Overpayment Recovery

REIMBURSEMENT POLICY STATEMENTD-SNP Policy Name & Number Date Effective Overpayment Recovery-DSNP-PY-1394 12/01/2025 Ohio inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Market(s): Georgia Ohio Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Overpayment Recovery-DSNP-PY-1394Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectOverpayment Recovery B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for 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 members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant eeclaims payment.Retrospective review of claims paid to providers assist CareSource with ensuring accuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified.Fraud, waste and abuse investigations are an exception to this policy. In these investigations, the look back period may go beyond 2 years.C. Definitions Claims Adjustment A claim that was previously adjudicated and is being updated for one of the following reasons: o denied as a zero payment o a partial payment o a reduced payment o a penalty applied o an additional payment o a supplemental payment Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource, and the other carrier is the primary insurance for the member. Credit Balance / Negative Balance Funds that are owed to CareSource because of a claim adjustment. Explanation of Payment (EOP) Contains payment and adjustment information for claims the provider submitted for payment to CareSource. Forwarding Balance (FB) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past claim has been adjusted to a different dollar amount and that funds are owed to CareSource. Overpayment Recovery-DSNP-PY-1394Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 Improper Payment A payment that should not have been made, or an overpayment was made. Examples include, but are not limited to: o payments made for an ineligible member o ineligible service payments o payments made for a service not received o duplicate payments Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 CFR. A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Provider Level Balancing (PLB) Adjustments to the total check/remit amount occur in the PLB segment of the remit. The PLB can 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 Beginning Segment for Payment Order/Remittance Advice (BPR), which means total payment within the EOP). Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. D. PolicyI. In accordance with 42 CFR 438.608, CareSource requires providers to report any overpayment received by the provider. Overpayment must be returned to CareSource within 60 calendar days after the date on which the overpayment was identified, and CareSource must be notified in writing of the reason for overpayment. II. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider:A. The patient’s name, date of birth, and Medicaid identification number. B. The date or dates of services rendered. C. The specific claims that are subject to recovery and the amount subject to recovery, including any interest charges, which may not exceed the amount specified in Ohio law or rule. D. The specific reasons for making the recovery for each of the claims subject to recovery. E. If the recovery is a result of member disenrollment from the CareSource, the effective date of disenrollment. F. An explanation that if a written response to the notice is not received within 30 calendar days from receipt of the notice, the overpayments will be recovered from future claims. G. How the provider may submit a written response disputing the overpayment. H. How the provider may submit a written request for an extended payment arrangement or settlement. III. Overpayment RecoveriesA. Lookback period is 24 months from the claim paid date. Overpayment Recovery-DSNP-PY-1394Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 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. IV. 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 submitted within original claim timely filing guidelines. V. Retro Active Eligibility RecoveriesA. Lookback period is 24 months from date CareSource is notified by Medicaid of the updated eligibility status.B. Advanced notification will occur 30 days in advance of recovery. VI. Management of Claim Credit Balances.A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decreases 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. 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 overpayment 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 claims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. Overpayment Recovery-DSNP-PY-1394Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 D. Providers are notified of negative balances through EOPs and 835s. Providers are expected to use this information to reconcile and maintain their AccountsReceivable (AR) to account for the reconciliation of negative balances. E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. Providers are expected to maintain their AR to account for the reconciliation of negative balances when they occur. E. State-Specific Information1. Payment, GA. CODE 33-20A-62 (2024). 2. Ohio a. Ohio Medicaid Provider Agreement For Managed Care Organization. Accessed August 20, 2025. www.medicaid.ohio.gov b. Payments Considered Final Overpayment, OHIO REV . CODE ANN . 3901.388 (2002). F. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. G. Related Policies/RulesCareSource Provider Manual National Agreement, Article V. C laims and payments , 5.11 (d). H. Review/Revision HistoryDATE ACTIONDate Issued 10/26/2022 New policyDate Revised 02/14/2024 09/10 /2025Annual review. Removed V. C. Updated references.Approved at Committee. Periodic Review. Updated E.2.a. and references. Approved at Committee. Date Effective 12/01/2025 Date Archived I. ReferencesLimitation on Recoupment (935) for Provider, Physicians and Suppliers Overpayments. Center of Medicare & Medicaid Services; May 22, 2025. Accessed August 20, 2025. www.cms.gov

