OH Med Admin Policy Archived

Program Integrity Provider Prepayment Review

ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-OH MCD-AD-0767 12/01/2024 Policy Type ADMINISTRATIVE Administrative 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 industry s tandards, 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 wit hout 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 l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates 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 Adminis trative Policy Statement. If there is a conflict between the Administrative 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 make 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 limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 5 F. Related Policies/Rules ………………………………………………………………………………………….. 5 G. Review/Revision History ………………………………………………………………………………………… 5 H. References ………………………………………………………………………………………………………….. 5 Program Integrity Provider Prepayment Review-OH MCD-AD-0767 Effective Date: 12/01/2024 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.2A. Subject Program Integrity Provider Prepayment Review B. Background CareSource Program Integrity (PI) operates a provider prepayment review program to detect, prevent, and correct fraud, waste, and abuse, and to facilitate accurate claim payments. Physicians and other healthcare professionals may have the right to appeal results of reviews. C. Definitions Provider Prepayment Review Reviews of medical record documentation and comparison billed services. Program Integrity (PI) The proper management and functioning of a health insurance program to ensure it is providing quality and efficient care while using funds taxpayer dollars appropriately and with minimal waste. Certified Professional Coder (CPC) The certified professional coder credential is offered through the American Academy of Professional Coders (AAPC). Professional coding is medical coding that is conducted in a professional environment such as a physician's office, outpatient setting, or hospital. Registered Health Information Administrator (RHIA) – A professional who handles patient health information. The RHIA role requires certification and must adhere to standards such as the Health Insurance Portability and Accountability Act and other privacy and security rules. Registered Health Information Technician (RHIT) – A certified professional who stores and verifies the accuracy and completeness of electronic health records and analyzes patient data with the goal of controlling healthcare costs and improving patient care. Soft Denial A denial applied to claims which are selected as part of the prepayment review audit . Soft denials do not require an appeal to resolve . Upload records to the CareSource Provider Portal for the denied claim . Soft denials are identified in the remittance advice by RARC code 127 Missing patient medical record for this service.D. Policy I. A provider prepay review involves reviewing medical records compared to services billed prior to claim adjudication. Providers are placed on prepay review to monitor for improper billing of medical claims including but not limited to the following reasons: A. overutilization of services B. billing for items or services not rendered C. selection of wrong CPT/HCPCS code or supplies D. lack of medical necessity E. billing/dispensing unnecessary services F. procedure repetition Program Integrity Provider Prepayment Review-OH MCD-AD-0767 Effective Date: 12/01/2024 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.3G. upcoding H. billing for services outside of provider specialty II. Placement on prepayment review will require the provider to submit medical records for all identified claims allowing CareSource to review the medical records in comparison to the billed services. A. Claims selected for prepayment review will be soft denied. B. Provider must upload medical records to the CareSource Provider Portal . It is not necessary to appeal a soft denial. C. Failure to submit medical records to CareSource in accordance with this provision will result in claim remaining denied. D. Failure to meet minimal documentation standards, such as member name and date of service on each page of the medical record, a signed dated order, and a valid provider signature, will result in claim denial. E. Providers must bill timely and accurate claims while under prepayment review. III. CareSource uses widely recognized sources to conduct reviews which includes, but is not limited to, the following: A. Centers for Medicare and Medicaid Services (CMS) guidelines, as stated in Medicare manuals B. Medicare local and national coverage determinations C. CareSource published policies (Administrative, Medical and Reimbursement), code-editing policies and CareSource provider manuals D. National Uniform Billing Guidelines from the National Billing Committee E. American Medical Association Current Procedural Terminology (CPT) guidelines F. Current American Medical Association Healthcare Common Procedure Coding System (HCPCS) Level II G. ICD 10-CM official guidelines for coding and reporting H. American Association of Medical Audit Specialists national healthcare billing audit guidelines I. industry-standard utilization management criteria and/or care guidelines, such as MCG guidelines (current edition on date of service) J. Food and Drug Administration guidance K. national professional medical societys guidelines and consensus statements L. publication from specialty societies, such as the American Society for Parenteral and Enteral Nutrition, the Substance Abuse and Mental Health Service Administration, and the American Association of Neuromuscular & Mental Health Services Administration M. nationally recognized, evidence-based published literature including, but not limited to, sources such as