n.d.). IC 27-13-36.2-8 Claim payment errors. Retrieved October 4, 202 1 from www. iga.in.gov 2. Indiana General Assembly. (n.d.). IC 27-13-36.2-9 Claim overpayment adjustment. Retriev ed October 4, 202 1 from www. iga.in.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Chiropractic Care Spinal Manipulation PY-133 2 09/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider co ntractual 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 diag nosis 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, dysfunctio n of a body organ or part, or significant pain and discomfort. These service s meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this P olicy 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 ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Chiropractic Care Spinal ManipulationINDIANA MARKETPLACEPY-133 2 Effective Date: 09/01/2021 2 A. SubjectChiropractic Care Spinal Manipulation 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. Rei mbursement 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 provi ders and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service tha t is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Chiropractic is a licensed healthcare profession where treatment typically involvesmanual therapy, often including spina l manipulation.C. Definitions NA D. Policy I. A service performed must be medically necessary and related to the treatment of a specifi c medical complaint. A. To determine medical necessity, CareSource requires all of the following: 1. A primary diagnosis of subluxation a. Examples include lumbar and sac ral ; and 2. A secondary diagnosis that supports the treatment provided. a. Examples include osteoarthritis and congenial musculoskeletal deformities of the spine. B. The manual manipulation must have a direct therapeutic relationship to the members condition as documented in the medical record. The lack of documentation specifying the relationship between the members condition and treatment shall result in the service being ineligible for reimbursem ent. 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. Chiropractic Care Spinal ManipulationINDIANA MARKETPLACEPY-133 2 Effective Date: 09/01/2021 3 F. Related Policies/RulesMedical Necessity Determination Policy CareSource Evidence of Coverage and Health Insurance Contract G. Review/Revision His tory DATE ACTIONDate Issued 05/26/2021Date Revised Date Effective 09/01/2021 Date Archived H. References 1. The Association of Chiropractic Colleges. (n.d.). Chiropractic Paradigm/Scope & Practice. Retrieved April 15, 2021 from www.chirocolleges.org The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
MEDICAL POLICY STATEMENT INDIANA MARKETPLACE Policy Name Policy Number Date Effective Drug Testing MM-0130 01/01/2022-1 1/ 30 /2022 Policy Type MEDICAL Administrative Ph ar mac y Reimbursement Table of ContentsMedical Policy Statement …………………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..3 E. Conditions of Co ve r age…………………………………………………………………………………………9 F. Related Polices/Rules …………………………………………………………………………………………..9 G. Review/Revision History ………………………………………………………………………………………..9 H. Ref er en ce s …………………………………………………………………………………………………………9 Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 wh ich 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 lo ca l area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Pro vi der Manuals, Member Handbooks, and/or other policies and procedures. Medical Po licy Statements prepared by CareSource a nd its a ffilia te s do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement 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. 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 t h an the limita tio n s that apply to medical conditions as covered under this policy. 2 Drug Tes ti ng INDIANA MARKET PLACEMM-0130 Effec ti v e Date: 01/01/2022 B. Bac k groundDrug testing is a p ar t o f me d ic al c ar e during the initial assessment, ongoing monitoring, an d recovery phase f or members with substance use disorder (SUD); for members who are at risk f or abuse/misuse or diversion of drugs; and/or f or other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of concern. Drug testing is one component of a comprehensive clinical approach during the initial assessment, stabilization, maintenance and recovery phase f or members with a substance use disorder (SUD). It is als o used to screen members periodically t h at ar e prescri bed chronic opioid therapy (COT) for pain based on a risk score. For substance-related disorders, drug testing may help the provider compare a members reported drug(s) of choice with the t es t results to verify subjective inf ormation. The assessment process including initial drug testing will aid the treatment provider to individualize the plan f or drug testing f or a member. Drug testing may help determine if a member is adhering to prescription medication, reveal nonprescribed drugs or illicit drugs, or provide evidence to suggest diversion. Providers requesting d r ug testing should h av e proficiency in drug t e st in t e r pr et at io n and understand what they are ordering. Urine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive an d conf irmatory. Drug testing is sometimes als o ref erred to as toxicology testing. C. Def initionsPresumptive/Qualitative t es t-The testing of a substance or mixt u r e to determine its chemical constituents, also known as qualitative testing. Confirmatory/Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or