Modifier 59, XE, XP, XS, XU

REIMBURSEMENT POLICY STATEMENTD-SNP Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-DSNP-PY-1376 10/01/2025 Ohio inactive as of 01/01/202 6 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Ohio Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 59, XE, XP, XS, XU B. BackgroundReimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Reimbursement modifiers are 2-digit codes that provide a way for physicians and otherqualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, their use does not guaran tee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when 2 Healthcare Common Procedure Coding System(HCPCS)/Current Procedural Terminology (CPT ) codes should not be reported together either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together, but are appropriate un der the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because 2 different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the 2 procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established four HCPCS modifiers to define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that th e Xmodifiers are more selective versions of modifier 59. 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 Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding review.A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims s ubmission, this will also result in a claims denial.IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59.VI. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available. Documentation s hould support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meets all the following: Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 1. are performed at different anatomic sites2. are not ordinarily performed or encountered on the same day 3. cannot be described by 1 of the more specific anatomic NCCI Procedure to Procedure (PTP) -associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1 – T9, LC, LD, RC, LM, RI) B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed during different patient encounters 2. cannot be described by 1 of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91) C. Modifier XE (or 59, when applicable) may also be used when 2 timed procedures are performed during the same encounter but occur 1 after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are either 1. performed at separate anatomic sites 2. performed at separate patient encounters on the same date of service E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when all the following apply: 1. diagnostic procedure is the basis for performing the therapeutic procedure 2. occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires 3. provides clearly the information needed to decide whether to proceed with the therapeutic procedure 4. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately. ) F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when all the following apply: 1. diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure 2. occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires 3. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the post-procedure diagnostic procedure is an inherent component or otherwise included (eg, not separately payable) post – procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately. ) E. State-Specific InformationNA F. Conditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes.Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.G. Related Policies/Rules Modifier s H. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised 08/02/2023 07/17/2024 07/16/2025 Annual review: updated references. Approved at Committee Review: updated references, approved at Committee Review: updated references, approved at Committee Date Effective 10/01/2025 Date Archived I. References1. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 202 5. Accessed June 27, 2025 . www.cms.gov 2. Mechanized Claims Processing and Information Retrieval Systems; Operational, etc., Requirements, 42. U.S.C. 1396b(r) (2024). 3. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services; 202 4. Accessed June 27, 2025. www.cms.gov 4. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicare and Medicaid Services. Updated April 11, 2025 . Accessed June 27, 2025 . www.cms.gov 5. MLN1783722 – Proper Use of Modifiers 59 & -X{EPSU}. US Centers for Medicare & Medicaid Services; 202 4. Accessed June 27, 2025. www.cms.gov 6. Transmittal R1422OTN – Publication 100-20 – MM8863 – Specific Modifiers for Distinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Accessed June 27, 2025 . www.cms.gov

Modifier 25

REIMBURSEMENT POLICY STATEMENTD-SNP Policy Name & Number Date Effective Modifier 25-DSNP-PY-1371 10/01/2025 Ohio inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Market(s): Georgia Ohio Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 25-DSNP-PY-1371Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 25 B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. CareSource may verify the use o f any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a 2-character 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. Modifier 25 is used to report an Evaluation andManagement (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association (AMA) Current Procedural Terminology (CP T) book defines modifier 25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of mo difier 25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a medically necessary,significant, and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by documentation that satisfies th e relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guide for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. This modifier is not used to report a n E/M service that resulted in a decision to perform surgery. See modifier 57 for a surgical decision . For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier throu gh prepayment and post-payment edit or audit. Using a modifierinappropriately 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 Care Sources request. CareSource uses published guidelines fromModifier 25-DSNP-PY-1371Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly. C. Definitions American Medical Association (AMA) A professional association of physicians and medical students that maintains the Current Procedural Terminology coding system. Current Procedural Terminology (CPT ) Codes that are issue d, updated, and maintained by the AMA that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 25 may be flagged for either a prepayment clinical validation or prepayment medical record coding review .A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims s ubmission, this will also result in a claims denial.IV. Standard appeal rights apply for both pre-and post-payment findings and outcome s of the review. V. Modifier 25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier 25, the code may be denied. VI. Appending modifier 25 to an E/M service is considered inappropriate in the followingcircumstances:A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. Modifier 25-DSNP-PY-1371Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 B. The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure.C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. H. The preventative E/M service is performed at the same time as a preventative care visit (eg, a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preve ntative, only 1 should be reported. I. The routine use of the modifier is reported without supporting clinical documentation. J. CareSource will not reimburse CPT 99211 when billed with modifier 25. K. HCPCS G2211 will only be reimbursed when billed with modifier 25 for the following services: 1. preventive services 2. immunization administrations 3. annual wellness visits E. State-Specific InformationNA F. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document.G. Related Policies/RulesModifiers H. Review/Revision History DATE ACTION Modifier 25-DSNP-PY-1371Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 Date Issued 08/17/2022 New PolicyDate Revised 08/02/2023 07/17 /2024 07/16/2025 Annual Review: updated references. Approved at Committee Review: updated references approved at Committee Review; added D.VI.J and K, updated references. Approved at Committee Date Effective 10/01/2025 Date Archived I. References1. American Medical Association. Reporting CPT modifier 25. CPT Assistant (Online). 2023;33(11):1-12. Accessed June 19, 2025 . www.ama-assn.org 2. Appropriate use of modifier 25. American College of Cardiology. Accessed June 19 , 202 5. www.acc.org 3. Chaplain S. Are you using modifier 25 correctly? American Academy of Professional Coders. March 25, 2022. Accessed June 19, 2025 . www.aapc.com 4. Chapter 1 General Correct Coding Policies for Medicare National Correct Coding Initiative Policy Manual . Centers for Medicare and Medicaid Services ; 2025 . Accessed June 19, 2025 . www.cms.gov 5. Evaluation and Management Services Guide . Centers for Medicare and Medicaid Services; 2024. MLN006764. Accessed June 19, 2025. www.cms.gov 6. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag . 2004;11(9):21-22. Accessed June 19, 2025 . www.aafp.org 7. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services ; 2024. Accessed June 19, 2025 . www.cms.go v 8. Transmittal 13015 Publication 100-20 Allow Payment for Healthcare Common Procedure Coding System (HCPCS) Code G2211 when Certain Part BPreventive Services are Provided on the Same Day. US Centers for Medicare and Medicaid Services; 2024. Accessed July 10, 2025. www.cms.gov