Medscape, the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) IV. The Program Integrity Provider Prepayment Review Team is comprised of clinical review Program Integrity Provider Prepayment Review-OH MCD-AD-0767 Effective Date: 12/01/2024 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.4and coding specialists who maintain CPC, RHIA, or RHIT designations. The team reviews provider documentation to determine whether the claim is appropriate for payment based on criteria including, but not limited to, provider documentation which establishes the following : A. Services were provided according to CareSource policy requirements. B. Members were benefit eligible on the date the services were provided. C. Prior authorization was obtained, if required by policy. D. Providers and staff were qualified, as required by state or federal law. E. The provider possessed the proper license, certification, or other accreditation requirements specific to the providers scope of practice at the time the service was provided to the member. V. Providers whose claims (or claim lines) are determined not payable via coding review audit after medical records submi ssion may dispute or appeal, whichever is appropriate, within timely filing limitations as outlined in the provider manual. Providers and/or billing managers may reach out directly to the program integrity prepayment review team to discuss specific claim denials. VI. Release from prepayment review includes the following steps : A. CareSource will review provider accuracy monthly to determine if the provider is eligible for release from prepayment review. Eligibility is as follows: 1. The provider has demonstrated a high accuracy rate on claim submissions for 3 consecutive months . 2. The volume of claims submissions remained consistent with the volume before prepayment review. 3. Provider maintains a high rate of records returned after soft denial. B. Once released from prepayment review, the provider/provider group will receive notification in writing as to the effective end date of review . Providers who demonstrate accurate billing practices and have been removed from prepayment review may be subject to future follow up reviews to ensure continued compliance with billing practices. C. If the provider fails to satisfy the requirements above, the following may be necessary: 1. If after 12 months on prepayment review the provider fails to satisfy the requirements under subsection A, CareSource may do the 1 of following: a. outreach to provider to educate on claim accuracy issues b. require a corrective action plan c. deny payment for services rendered during a specified period of time d. terminate the provider agreement 2. If a provider has been on a prepayment review for 12 months, CareSource may terminate the provider agreement i n the following conditions: a. no billing activity for 6 months Program Integrity Provider Prepayment Review-OH MCD-AD-0767 Effective Date: 12/01/2024 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.5b. claim submission volume during review period is not consistent with the volume before prepayment review E. Conditions of Coverage N/A F. Related Policies/Rules N/A G. Review/Revision History DATES ACTION Date Issued 01/08/2020 New Policy Date Revised 08/19/2020 07/20/2022 08/02/2023 08/14/2024 Updated Section VII .Editorial updates only.Added definition Soft Denial. Removed 30 day requirements and substitutes all identified claims Removed old section III. Removed IV.A.2. Removed old section V I. And VII. Added new IV. Release from prepayment review. Removed from section D. II. CareSource will provide a written notice to the provider/provider group advising the effective date of prepayment review. Approved at Committee. Date Effective 12/01/2024 Date Archived H. ReferencesN/A Approved by ODM 8/29/2024

Acute Hospital Care at Home

Administrative 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 industry 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 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates 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 Administrative Policy Statement. If there is a conflict between the Administrative 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 make 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 limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Acute Hospital Care at Home-OH MCD-AD-1213 12/01/2024-10/31/2025 Policy Type ADMINISTRATIVE Table of ContentsA. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules …………………………………………………………………………………………… 5 G. Review/Revision History …………………………………………………………………………………………. 6 H. References …………………………………………………………………………………………………………… 6Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 12/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 2 A. SubjectAcute Hospital Care at HomeB. Background The Johns Hopkins School of Medicine created a hospital at home program in 1995 to provide safe and effective hospital level care in the home setting. Since then, numerous studies and trials have evaluated and demonstrated the efficacy of this model. In November 2020, the Centers for Medicare & Medicaid Services (CMS) initiated a program to allow patients to be treated outside the traditional hospital setting in an effort to increase health care system capacity amid an increasing number of coronavirus disease (COVID-19) hospitalizations. At that time, the Ohio Department of Medicaid (ODM) adopted this model. Health care organizations are using an innovational care model for hospital care in the home as a full substitute for acute hospital care. The model was developed to support acute hospital care in the home setting following reports of success in leading hospital institutions and networks. CMS believes that treatment for more than 60 different acute conditions, such as exacerbations of asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) care