def initive testing. Random drug test-A laboratory drug test administered at an irregular interval that is not known in advance by the member. Relapse-When a person with addiction returns to use af t er a period of sobriety. Ab erran t behavior-Members behaviors t h at may indicate medication/drug abuse or misuse such as losing prescriptions, early ref ill requests, or multiple prescribers f or controlled substances on the states Prescription Drug Monitoring Program (PDMP). Independent labo rato ry-A laboratory certif ied to perform diagnostic and/or clinical tests independent of an institution or a providers office. Participating/non-pa rt icip at ing-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSource. Op ioid treatmen t program (OT P) – Program or qualif ied provider delivering opioid treatment to members with an opioid agonist treatment medication. A. Subjec tDru g Testing 3 Drug Tes ti ng INDIANA MARKET PLACEMM-0130 Effec ti v e Date: 01/01/2022 Residential treatment services-Per the Evidence of Coverage these health c ar e services c an include individual an d group psychotherapy, f amily counseling, nursing services, and pharmacological therapy with 24 hour support. Clinical Laboratory Improvement Amendments (CLIA ) – The Centers f or Medicare & Medicaid Services (CMS) regulates programs that test human specimens to ensure ac c u r at e , reliable an d timely patient test results regardless of where a test is perf ormed and includes physician offices. Chronic opioid therapy-Ref ers to the use of opioids to treat chronic pain more than three months or past the time of normal tissue healing. Diversion-Unlawf ul channeling of regulated pharmaceuticals f rom legal sources to the illicit marketplace and includes transf erring drugs to people they were not prescribed f or. D. Polic yI. UDT order A. An order f or UDT mu st include at a min imu m all of the f ollowing: 1. List the type of test to be performed (presumptive or co nf ir mat o ry). 2. Include all medications currently prescribed to the member. 3. Drug an d drug class to be tested. 4. Clinical indication. 5. Be signed an d dated by a qualif ied provider. 6. UDT order mu st specif ically mat c h the number, level an d complexity of t h e testing components performed. B. Copies of test results alone without the p r op er providers order f or the test ar e not suf f icient documentation of medical necessity to support a claim. II. Provider Documentation A. Provider mu st main t ain a complete legible medical record f or the member and include the f ollowing: 1. Complete member n ame an d identif ication on e ac h page of record. 2. Identif ication of the provider responsible for providing member c ar e . 3. Appropriate indication f or UDT. 4. How the UDT result will guide the p lan of treatment. 5. CPT code t h at ac c u r at e ly describes the service performed. B. Provider documentation mu st support medical necessity of UDT. 1. All components of a UDT panel mu st be supported by medical necessity. 2. A panel of drugs may be perf ormed as part of an initial assessment to develop a monitoring plan as long as it is supported with medical necessity. A panel of drugs should only be conducted based on an individualized treatment p lan noting the need f or confi rmat o r y test with greater t h an 14 drug tests. These tests are rarely indicated f or routine UDT. III. Prior Authorization (PA) A. CareSource will consider all prior authorization requests when they ar e medically necessary to the members treatment and care. Presumptive testing should be the initial test considered, as of ten a positive result of a drug class is enough to inf orm the provider about a need to change the treatment plan. Higher number 4 Drug Tes ti ng INDIANA MARKET PLACEMM-0130 Effec ti v e Date: 01/01/2022 drug panels are rarely indicated f or routine urine drug testing as lower number panels are suf f icient f or modif ying treatment plans in the majority of cases. B. CareSource will cover up to 30 presumptive an d 12 definitive UDT per member per calendar year bef ore a PA is required. 1. Appropriate clinical documentation mu st be included with PA request to determine appropriate medical necessity. a. PA needs to mak e a c le ar case f or medical necessity f or the level of testing being requested, it may include but is not limited to: 01. Ph as e of treatment (e.g. assessment, e ar ly recovery, induction, stabilization, m aintenance). 02. Current level of c ar e (e.g. use of ASAM levels). 03. Member drug(s) of choice. 04. Day s since las t drug test with unexpected r e su l t s. 05. Current prescribed drugs including o v er-th e-counter drugs an d illicit drugs that have had unexpected results in recent tests. 06. Member current active symp t o ms t h at led to the r eq ue s t. 07. Provider actions t ak e n on recent unexpected test results an d member response to that action. 08. The clinical documentation shows t h at the member is contesting the result of an unexpected presumptive test. 09. The test is not being requested for third party reasons, or as a condition to s t ay in sober housing or r es id en t ial f acility (see additional inf ormation below). 