Interest Payments

MEDICAL POLICY STATEMENTDSNP Policy Name & Number Date Effective Interest Payments-DSNP-PY-1427 04/01/2025 Ohio inactive as of 1/1/2026 Policy Type MEDICAL Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Ohio Table of ContentsA. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments-DSNP-PY-1427Effective Date: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectInterest Payments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office 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 that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and additional elements, or revisions to data elements, of which the provider has knowledge. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by State and/or Federal regulation defining timeliness and interest requirements. D. Policy I. CareSource strictly adhere to all regulatory guidelines relating to interest. CareSource follows the guidelines outlined in Prompt Payment regulations. (42 CFR 422.520) II. Payment of interest on original claims is made when CareSource fails to adjudicate original claims within the applicable state and federal prompt pay timeframes on clean claims. III. Payment of interest on adjusted claims starts on the date the provider disputes the original payment with CareSource. IV. CareSource considers interest payment on claims that were not paid accurately on prior processing attempts. If CareSource had the information to pay the claim correctly on a previous payment but failed to do so, CareSource will pay the claim Interest Payments-DSNP-PY-1427Effective Date: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 within the allotted timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe.V. CareSource only pays interest on claim payments that are occurring under prompt pay regulations. A contractual adjustment of a claim is not subject to state and federal regulations for interest payment. VI. CareSource performs regular reviews of our paid claims to correct claim payment.A. Reviews can include items such as retroactive eligibility updates, authorization updates, coordination of benefits (COB) updates, and fee schedule updates. B. Reviews include proactive measures to correct claim payment when it has been determined that a systemic issue has paid claims incorrectly. C. Claims are not subject to interest payment when CareSource takes proactive measures to pay claims correctly. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 04/12/2023 New PolicyDate Revised 01/31/2024 01/15/2025 Updated references; Approved at Committee. Updated references; Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. Interest, 41 U.S.C. 7109 (2024). 2. Interest Penalties, 31 U.S.C. 3902 (2024). 3. Interest rates. Bureau of the Fiscal Service. Updated August 15, 2024. Accessed December 15, 2024. www.fiscal.treasury.gov 4. Prompt Payment Interest Rate; Contract Disputes Act, 88 Fed. Reg. 55,501 (Aug. 15, 2023). Accessed December 15, 2024 . www.govinfo.gov 5. Prompt Payment of Claims, 42 U.S.C. 1395h(c)(2)(B) (2021). 6. Prompt Payment of Claims, 42 U.S.C. 1395u(c)(2)(B) (2021). 7. Prompt Payment by MA Organization, 42 C.F.R. 422.520 (2022).