can be treated appropriately and safely in home settings with proper monitoring and treatment protocols. Participating hospitals are required to have appropriate screening protocols before care at home begins to assess both medical and non-medical factors, including working utilities, assessment of physical barriers and screenings for domestic violence concerns. Beneficiaries will only be admitted from emergency departments and inpatient hospital beds, and an in-person physician evaluation is required prior to starting care at home. A registered nurse will evaluate each patient once daily, either in person or remotely, and two in-person visits will occur daily by either registered nurses or mobile integrated health paramedics based on the patients nursing plan and hospital policies. This program is designed for patients who meet acute inpatient or have failed observation admission criteria for hospital-level care and can be treated safely in a home setting with appropriate monitoring and treatment protocols. The patients home is considered part of the hospital during the admission. The program does not have to be physically administrated within a hospital, but a hospital must accept responsibility for the program in order to satisfy the Conditions of Participation (CoP) for this level of patient care. Additionally, the program must be integrated within a hospital to a sufficient degree to ensure that rapid escalation of care is seamless. The program will be closely monitored to safeguard members. Hospitals will be required to report quality and safety data on a frequency that is based on their prior experience with the Hospital at Home model. (CMS 2021) Hospitals must submit an application to CMS in order to qualify and be certified to participate in this program. This information can be accessed on the CMS website. Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 12/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 3 Waiver requests will be divided into two categories based on the hospital applicants prior experience with acute hospital care at home. Participating hospitals are required to submit appropriate screening protocols for medical necessity review before care at home begins.C. DefinitionsHealth Care Facilities Code (HCFC) A set of requirements intended to provide minimum requirements for the installation, inspection, testing, maintenance, performance and safe practices for facilities, material, equipment, and appliances. Life Safety Code (LSC) A set of fire protection requirements designed to provide a reasonable degree of safety from fire. Remote Monitoring Monitoring of physiologic parameters, including weight, blood pressure, heart monitoring, pulse oximetry and respiratory flow rate. D. Policy I. CareSource considers acute hospital care at home medically necessary when ALL of the criteria in this policy are met. A prior authorization will be required for the approval of acute hospital care at home services. Appropriate and complete documentation to support medical necessity must be presented at the time of the review. Participating hospitals should submit appropriate screening protocols for medical necessity review before care at home begins. Acute hospital care at home services are subject to subsequent reviews following initial approval. Reviews will be based on clinical status of the member, and additional documentation may be requested. A. CMS-Approved Requirements for Participating Hospitals 1. The hospital must be CMS-certified. 2. Participating hospitals are required to have appropriate screening protocols in place before care at home begins, including all the following: a. Verification that the members home meets their needs for safety, shelter and basic working utilities, including completion of a HCFC and LSC form; b. Assessment of physical barriers; and c. Screenings for domestic violence concerns and completion of form. 3. The members broadband service must meet 4G/5G requirements. 4. The member needs inpatient-level of hospital care. 5. The member must be identified and assessed by hospital staff as meeting the qualifying criteria for home admission and treatment. 6. The member must sign a consent agreeing to receive care at home under the program. 7. The member must meet one of the following acute conditions including, but not limited to: a. exacerbations of congestive heart failure b. community-acquired pneumonia c. exacerbations of chronic obstructive pulmonary disease (COPD) d. exacerbations of asthma Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 12/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 4 e. cellulitis f. urinary tract infection (UTI) g. volume depletions / dehydration 8. The member must enter the acute hospital care at home from either the Emergency Department or an inpatient hospital setting. 9. An in-person physician evaluation and exam must be completed prior to the member being transferred home. a. The in-person physician exam may be performed by the inpatient hospitalist, admitting physician or emergency room physician. b. The in-person physician evaluation must be performed by the same or designated physician completing the initial history and physical exam documentation and admission orders consistent with hospital policies. 10. The member must be considered clinically and hemodynamically stable. B. Home Care Requirements 1. The assigned physician must complete daily evaluations (telehealth or in-person) of the member, including an assessment and continued management of appropriate diagnostic and therapeutic measures. a. The physician must make one or more visits daily and must be available 24 hours a day, seven days a week for any emergent issues. b. Provider assessments should be consistent with the existing medical staff policies for requirements for physical assessments. 