10. Results of an y pill counts performed by t r eat me n t t e am. 2. PA is NOT required in an emergency room setting. Confirmatory testing is rarely needed in this setting. UDT utilization will be monitored by CareSource. C. If needed, the licensed practitioner t h at is operating in his/her scope of practice must obtain the prior authorization IV. Quantity Limitations A. CareSource will cover up to 30 presumptive an d 12 definitive UDT per member per calendar year bef ore a PA is required. B. Eac h CPT code is counted as one test. C. In determining medical necessity f or additional tests, current clinical inf ormation will be considered as well as review of prior medical records will be performed to determine the medical appropriateness of the initial 30 presumptive and 12 def initive drug tests ordered within a calendar year. V. Providers and laboratories will need to ensure specimen integrity appropriate f or the stability of the drug being tested i.e. f reezing specimen. Diluted, substituted or adulterated urine samples will alter a test result. Checking f or color, specific gravit y, temperature an d creatinine c an help determine the specimen integrity. If tampering is suspected, the sample should be discarded and when possible, the member should remain at provider f acility until a new specimen obtained can be tested.5 VI. LaboratoryDrugTes ti ng INDIANA MARKET PLACEMM-0130 Effec ti v e Date: 01/01/2022A. CareSource may require documentation of FDA-approved complexity level f or instrumented equipment, and/or Clinical Laboratory Improvement Amendments (CLIA) Certif icate of Registration, Compliance, or Accreditation as a high complexity lab. B. Laboratories mu st main t ain h ar d copy documentation of lab results with copies of the order f or the drug test. VII. Clinical Indications Testing should be individualized to the specific member. Analytes tested should be ordered based on the members drug(s) of choice. Periodica lly, drugs that are commonly used may be rotated into the random test schedule. Regionally prevalent drugs may be periodically rotated into the random test schedule. The rationale f or which tests is not meant to include all drugs all of the time, rather the drugs most likely to be seen in the individual. This inf ormation helps the provider focus the testing to likelihood it would be used. Testing should be at the lowest level to inf orm the provider that an intervention is needed based on the individual history of the member. Drug testing is ideally perf ormed on a random unannounced schedule with a specif ic time f rame to produce a specimen. ASAM recommends a random-interval schedule to a f ixed-interval schedule as it eliminates known non-testing periods. Testing every day, at every visit, on the same day of the week or at the same time is not rando m (ASAM ref erence). Providers should understand windows of detection time to determine f requency of testing. Too short of an interval may raise an issue of presumption of renewed when the same drug that was recently tested is still within its detection wi ndow. Drug testing does not have to be associated with an office visit when patients are called to do random tests. Providers should be aware of the potential f or cross-reactivity when using presumptive tests. Per SAMHSA, cross reactivity h as a positive side. For example, a conf irmatory test f or a specif ic opioid analyte will miss other opioids a member may be taking. Theref ore, an opioid screen is preferred over a specif ic test when looking f or opiate type drugs. When testing f or alcohol, SAMHSA als o states t h at a breathalyzer gives an estimate of blood alcohol level. This method is simple to use, inexpensive, gives instant results, and is noninvasive. A. Drug Testing in Addiction Tr eat me n t 1. UDT f requency is expected to be more f requent when medically necessary e ar ly in treatment or when tapering. UDT f requency is expected to decrease as member stabilizes. 2. Prior to Initiation or in the Induction Ph as e (early recovery). a. Obtain history as well as a medical an d psychological assessment.b. Review approximate t ime f r ame of drug detected in urine. 6 DrugTes ti ng INDIANA MARKET PLACEMM-0130 Effec ti v e Date: 01/01/2022c. Identif y questions seeking to answer as well as treatment p lan based on potential UDT results. d. Obtain an individualized baseline UDT based on members unique clinical presentation, prescribed medications, members self-reported drugs of choice, and regional drug trends. e. At le as t weekly (cite ASMA consensus guidelines). f. Discuss results with member. g. Agree on p lan of c ar e t h at includes treatment in t er v en t io ns an d goals. h. This phase includes members t h at h av e relapsed. 3. Maintenance phase. a. At le as t once per month. 4. Intensive outpatient. a. At le as t weekly. 5. Substance use disorder residential treatment p ro gr am. a. At le as t monthly. 6. St ab le recovery. a. Drug testing may be done less f requently if in s t ab le r e co v er y. 7. For members t ak in g long-ac t in g naltrexone. a. At le as t monthly. B. Drug testing in an Opioid Treatment Program (OT P) 1. In maintenance treatment, f ederal regulations governing OTP require initial toxicology plus 8 random UDT screens per year per member. 2. In short-term detoxification treatment, one initial UDT per member. 