This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment Policy Subject: Emergency Department EKG and Imaging Interpretation Po l i c yCareSource reimburses for emergency department services provided to CareSource enrolled members, including reimbursement for the complete and definitive interpretation of EKGs and imaging studies provided for evaluation and management of the emergency care. De f i n i t i o n sEmergency medical condition ,” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. (From OAC 5101:3-26-01 (W, X)) “Emergency services ,” means covered inpatient services, outpatient services, or medical transportation that are provided by a qualified provider and are needed to evaluate, treat, or stabilize an emergency medical condition. As used in this policy, providers of emergency ser vices also include physicians or other health care professionals or health care facilities not under employment or under contractual arrangement with an MCP.(From OAC 5101:3-26-01 (W, X)) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior Authorization Emergency services (as defined above) do not require prior authorization.Only those services that are medically necessary for the evaluation and management of the patient in the ED setting will be reimbursed. Complete and Definitive Interpretation of EKGs and Imaging Studies refers to the interpretation that is provided by a physician with documented specialized education and training appropriate to the service provided and which is reported separately, documenting all findings typically reported for the particular exam and which is considered final and the report of record for the medical chart and which is separately retrievable. EKG and Imaging interpretations billed by ED physicians and other specialists in the ED setting will not be reimbursed separately if they do not conform with the above definition as they are considered to be an integral part of the evaluation and management services reimbursed to the physician. Archived This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Hospital emergency department services billed by the facility are usually accompanied by global charges for any EKG and Imaging services provided. Interpretations for these services are usually considered the complete and definitive interpretations that are provided by specialists contracted on behalf of the hospital and which are reimbursed as part of the global reimbursement paid to the facility. Duplicate charges for interpretation of EKG or imaging services rendered by ED or other specialty physicians will not be reimbursed. Ultrasound diagnostic procedures provided in the ED will be reimbursed when medically necessary, consistent with CPT definition, if accompanied by a separate report and not billed also by the hospital or a radiologist providing an over-read. Re l a t e d Po l i c i es & Re f e r e n c e s OAC 5160-2-21(H), Policies for outpatient hospital services, Emergency room visit claims. CareSource-Post Stabilization Care Policy St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y 10/31/2013OAC Rule renumbered from 5101:32-21(H), per Legislative Service Commission Guidelines. Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment Policy S ubject: Blood Specimen Collection Fee [Venipuncture] Policy CareSource will not reimburse providers for the collection of blood samples when the provider also performs a blood laboratory service because the collection of the sample is an integral part of the lab service. Definitions Encounters are face-to-face contacts between a patient and a health provider for medically necessary services and includes the recipients visit to the center, including all services and supplies incidental to a practitioners services, if the services or supplies are of a type commonly furnished in a practitioners office, commonly furnished either without charge or included in the FQHCs claim , and furnished as an incidental, although integral part of provider services. (CareSource internal definition.) Service is a clinical diagnostic laboratory test. (CareSource internal definition.) Provider Reimbursement Guidelines Specimen collection fee CareSource will reimburse for a specimen collection fee only when the provider drawing the venous sample is not the same provider or provider affiliate that is testing the specimen. W hen submitting claims for laboratory services [88002-85999 or 87800-87906] a provider may use the following specimen collection CPT codes; however CareSource will not reimburse the provider for these specimen collection fees as they are considered to be bundled with CPT codes 88002-85999 or 87800-87906. Code Description 36415 Collection of venous blood by Venipuncture 36416 Collection of capillary blood specimen (eg. finger, heel, ear stick) 36591 Collection of blood specimen from a completely implantable venous access device 36592 Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified A physicians office is reimbursed only one specimen collection fee per encounter regardless of the number of samples drawn or tests performed from a sample. Archived This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Related Polic ies & References Medicare Claims Processing Manual Chapter 16 Laboratory Services 907 KAR 3. 010 Physicians services State Exceptions NONE Document Revision History Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 1 Payment Policy Subject: Acupuncture Services Po l i c yCareSource will not reimburse for acupuncture services. De f i n i t i o n s”Acupuncture ” is a system of complementary medicine that involves pricking the skin or tissues with needles, used to alleviate pain and to treat various physical,mental, and emotional conditions.(from oxforddictionaries.com) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sAcupuncture is considered investigational and unproven and is not a covered benefit. Re l a t e d Po l i c i es & Re f e r e n c e s OAC Chapter 5160-4- 28(J) Physician Services / Noncovered services. KA RRule 3:005 Section 4-10 Services not covered. Ohio Department of Job and Family Services, Ohio Medical Assistance ProviderAgreement for Managed Care Plan Appendix G: Coverage and Services. St a t e Ex c e p t i o n sNONE Do c u m e n t Re v i s i o n Hi s t o r y10/31/2013OAC Rule renumbered from 5101:3-4-28(J), per Legislative Service Commission Guidelines.Archived
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