2. Daily in-person visits a. An RN must evaluate the member daily. This may be in-person or remote. An RN must be available 24/7 in person and remotely. b. Two daily in-person (not remote) visits are required with a set of vital signs and may be performed by either: 01. An RN, if the team determines that an RN should see the patient in-person. 02. A Mobile Integrated Health Paramedic if the team determines this is appropriate.3. Remote Monitoring a. Remote monitoring must be consistent with the hospital policies and standards of care. b. Remote monitoring can be continuous or intermittent, and the intensity should be appropriate according to each members needs. c. Assistive technology may be used for auscultative transmission of heart and lung exams. 01. If physician or APP performed heart and lung exams are indicated, they may be performed via technological transmission or in-person examination. 02. It is also acceptable to verify these parts of the exam with the RN and/or paramedic and exclude them from the daily physician exam based on the members condition. 4. Discharge Planning Documentation should support the following discharge standards:Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 12/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 5 a. A discharge plan that includes the provider(s) responsible for follow up care (the discharge planning evaluation should be used as a guide in the development of the discharge plan) b. All necessary medical information pertinent to illness and treatment and post-discharge goals of care were provided to the appropriate post-acute care service providers at the time of discharge c. Coordination and/or referrals with the CareSource case manager, community agencies, and providers responsible for follow up care d. Completion of medication reconciliation/management; e. Needed DME and supplies are in place prior to discharge f. Scheduled appointments are listed with dates, times, names, telephone numbers and addresses and g. Member/guardian and family engagement, as needed. II. Quality of Care A. Hospitals are required to maintain specific standards of care to ensure patient safety and high quality of care, including tracking and maintaining documentation of preventable and non-preventable adverse events. CareSource may request documentation regarding hospital at home incidents and healthcare acquired conditions, including but not limited to the following: 1. falls with serious injury 2. pressure ulcers and injuries 3. catheter-associated urinary tract infections (CAUTI) 4. vascular catheter-associated conditions 5. patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility 6. patients death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended 7. patients suicide, or attempted suicide resulting in serious disability while being cared for in a hospital at home setting 8. serious injury to staff secondary to assault in the home environment III. This program is not intended to be used by independent nursing home facilities that are not associated with the hospital participating in the acute hospital care at home program.E. Conditions of CoverageNA F. Related Policies/Rules Sentinel Events and Provider Preventable Conditions Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 12/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 6 G. Review/Revision HistoryDATE ACTIONDate Issued 09/15/2021 New Policy Date Revised 05/11/2022 Changed from Medical to Admin. Added UTI and 26 th ed. MCG references.08/16/2023 Added new MCG Covid-19: Hospital-at-Home. M-281-HaH(ISC). Updated references. Approved at Committee08/14/2024 Updated references. Added Sentinel Events and ProviderPreventable Conditions to F. Related Policies/Rules.Approved at CommitteeDate Effective 12/01/2024 Date Archived 10/31/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H. References1. Acute hospital care at home individual waiver only (not a blanket waiver). Centers for Medicare and Medicaid Services. Accessed July 8, 2024. www.cms.gov 2. Acute hospital care at home resources. QualityNet, Centers for Medicare and Medicaid Services. Updated August 24, 2023. Accessed July 8, 2024. www.qualitynet.cms.gov 3. Cellulitis: hospital-at-home: M-70-HaH. MCG Health. 28th ed. 2024. Accessed July 8, 2024. www.careweb.careguidelines.com 4. Chronic obstructive pulmonary disease: hospital-at-home: M-100-HaH. MCG Health. 28th ed. 2024. Accessed July 8, 2024. www.careweb.careguidelines.com 5. Clarke DV, Newsam J, Olson DP, et al. Acute hospital care at home: the CMS waiver experience. NEJM Catalyst . December 7, 2021. doi:10.1056/CAT.21.0338 6. CMS announces comprehensive strategy to enhance hospital capacity amid COVID-19 surge. News release. Centers for Medicare and Medicaid Services. November 25, 2020. Accessed July 8, 2024. www.cms.gov 7. Covid-19: hospital-at-home: M-281-HaH. MCG Health. 28th ed. 2024. Accessed July 8, 2024. www.careweb.careguidelines.com 8. Friedberg M, Landon B. Measuring quality in hospitals in the United States. UpToDate. Updated April 10, 2024. Accessed July 8 2024. www.UpToDate.com 9. Heart failure: hospital-at-home: M-190-HaH. MCG Health. 28th ed. 2024. Accessed July 2, 2024. www.careweb.careguidelines.com 10. Hospital at home. John Hopkins Medicine Healthcare Solutions. Accessed July 8, 2024. www.johnhopkins.com 11. Leff B, Burthon L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143(11):798-808. doi:10.7326/0003-4819-143-11-200512060-00008 12. Life safety code and health care facilities code requirements. Centers for Medicare and Medicaid Services. Accessed July 8, 2024. www.cms.gov 13. National Patient Safety Goals Effective January 2021 for the Hospital Program . TheAcute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 12/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 7 Joint Commission; 2021. Accessed October 2, 2023. www.jointcommission.org 14. Pneumonia: hospital-at-home: M-282-HaH. MCG Health. 28th ed. 2024. Accessed July 8, 2024. www.careweb.careguidelines.com 15. Edgar K, Iliffe S, Doll HA, et al. Admission avoidance hospital at home. Cochrane Database Syst Rev . 2024;3:CD007491. doi:10.1002/14651858.CD007491.pub3 16. Urinary tract infection (UTI): hospital-at-home: M-300-HaH. MCG Health. 28th ed. 2024. Accessed July 8, 2024. www.careweb.careguidelines.com 17. Viral illness, acute: hospital-at-home: M-280-HaH. MCG Health. 28th ed. 2024. Accessed July 8, 2024. www.careweb.careguidelines.com 18. West N, Eng T. Monitoring and reporting hospital-acquired conditions: a federalist approach. Medicare Medicaid Res Rev . 2015;4(4):e1-e16. doi:10.5600/mmrr.004.04.a04e Approved by ODM 8/22/2024