3. In long-term detoxification treatment initial an d monthly random UDT per member. C. Drug testing by advanced practice register ed n ur se 1. Prescribing naltrexone to t r e at opioid use d is or de r a. Complete UDT or serum medication levels at le as t every 3 months f or t h e f irst year and then at least every 6 months thereaf ter 2. Prescribing buprenorphine products a. Complete UDT or serum medication levels at le as t twice per quarter f or the f irst year of treatment and once per quarter thereaf ter. D. Chronic Pain Management 1. Prior to or when initiating treatment a. Complete an assessment f or risk of substance abuse using a validated risk assessment screening tool such as Screener an d Opioid Assessment f or Patient with Pain-Revisited (SOAPP-R) or the Opioid Risk Tool (ORT). b. Review the state prescription d r ug monitoring program d at a (PDMP) c. Obtain baseline UDT screening. d. Discuss results with member. e. Agree on p lan of c ar e t h at includes treatment goals, educating on risks and benef its, and strategies to mitigate risks. f. Combine evidence-based non-pharmacologic an d non-opioid pharmacologic therapy as necessary. 2. Ongoing monitoring of t r eat me n t is determined by level of risk for substance use a. Low risk UDT once a y e ar . 7 b. Moderate risk UDT twice a y e ar . c. High risk UDT up to 4 t ime s a y e ar .DrugTes ting INDIANA MARKET PLACEMM-0130 Effec ti v e Date: 01/01/2022d. UDT when member shows aberrant drug-r elat e d behavior. e. Review PDMP d at a every 1-3 months. f. Ev alu at e benef its an d h ar ms of treatment at le as t every 3 months. E. Unexpected Results 1. Discuss with member to understand an y possible aberrant behavior. 2. Potential reasons f or unexpected results may include: a. Nonadherence (either r ec e nt ly or not at all). b. Member utilizing drug amount below detection threshold. c. Substance cannot be identif ied in type of t e s t performed. d. Lab error. e. Member absorbs, excretes, an d / or metabolizes at dif f erent r at e . f. Not members urine sample. g. Diluted urine f r om wat e r loading. h. Adulterated specimen. i. Diversion. j. Cross-reactivity with other medications or f ood . 3. Potential interventions for unexpected r e s ult s ar e dependent on assessment and may include: a. Ev alu at e an d discuss f ac t o r s contributing to r e lap s e. b. Minimize tampering opportunities during collection of sample. c. Monitor pill counts. d. Dose adjustment. e. Review PDMP. f. Collaborate or ref er with specialist. g. Change in level of c ar e or intensity of treatment. h. Change in lif estyle i.e. housing, support system. i. Change in p lan of treatment i.e. addition of behavioral therapy or community supports. j. Attend to psychosocial barriers i.e. transportation, f in an c ial k. Address co-occurring medical or behavioral needs. l. Obtain conf irmatory UDT (see Section VIII of this policy). VIII.Conf irmatory Te s t ing A. Should not routinely be utilized as the f irst choice for UDT. B. Medical necessity criteria f or conf irmatory testing is me t when one of the f ollowing is in the medical documentation: 1. Presumptive testing was negative f or prescription medications and provider was expecting the test to be positive f or prescribed medication an d me mber reports taking medication as prescribed; 2. Presumptive testing was positive f or prescription d r ug with abuse potential that was not prescribed by provider and the member disputes the presumptive testing results; 3. Presumptive testing was positive f or illegal drug and the member disputes t h e presumptive testing results; or8 Drug Tes ti ng INDIANA MARKET PLACEMM-0130 Effec ti v e Date: 01/01/2022 A specif ic substance or metabolite is needed to be identified that cannot be identif ied by a presumptive testing. (e.g. se mi-s y nt h et ic an d synthetic opioids, certain benzodiazepines). IX. Blood Testing A. Blood drug testing is considered medically necessary when it is in the emergency room setting.X. Testing t h at is not medically necessary A. CareSource considers the f ollowing as not medically necessary f or e it her presumptive or conf irmatory testing: 1. Testing t h at is not individualized such as : a. Ref lexive testing. b. Routine orders. c. St an d ar d orders. d. Preprinted orders. e. Requesting all tests t h at a machine is c ap ab le of doing solely because a result may be positive. f. Large, arbitrary panels. g. Universal testing. h. Conduct additional testing as needed. B. Testing required by third parties such as : 1. Testing ordered by a court or other medico-le gal purpose such as child custody. 2. Testing f or p re-employment or random testing t h at is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, v e te r inar ian s , pharmacists, etc.). 4. School entry or testing for athletics. 5. Testing required f or military service. 6. Testing in residential treatment f acility, p ar t ial hospital, or sober living as a condition to remain in that community. 7. Testing with another p ay source t h at is primary such as a county, state or f ederal agency. 8. Testing f or mar r iag e license. 9. Forensic. 10. Testing f or other ad min purposes. 11. Routine physical/medical examination. C. Testing f or validity of specimen 1. It is included in the payment f or the test an d will not be reimbursed separately. D. Blood drug testing when completed outside of the emergency r oo m. E. Hair, s aliv a, or other body f luid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine d r ug panels. H. Routine use of confirmatory testing f ollowing a negative presumptive expected result. 4. 