Single Dose Vial – Claims Modifiers

REIMBURSEMENT POLICY STATEMENTOhio D-SNP Policy Name Policy Number Effective Date Single Dose Vial Claims Modif ier s PY-PHARM-010 7 07-01-2023 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 lo gic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CareSource and it s 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 f or 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. Def initions ………………………….. ………………………….. ………………………….. …………………… 3 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Sin g le Do se Vial Claims Mo d ifiersOh io D-SNPPY-PHARM-0107 Effective Date: 07-01-2023 2 A. SubjectThis policy provides guid ance for claims billing documentation and reimbursement of single dose injectable vials. B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and polic y clarif ication. These proprietary policies are 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 actual services provided to a member and 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 verif y members eligibility. It is the responsibility of the submitting provider to submit the most a ccurate andappropriate CPT/HCPCS /ICD-10 code(s) f or 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. This policy describes documentation require ments and reimbursement guidelines f orbilling of the administered and discarded portion (s) of drugs and biologicals . Providers shall bill and receive reimbursement f or both the dose administered and the unused portion of weight-based or variable dosing injectable drugs that are manuf actured and supplied only in single dose or single use f ormat. The JW modif ier is required to be reported on a claim to report the amount of drug that is discarded and e ligible f or payment and should be used only f or claims that bill single-dose container drugs. The discarded portion of single use or single dose vials must be identif ied with the JW Modif ier as a separate line item f rom the dose or administered portion. Pr oviders may be reimbursed f or the discarded portions of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropriately reported based on the policy reimbursement guidelines. As of July 1, 2023, providers and suppliers a re required to report the JZ modif ier on allclaims that bill f or drugs f rom single-dose containers when there are no discarded amounts. The JZ modif ier is reported on a claim to attest that no amount of drug was discarded and should only be used f or claim s that bill f or single-dose container drugs. Claims containing drug administered f rom multi-dose vials are not subject to this requirement. Under this policy, a ll claims for separately payable single dose format injectabledrugs must include either a JW modifier or a JZ modifier after 7-1-2023 in order to be reimbursed Sin g le Do se Vial Claims Mo d ifiersOh io D-SNPPY-PHARM-0107 Effective Date: 07-01-2023 3 MODIFIER SHORT DESCRIPTOR LONG DESCRIPTORJW Discard ed p o rtio n o f d rug no t ad ministered Drug amo unt d iscard ed /no t ad ministered to any p atient JZ All d rug ad ministered no ne d iscard ed Zero d rug amount d iscarded/not administered to any p atient C. Def initionsModif ie r JW ref ers to the drug amount discarded (wasted)/not administered to any patient . Modif er JZ ref ers to zero drug amount discarded/not administered to any patient. Discarded Wastage or Unused Portion is def ined as the amount of a single use/dose vial or other single use/dose package that remains af ter administering a dose/quantity of a drug or biological. Single Dose Vial is def ined as a vial of medication intended f or administration by injection or inf usion that is meant f or use in a single patient f or a sing le procedure. These vials are labeled as single-dose or single-vial by the manuf acturer and typically do not contain a preservative. Multi-Dose Vial is def ined as a vial of medication intended f or administration by injection or inf usion that contains more than one dose of medication. These vials are labeled as multi-dose by the manuf acturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. D. PolicyModif ier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modif ier JW. Both details are reimbursable. CareSource will consider reimbursement f or: I. A single-dose or single-use vial drug that is wasted, when Modif ier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not administered to another patient. CareSource will NOT consider reimburse ment f or:I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. NOTE: The JZ modif ier is required when there are no discarded amounts of a single – dose container drug f or which the JW modif ier would be required if there were discarded Sin g le Do se Vial Claims Mo d ifiersOh io D-SNPPY-PHARM-0107 Effective Date: 07-01-2023 4 amounts. The JZ modif ier is required to attest that there were no discarded amounts,and no JW modif ier amount is reported. E. Conditions of Coverage Providers must not use the JW modif ier f or medications manuf actured in a multi – dose vial f ormat. Providers must choose the most appropriate vial size(s) required to prepar e a dose to minimize waste of the discarded portion of the injectable vials. Claims considered f or reimbursement must not exceed the package size of the vial used f or preparation of the dose. Providers must not bill f or vial contents overf ill. Providers must not use the JW modif ier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modif er is only applied to the amount of drug or biological that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modif ier. 1. Claim Line #1 HCPCS code f or drug administered and the amount admistered to the patien t. 2. Claim Line #2 HCPCS code f or drug discarded (wasted) with JW modif ier appended to indicate waste and the amount discarded (wasted). The JZ Modif ier is applied when zero amounts of a single-dose container drug is discarded. F. Related Policies/Rules Chapt er 17, Section 40.1 of CMS Medicare Claims Processing Manual G. Review/Revision History DATE ACTIONDate Issued 01-22-2023 Original ef f ective dateDate Revised 08-25-2023 Updated policy to include JZ modif ier. Updated policy name and ref erences. Date Effective 07-01-2023 Date Archived H. Ref erences 1. Billin g an d Co d ing : JW an d JZ Mo d ifier Billin g Guid elines Article – Billin g an d Co d in g : JW an d JZ Mo d ifier Billin g Guid elin es (A55932) (cms.g o v) 2. New JZ Claims Mo d ifer fo r Certain Med icare Part BDru gs h ttp s://www.cms.g o v/files/d ocumen t/mm13056-n ew-jz-claims-modifier-certain-med icare-part-b- d rug s.p d f 3. Discard ed Drug s an d Bio lo g icals JW Mo d ifier an d JZ Mo d ifier Po licy FAQs. jw-mo d ifier – faq s.p d f (cms.g o v) The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in theReimbursement Policy Statement Policy and is app roved.