Experimental or Investigational Item or Service

ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Experimental or Investigational Item or Service-OH MCD-AD-0006 06/01/2024 Policy Type ADMINISTRATIVE Administrative 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 industry 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 which the patient can be expected to su ffer 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 l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other polic ies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates 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 Administrative Policy Statement. If there is a conflict between the Administrative 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 make 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 limitations that are less favorable than the limit ations 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/R ules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Experimental or Investigational Item or Service-OH MCD-AD-0006 Effective Date: 06/01/2024 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.2A. Subject Experimental or Investigational Item or Service B. Background Experimental and/or investigational items or services are not covered. This includes, among other things, services or procedures considered to be investigational, cosmetic, or not medically necessary . This policy defines the medical review decision process around such treatment requests. CareSource members have the right to refuse or participate in experimental or investigational items or services. Providers are encouraged to inform members in advance when they may be financially responsible for the cost of non-covered or excluded services. C. Definitions CPT Category III codes A set of temporary (T) codes assigned to emerging technologies, services, and procedures. These codes are intended to be used for data collection to substantiate more widespread usage or to provide documentation for the Food and Drug A dministration (FDA) approval process . Experimental or Investigational Items or Services Medical, surgical, diagnostic, psychiatric, substance use disorders treatment or other health care services, technologies, equipment, supplies, treatments, procedures, therapies, biologics, drugs, or devices (each a Health Care Item or Ser vice) that, at the time CareSource has made a determination regarding coverage in a particular case, are: o not approved by the United States Food and Drug Administration (FDA) to be lawfully marketed for the proposed use o not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use, or o determined by the FDA to be contraindicated for the specific use o subject to review and approval by any institutional review board or other body serving a similar function for the proposed use, and such final approval has not been granted o the subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 , or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight o pro vided as part of a clinical research protocol or clinical trial or is provided in any other manner that is intended to evaluate the safety, toxicity, or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply o provided pursuant to informed consent documents that describe the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply as e xperimental or i nvestigational, or otherwise indicate that the safety, toxicity , or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is under evaluation o the subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is Experimental or Investigational Item or Service-OH MCD-AD-0006 Effective Date: 06/01/2024 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.3actually subject to FDA oversight. This includes diagnostic testing for purposes of p ossible inclusion in a clinical trial Devices that are FDA approved under the Humanitarian Use Device exemption are not considered to be experimental or investigational. Drugs used in Phase 4 trials may be covered if they are part of the formulary . D. Policy I. Any health care item or service CareSource determines in its sole discretion to be experimental or investigational is not covered. II. Any health care item or service not deemed experimental or investigational based on the criteria in Section C. may still be deemed experimental or investigational if it is not supported by credible research that soundly demonstrates that such item or service will have a measurable and benefic ial health outcome. In determining whether such health care item or service is experimental or investigational, CareSource, in its sole discretion, will consider the information and evidence from one or more of the sources in Section III below and assess w hether: A. The scientific evidence is conclusory concerning the effect of the health care item or service on health outcomes . B. The evidence demonstrates the health care item or service improves net health outcomes of the total population for whom t he item or service might be proposed by producing beneficial effects that outweigh any harmful effects . C. The evidence demonstrates the health care item or service has been shown to