9 Drug Tes ti ng INDIANA MARKET PLACEMM-0130 Effec ti v e Date: 01/01/2022 I. Custom Prof iles, standing orders, drug screen panel, custom panel, b lan k et orders, ref lex testing or conduct additional testing as needed orders. J. A conf irmatory test p r ior to discussing r es u lt s of presumptive test with me mb er . NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment d at a analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review.E. Conditions of Cov erage NA F. Related Polic es/Rules CareSource Evidence of Coverage an d Health Insurance Contract G. Rev iew/Rev ision History DATE ACTIONDate Issued 12/13/2017Date Revised 05/01/2019 08/01/2019 Up d ated clinical indications , q uantity limits, and p rio rautho ri zati o n req uirements01/01/2020 Remo v ed q uantity limits and p rio r authorizationreq uirements.09/02/2020 Up d ated D. III. And D. IV .09/01/2021 Ref o rmatted. Remov ed related reimburs ement p olicy.Up d ated ref erences. Approved at PGCDate Effecti ve 01/01/2022Date Archived 11/30/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uidelines without a f ormal d o c umented Policy . H. Ref erenc es1. A. Jaf f e, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016, Jan u ar y ) . Review an d recommendations for drug testing in substance use treatment contexts. Journal of Reward Def iciency Syndrome and Addiction Science. 2(1): 28-45. doi: 10.17756/jrdsas.2016-02 5 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their wo rk with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. (14) 64-80. doi: 10.1007/s11469-015-9569-7 3. Ame r ic an Society of Addiction Medicine. ( 20 1 7, May / Ju ne ) . Appropriate use of dr u g testing in clinical addiction medicine. 11(3) 163-173. doi: 10.1097/ADM.0000000000000323 4. Andersson, H. W., Wenaas, M., & Nordf jrn, T. (2019). Relapse af ter inpatient substance use treatment: A prospective cohort study among users of illicit substances . Addictive Behaviors, (90)222-228. doi:10.1016/j.addbeh.2018.11.008 5. Ame r ic an Society of Addiction Medicine (2010, October). Public Policy St at e me nt on Drug Testing as a Component of Addiction Treatment an d Monitoring Programs and in other Clinical Settings. Retrieved August 9, 2021 from www.asam.org 10 Drug Tes ti ng INDIANA MARKET PLACEMM-0130 Effec ti v e Date: 01/01/2022 6. Dowell, D., Haegerich, T. M., & Chou, R. (2016, March). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. Retrieved August 9, 2021 f rom www.cdc.gov 7. eCFR Code of Fe d er al Regulations. 42 Code of Fed e ral Regulations (CFR) Par t 8. (n.d.). Retrieved August 9, 2021 f r om www.ecfr.gov 8. Gourlay, D. L., Heit, H. H., & Caplan, Y. H. (2015, August 31). Urine Drug Testing in Clinical Practice The Art an d Science of Patient Car e (Edition 6). Ph ar maCo m Group Inc./Center f or Independent Healthcare Education 9. Jarvis, M, Williams, J, Hurf ord, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Saf ar ian , T. (2017, April 5). Appropriate Use of Drug Testing in Clinical Addiction Medication. Journal of Addiction Medicine. Retrieved August 9, 2021 f rom www.dca.ca.gov 10. Medicare Learning Network. (2020, May). CLIA Program an d Medicare Laboratory Services. Retrieved August 12, 2020 f rom www.cms.gov 11. National Academies of Sciences, Engineering, and Medicine. 2017. Pain management an d the opioid epidemic: Balan c in g societal an d individual benef its and risks of prescription opioid use. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24781. 12. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendations an d Best Practices. Pain Physician Journal. 15, ES119-ES133. Retrieved August 9, 2021 f rom www.painphysicianjournal 13. Reisf ield, MD, G. M., Webb, PhD, F. J., Bertholf, PhD, R. L., Sloan, MD, P. A., & Wilson, MD, G. R. (2007). Family physicians prof iciency in urine drug test interpretation. Journal of Opioid Management, 3(6), 333. doi:10.5055/jom.2007.0022 14. Substance Abuse an d Mental Health Services Administration. Clinical Drug Testing in Primary Care. Technical Assistance Publication (TAP) 32. HHS Publication No. (SMA) 12-4668. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. 15. Stanos, S. P. (2017, October 10). Presidents Message. National Academies of Sciences, Engi neering, an d Medicine (NASEM). Pain Medicine, 18(10), 1835-1836. doi:10.1093/pm/pnx224 16. U.S. Department of Veterans Af f air s . (2017, Feb r uar y ) . VA/DoD Clinical Practice Guideline f or Opioid Therapy for Chronic Pain. Retrieved August 9, 2021 f rom www.va.gov 17. Agency Medical Directors Group. (2010). Interagency Guideline on Opioid Dosing f or Chronic Non-cancer Pain. Retrieved August 9, 2021 f rom www.agencymeddirectors.wa.gov The Medical Policy Statement detailed above has received due consideration as defined in the Medical Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date COVID-19 Vaccine Reimbursement PY-PHARM-0076 03/15/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. 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, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e 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 t o 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), cov erage 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 Cov erage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Interest Payments PY-1318 07/01/2021-0 7/ 31 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e me nt ………………………………………………………………………………… 1 A. Subject …………………………………………………………………………………………………………….. 2 B. Bac k g r ou nd ………………………………………………………………………………………………………. 2 C. Def initions …………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………. 2 E. Conditions of Co v er ag e ……………………………………………………………………………………….. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Revie w/ Re vision History ………………………………………………………………………………………. 