be as beneficial for the total population for whom the service might be proposed as any established alternatives . D. The evidence demonstrates the health care item or service has been shown to improve the net health outcomes of the total population for whom the service might be proposed under the usual conditions of medical practice outside clinical investigatory settings. III. When reviewing requests, CareSource will consider information and evidence from the following non-exhaustive list: A. published authoritative, peer-reviewed medical or scientific literature, or the absence thereof B. evaluations of national medical associations, consensus panels, and other technology evaluation bodies C. documents issued by and/or filed with the FDA or other federal, state or local agency with the authority to approve, regulate, or investigate the use of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply D. documents of an institutional review board or other similar body performing substantially the same function Experimental or Investigational Item or Service-OH MCD-AD-0006 Effective Date: 06/01/2024 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.4E. consent document(s) and/or the written protocol(s) used by providers studying substantially the same drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply F. m edical records G. the opinions of consulting providers and other exper ts in the field E. Conditions of Coverage NA F. Related Policies/Rules Clinical Trial Coverage Medical Necessity Determinations policy G. Review/Revision History DATES ACTIONDate Issued 01/31/2024 New PolicyDate Revised Date Effective 06/01/2024 Date Archived H. References1. Biological Products, 21 C.F.R. 600.2-.90 (202 3). 2. Coverage and Authorization of Services, 42 C.F.R. 438.210 (2022). 3. EPSDT-A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents . Centers for Medicare & Medicaid Services; 2020. HHS-0938-2014-F-1347. Accessed January 8, 2024. www.hhs.gov 4. Investigational Device Exemptions, 21 C.F.R. 812.1- .46 (2023). 5. Medical Services Coverage Decisions That Relate to Health Care Technology, 42 C.F.R. 405.201- .215 (2022). 6. Medicare Coverage of Items and Services in Category A and BInvestigational Device Exemption (IDE) Studies . Centers for Medicare & Medicaid Services; 2015. MLN Matters MM8921. Accessed January 8, 2024. www.cms.gov 7. Non-Covered Services, O HIO ADMIN . CODE 5160-1-61 (2022). 8. Phases of an Investigation, 21 C.F.R. 312.21 (2023). 9. Premarket Approval of Medical Devices, 21 C.F.R. 814.1 -.19 (2023). 10. Utilization Control, 42 C.F.R. 456.1-. 725 (2022). Approved by ODM on 03/14/2024

Cystic Fibrosis Testing

ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Cystic Fibrosis Testing-OH MCD-AD-0837 06/01/2024 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technol ogy assessment guidelines, other medical management industry 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 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 ser vices 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 Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates 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 Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidenc e of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make 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 limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subjec t ………………………….. ………………………….. ………………………….. …………………………. 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. Re ferences ………………………….. ………………………….. ………………………….. ……………………. 4 Cystic Fibrosis Testing-OH MCD-AD-0837Effective Dat e: 06/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. Subjec tCystic Fibrosis Testin g B. BackgroundCystic fibrosis (CF) is a recessive genetic disorder caused by mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene . When an individual inherits two abnormal CFTR genes from their parents, they may develop dysregulation of the epithelial lining fluid transport , affecting systemic mucus production . Diagnosis of CF is based upon the finding of genetic and/or functional abnormalities of the CFTR gene (CFTR variants) and is typically associated with progressive lung disease , pancreatic insufficiency, and elevated sweat chlorid e levels . Many individuals with CF demonstrate mild or atypical symptoms and can present laterin childhood or as adults , while others may test positive for CF, yet remain asymptomatic(CRMS). U ntreated CF in some can lead to early mortality and infertil ity . This makes early CF diagnosis and identification of carriers of CF important for early intervention to mitigate disease progression as well as to allow for more informed health determinations . Advances in CF research has led to steadily evolving tests that can identify abnormal CF TR genes as well as tailored treatments to address the underlying mechanisms leading to disease. More than 10 million Americans are carriers of a defective CF TR gene and show nosymptoms of the disease . Others who do not fit CF diagnostic criteria still go on to develop disease associated with evidence of CFTR dysfunction limited to one organ (CFTR-related disorder) . Carrier testing may provide an early indication as to whether a person might develop a CFTR-related disorder . Potential parents who test positive as carriers for CF will be able to make educated reproductive decisions, better prepare for birth, and investigate additional testing for CF-related health conditions. A negative screening result does not completely rule out the possibility that a person is a CF carrier. A negative screening test only rules out the specific CF variants that were part of the screen. Diagnosis of CF is a multistage process. Individuals must have clinical symptoms consistent with CF in at l east one organ system, have a positive newborn screen, orhave a sibling with CF. In addition, there must be evidence of CFTR dysfunction via elevated sweat chloride, presence of two disease-causing CFTR mutations (one from each parent), or abnormal nasal potential difference (NPD). Newborn screening involves immunoreactive trypsinogen (IRT), sweat chloride testing, and genetic testing. C. Definitions American College of Medical Genetics and Genomics (ACMG) A nationally recognized interdisciplinary organiz ation dedicated to the practice of medical genetics. The ACMG regularly posts technical recommendations for genetic diseases, including cystic fibrosis. Cystic Fibrosis Testing-OH MCD-AD-0837Effective Dat e: 06/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 Autosomal Recessive A trait or disorder requiring a deleterious variant in both copies of the gene to express a phenotyp e. Carrier An individual with a gene variant for a disease or disorder who can pass the variant on to offspring but does not have symptoms or features of the disorder . Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Transmembrane protein that functions as a regulated anion channel to maintain a gradient necessary for normal cell function. Mutations that alter the function of the CFTR protein are associated with CF. CFTR-Related Disorder A single pathogenic CFTR vari ant leading to the develop ment of disease limited to one organ system in a n individual who does not fit the CF diagnosis . CFTR-Related Metabolic Syndrome (CRMS) Infants and children who are asymptomatic but have positive CF screening results. Found in 3-4% of infants with a positive newborn CF screen , CRMS is a lso known as CF screen positive, inconclusive diagnosis (CFSPID). Immunoreactive Trypsinogen (IRT) A pancreatic enzyme precursor measured in newborns to screen for the presence of CF. D. PolicyI. Genetic testing for CF should only be performed once in a lifetime and the results documented in the members health record . All genetic testing for CF should use currently recommended ACMG CFTR panels. Prior authorization is only required for CF genomic sequence analysis. II. Diagnostic testing is considered medically necessary when the member meets any of the following criteria : A. clinical presentation of CF B. infertility from oligospermia/azoospermia/congenital bilateral absence of vas deferens (CBAVD) C. infant with meconium ileus or other symptoms indicative of CF but unable to produce adequate amounts of sweat for a sweat chloride test D. infant with an elevated IRT value on newborn screening and a sweat chloride of at least 60 mmol/L or intermediate sweat chloride (between 30 mmol/L and 59 mmol/L) III. Carrier screening is indicated when the member meets any of the following criteria:A. me mbers who are pregnant or of reproductive age with intent and potential to procreate B. members whose partner tests positive while the member is pregnant or intending to become pregnant C. members with a family history of CF D. members where both parents are CF car riers Cystic Fibrosis Testing-OH MCD-AD-0837Effective Dat e: 06/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 IV. The following are not considered medically necessary and will not be covered:A. repeat testing B. gene sequencing of anything other than the CFTR gene C. Fetal testing is generally not considered medically necessary. However, fetal testing is medically necessary with the presence of any of the following: 1. Both parents have disease-causing mutations of the CFTR gene. 2. Echogenic bowel is detected on ultrasound examination of fetus during pregnancy. 3. The mother is a confirmed carrier, and father is unknown or unavailable for testing. E. Conditions of CoverageCareSource may request documentation for post-payment review of claims submitted for payment of CF testing. If documentation is not provided, CareSource may recoup previously paid claim(s). F. Related Policies/RulesGenetic Testing and Genetic Counseling G. Review/Revision HistoryDATES ACTIONDate Issued 09/02/2020Date Revised 07/2 0/2022 02/14/2024 Addition of Section D , IV and V. Annual review: c hanges to title, background, and definitions, expanded policy to include diagnostic testing, and u pdated references. Approved at Committee . Date Effective 06/01/2024 Date Archived H. References1. Barben J, Castellani C, Munck A, et al. Updated guidance on the management of children with cystic fibrosis tran smembrane conductance regulator-related metabolic syndrome/cystic fibrosis screen positive, inconclusive diagnosis (CRMS/CFSPID). J Cyst Fibros . 2021;20(5):810-819. doi:10.1016/j.jcf.2020.11.006 2. Bienvenu T, Lopez M, Girodon E. Molecular diagnosis and genetic counseling of cystic fibrosis and related disorders: new challenges. Genes (Basel) . 2020;11(6):619. doi: 10.3390/genes11060619 3. Bombieri C, Claustres M, De Boeck K, et al. Recommendations for the classification of diseases as CFTR-related disorders. JCyst Fibros . 2011;10(Suppl 2):S86-S102. doi:10.1016/S1569-1993(11)60014-3 4. Carrier. National Human Genome Research Institute. Updated October 15, 2023. Accessed December 28 , 2023. www.genome.gov 5. Carrier testing for cystic fibrosis. Cystic Fibrosis Foundation . Accessed December 28 , 2023. www.cff.org Cystic Fibrosis Testing-OH MCD-AD-0837Effective Dat e: 06/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 6. Committee on Genetics : c arrier screening for genetic conditions. American College of Obstetricians and Gynecologists. Re affirmed 2023. Accessed December 28 , 2023. www.acog.org 7. Cystic fibrosis CFTR gene and mutation panel: A-0597. MCG. 27 th ed. Updated September 21, 2023. Access ed January 3, 2023. www.careweb.careguidelines.com 8. De Boeck K. Cystic fibrosis in the year 2020: a disease with a new face. Acta Paediatr . 2020;109(5):893-899. doi:10.1111/apa.15155 9. Deignan JL, Astbury C, Cutting GR, et al. CFTR variant testing: a technica l standard of the American College of Medical Genetics and Genomics (ACMG). Genet Med . 