3 H. Ref er en ce s ……………………………………………………………………………………………………….. 3 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding b illin g , coding a nd documentation guidelines. Coding methodology, regulatory requirements, industry-stan dard 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 p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, a nd a pp lica ble r eferral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re no t limite d t o, 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, dysfunc t ion 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. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does n ot ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy 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 a ffilia te s ma y use reasonable discretion in interpreting and applying t his Po licy to se rv ice s 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 t h at a re le ss favorable than the limita tio n s t h at apply to medical conditions as covered under this policy. 2 A. Subjec tInterest Payments In teres t Pay men ts INDIANA MARKET PLACE PY-1318 Effec ti v e Date: 07/01/2021B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies ar e not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the ac t u al services provided to a member an d will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to s u bmit the mo st ac c u r at e and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service t h at is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Def initions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim has no def ect, impropriety, or special circumstance, including incomplete documentation t h at delays timely payment. A provider submits a c le an claim by providing the required d at a elements on the s t an d ar d claims f o r ms t h at ar e ac c u r at e at the t ime of payment, along with an y attachments an d additional elements, or revisions to data elements, attachments and additional elements, of which the provider has knowledge. Original Claim Th e initial complete claim f or one or mo r e benefits on an application f orm. Pro mp t Payment Prompt payment is def ined by State and/or Federal regulation def ining timeliness and interest requirements. D. Polic y 1. We strictly adhere to all regulatory guidelines relating to interest. We f ollow the guidelines outlined in Prompt Payment regulations. (IC 12.15.21.3 , IC 27.13.36.2.4) I I. Payment of interest on o r igin al claims is mad e when CareSource f ails to adjudicate original claims within the applicable state and f ederal prompt pay timef rames on clean claims. III. Payment of interest on adjusted claims starts on the d at e the provider disputes the original payment with CareSource. IV. CareSource considers interest pa yment on claims t h at were not p aid ac c u r at e ly on prior processing attempts. If CareSource had the inf ormation to pay the claim correctly on a previous payment but f ailed to do so, CareSource will pay the claim within the allotted 3 In terest Pay men ts INDIANA MARKET PLACE PY-1318 Effec ti v e Date: 07/01/2021timef rame f rom Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timef rame. V. CareSource only p ay s interest on claim payment t h at is occurring under prompt p ay regulations. A contractual adjustment of a claim is not subject to state and f ederal re gulations f or interest payment. VI. CareSource performs r e gu lar reviews of our p aid claims to correct claim payment. A. Reviews c an include it e ms such as retroactive eligibility updates, authorization updates, COB updates, and f ee schedule updates. B. Reviews include proactive measures to correct claim payment when it h as been determined that a systemic issue has paid claims incorrectly. C. Claims ar e not subject to interest payment when CareSource t ak e s proa ctive measures to pay claims correctly. E. Conditions of Cov erageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Ple as e ref er to the individual f ee schedule f or appropriate codes. F. Related Polic ies/RulesNA G. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 03/31/2021 New Policy Date Revised Date Effective 07/01/2021 Date Archived 07/31/2022 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 f ollow CMS/State/NCCI guidelines without a f ormal documen ted Policy. H. Ref erenc es1. Legal Inf ormation Institute. 42 CFR 422.520-Prompt payment by MA organization. Retrieved 16 February 2021 from www.law.cornell.edu 2. Social Security Association. Sec 1816(c)(2)(B. Retrieved 16 February 2021 f r o m www.ssa.gov 3. Social Security Association. Sec 1842(c)(2)(B). Retrieved 16 February 2021 f r o m www.ssa.gov 4. United States Government Publishing Office. Title 31, Section 3902. Retrieved 16 February 2021 f rom www.govinfo.gov 4 In teres t Pay men ts INDIANA MARKET PLACE PY-1318 Effec ti v e Date: 07/01/20215. United States Government Publishing Office. Title 42, Section 7109. Retrieved 16 February 2021 f rom www.govinfo.gov 6. Federal Register. Prompt Payment Interest Rat e ; Contract Disputes Act. Retrieved 16 February 2021 f rom www.f iscal.treasury.gov 7. Bureau of the Fiscal Service. (2013, Jan u ar y-2021, June). Interest Rates. Retrieved 16 February 2021 f rom www.f iscal.treasury.gov 8. Centers f or Med ic ar e & Medicaid Services. (2019, Jan u ar y ) . Notice of New Interest Rate f or Medicare Overpayments and Underpayments-2nd Qtr. Retrieved 16 February 2021 f rom www.cms.gov 9. Indiana General Assembly. (2021). IC 27-13-36.2-4. Retrieved 16 Feb ru ar y 2021 f rom www.iga.in.gov 10 . Justia US Law. (2021). 2018 India na Code Title 12. Human Services Article 15. Medicaid Chapter 21. Rules 12-15-21-3. Re qu ir ed r u les . Retrieved 16 March 16, 2021 f rom https://law.justia.com/codes/indiana/2018/title-12/article-15 / c hap t e r-21/section-12-15-21-3/ The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center PY-1305 05/01/2021 Policy 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, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of service s is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be ex pected 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 alte rnative, 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, Provi der Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 4 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterINDIANA MARKETPLACEPY-1305 Effective Date: 05/01/2021 2 A. SubjectDental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center 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 a re not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qu alifications. 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-servic e 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. T heinclusion 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 comm unicative 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 disabil ities, 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 requir e 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) – An ambulatory surgery center is a health care facility that specializes in providing surgery, pain management and certain diagnostic (e.g., colonoscopy) services in an outpatient setting. In simple terms ambulatory surgery center procedures are more intens ive than t hos e done in the average doctors office but not so intensive as to require a hospital stay. o Sec. 14. (a) Definition “Ambulatory outpatient surgical center”, for purposes of IC 16-21, IC 16-32-5, and IC 16-38-2, means a public or private institution that meets the following conditions listed in Indiana Code IC 16-18-2-14 . o Any facility that meets the definition of an ambulatory outpatient surgical center found in Indiana Code IC 16-18-2-14″Ambulatory outpatient surgical center” must be licensed by the Indiana State Department of Health (ISDH) on an annual basis. Hospital – A hospital is a health care facility that generally is an institution, a place, a building, or an agency that holds out to the general public that it is operated for hospital purposes and that it provides care, accommodations, facilities, and equipment, in connection with the services of a physician, to individuals who may need medical or surgical services. Any facility that meets the definition of a hospital found in Indiana Code 16-18-2-179 must be licensed Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterINDIANA MARKETPLACEPY-1305 Effective Date: 05/01/2021 3 by the Indiana State Department of Health (ISDH) .o Inpatient Hospital – A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation service s 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 rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. o Short Procedure U nit (SPU ) – A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic or medical services. Medically N ecessary – 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 your medical condition. o Are provided for the diagnosis, direct care, and treatment of your medical condition. o Meet the standards of good medical practice in the local area and are not mainly for the convenience of you or your doctor. 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 r eflexes 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 requi red to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Monitored Anesthesia Care (MAC ) – Do es 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 diag nostic or therapeutic procedure . Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. Deep Sedation (Analgesia ) – A drug-induced depression of consciousness during which patients cannot be easily ar oused 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 i s 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 assis tance in Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterINDIANA MARKETPLACEPY-1305 Effective Date: 05/01/2021 4 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 howan individual patient will respond. Hence, practitioners intending to produce a given level of seda tion should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (Conscious Sedati on) should be able to rescue patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analg esia should be able to rescue patients who enter a stat e 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 consequence s of the deeper-than-intended level ofsedation (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. Pol icy 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 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 o ral 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 CareSource 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 c onsidered 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. Medic al 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 Market place covered service. As such, it would exclude any diagnostic or Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterINDIANA MARKETPLACEPY-1305 Effective Date: 05/01/2021 5 preven tive dental services delivered in a hospital setting, if these services cannot be performed in office. I. Dental Prior A uthorization Process A. A prior authorization is required for all dental services performed in a Hospital Inpatient or Outpatient Facility , or an Ambulatory Surgery Center Facility . B. Dental Services Autho rization for an Outpatient/ASC setting : 1. Requests for dental services under general anesthesia are submitted to DentaQuest Dental Utilization Review . 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 servic e request does not meet medical necessity criteria, t he 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 p rovider 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 www.caresource.com >Login >Provi der 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 DentalAuthorization Approval Letter and the dental authorization number . 3. CareSource Medical Utilization Management team will complete ALL of the following: a. Verify that the 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 the CareSource Provider portal . NOTE : The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submit s a claim for aprocedure, 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 approp riate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterINDIANA MARKETPLACEPY-1305 Effective Date: 05/01/2021 6 The following list(s) of cod es 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) Inpatient Hospital Facility POS (21) All services as well as any additional Room and Board fees would have to be pre-certified and receive medical necessity review. Services are subject to benefit provisions and criteria for dental hospital admissions for both adult and pediatric members is in accordance with CareSource and Dental Benefits Administrator clinical guidelines. Dental/O ral Surgery Professional ServicesThe 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. The professional dental procedure codes listed are f or reference only and do not imply coverage of dental procedures. Information on dental benefits, please consult the DentaQuest Office Reference Manual for clinical guidelines, policies, and procedures . Facility Reimbursement PolicyUse CPT code 41899 as Facility Fee code Will be paid according to CareSource contract and the Medicare Physician Fee Schedule (PFS). Dental-related facility charges must be billed on an institutional claim (UB-04 claim form, Portal institutional claim, 837I transaction). Anesthesia Professional Services Reimbursement Policy CPT Anesthesia Code 00170 Anesthesia for intraoral treatments, including biopsy; not otherwise specified The administration or management of anesthesia as a non-institutional professional service rendered by qualified medical practitioners Will be paid according to CareSource contract and the Medicare Physician Fee Schedule (PFS). All associated professional services, such as radiology and anesthesia, as well as ancillary services related to the dental services, must be billed on a professional claim (CMS-1500 claim form or electronic equivalent). Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterINDIANA MARKETPLACEPY-1305 Effective Date: 05/01/2021 7 CDT Code Description (D0 100 – D9999) Reimbursed according to provider contractual rate Through CareSource s Marketplace Dental Benefits Administrator (DentaQuest) covered services provided outside the dental office are reimbursed at the amount allowed for the same service provided in the office. It is not appropriate f or providers to bill DentaQuest or member (members family) an additional charge for performing covered dental services in a hospital or surgery center setting. Dental-related services provided in an inpatient, outpatient, or ASC setting can be billed with CDT codes on the ADA dental claim form or electronic equivalent. Billed to (DentaQuest) the Dental Benefits Administrator for CareSource Marketplace . F. Related P olicies/Rules Temporomandibular or Craniomandibular Joint Disorder and Craniomandibular Jaw Disorder (TMJ) Dental and Oral & Maxillofacial Surgical Services Covered under Medical Plan CareSource and Dental Benefits Administrator Clinical Guidelines. CareS ource Office Reference Manual for Clinical G uidelines, Policies and P rocedures .G. Review/Revision HistoryDATE ACTIONDate Issued 01/20/2021 New PolicyDate Revised Date Effective 05/0 1/2021 Date Archived H. References 1. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. (2018, Octob er 23). Retrieved July 30, 2020 from www.asahq.org 2. American Academy of Pediatric Dentistry. Oral Health Policies and Recommendations. (2019). Retrieved July 20, 2020 from www.a apd.org 3. American Association of Oral and Maxillofacial Surgeons, Ambulatory Surgical Center Coding and Billing. Retrieved April 5, 2019 from www.aaoms.org 4. Indiana Department of Health. Ambulatory Outpatient Surgical Centers (ASC) Licensing and Certificati on Program. Retrieved December 11, 2020 from www.in.gov 5. Indiana General Assembl y. Indiana Code. Retrieved December 11, 2020 from www.iga.in.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date COVID-19 Vaccine Reimbursement PY-PHARM-0076 12/18/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. 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, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e 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 t o 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 t o 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 …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4
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