2020;22(8):1288-1295. doi:10.1038/s41436-020-0822-5 10. Deignan JL, Gregg AR, Grody WW, et al. Updated recommendations for CFTR carrier screening: a position statement of the American College of Medical Genetics and Genomics (ACMG). Genet Med . 2023;25(8):100867. doi:10.1016/j.gim.2023.100867 11. Katkin JP. Cystic f ibrosis: clinical manifestations and diagnosis. UpToDate. Updated March 7, 2023. Accessed December 28 , 2023. www.uptodate.com 12. Katkin JP. Cystic fibrosis: genetics and pathogenesis. UpToDate. Updated February 8, 2023. Accessed December 28, 2023. www.uptoda te.com 13. Langfelder-Schwind E, Karczeski B, Strecker MN, et al. Molecular testing for cystic fibrosis carrier status practice guidelines: recommendations of the National Society for Genetic Counselors . JGenet Couns . 2014;23(1):5-15. doi:10.1007/s10897-013 – 9636-9 14. Marwaha S, Knowles JW, Ashley EA. A guide for the diagnosis of rare and undiagnosed disease: beyond the exome. Genome Med . 2022;1 4(1):23. doi:10.1186/s13073-022-01026-w 15. Medicaid fee schedule: laboratory services. Ohio Dept of Medicaid. Accessed December 28, 2023. www.medicaid.ohio.gov 16. Medicaid Waiver for Individuals with Cystic Fibrosis, OHIO REV . CODE 5166.32 (2023). 17. Procedure Following Repeat Screening or Diagnostic Testing , OHIO ADMIN . CODE 3701-55-08 (2023). 18. Russo ML. Cystic fibrosis: carrier screening. UpToDate. Updated February 8, 2023. Accessed December 28, 2023. www.uptodate.com 19. Shteinberg M, Haq IJ, Polineni D, Davies JC. Cystic fibrosis. Lancet . 2021;397(10290):2195-2211. doi:10.1016/S0140-6736(20)32542-3 ODM approved 2/29 /2024

Bilateral Procedures

Against Medical Advice

ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Against Medical Advice-OH MCD-AD-0788 05/01/2024 Policy Type ADMINISTRATIVE Administrative 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 which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically n ec-essary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Pro-vider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of ser-vices. Please refer to the plan contract (often referred to as the E vidence of Coverage) for the service(s) referenced in the Ad-ministrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e. , Evi-dence of Coverage), then the plan contract (i.e., Evidence of Cove rage) will be the controlling document used to make the deter-mination. 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 tions that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. Re ferences ………………………….. ………………………….. ………………………….. ……………………. 3 Against Medical Advice-OH MCD-AD-0788Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectAgainst Medical Advice B. BackgroundStudies show that approximately 1-2% of all hospitalizations result in discharge against medical advice (AMA). Discharges AMA are at higher risk for inadequately treated medical conditions, readmissions, and /or negative health outcomes when compared to planned discharges. Documented reasons for leav ing AMA may include a lack of satisfaction with the treatment team , treatment team members or facility, a general mistrust of medical systems, underutilization of social support, and/or a lack of health insurance or low socio-economic status. Additionally, research also indicates that previous medical diagnoses substantially impact rates of discharge AMA with psychiatric, substance abuse , and patients with human immunodeficiency virus exhibiting the most significant risk. C. Definitions Against Medical Advice (AMA) A member chooses to leave the hospital or acute care setting before a provider writes the order for discharge. D. PolicyI. CareSource will only pay for services, procedures, and supplies rendered. II. The discharge status code on the submit ted claim must indicate that the member left against medical advice. III. If a member leaves against medical advice from the emergency department and the facility has submitted a medical necessity review for inpatient services, only services rendered as part o f the emergency department visit will be considered for payment. IV. Claims are subject to retrospective review , and CareSource reserves the right to adjust reimbursement in accordance with the policies above . E. Conditions of CoverageMember must be eligible a t the time the service, procedure , or supply was provided, and the service, procedure, or supply must be a covered benefit. Reimbursement is depen dent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. All services, procedures, and supplies are subject to review for medical necessity, which does not guarantee reimbursement. F. Related Policies/RulesMedical Necessity Determinations Against Medical Advice-OH MCD-AD-0788Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 G. Review/Revision HistoryDATES ACTIONDate Issued 02/05/2020Date Revised 12/16/2020 02/07/2022 04/12/2023 01/29/2024 Annual review.Annual review. Approved at Committee.Annual review: editorial changes to document language, additions to background, and updated references. eVote approved at Committee. Date Effective 05/01/2024 Date Archived H. References1. Albayati A, Douedi S, Alshami A, et al. Why do patients leave against medical ad- vice? Reasons, consequences, prevention, and interventions. Healthcare (Basel) . 2021;9(2):111. doi:10.3390/healthcare9020111 2. Alper E, OMalley T, & Greenwald J. Hospital discharge and readmission . UpToDate. Updated February 3, 2023. Accessed December 28, 2023. www.uptodate.com 3. Hasan O, Samad MA, Khan H, et al. Leaving against medical advice from in-patient departments rate, reasons and predicting risk factors for re-visiting hospital retro- spective c ohort from a tertiary care hospital. Int JHealth Policy Man . 2019;8(8):474 – 479 . doi:10.15/2019.26 4. Holmes EG, Cooley BS, Fleisch SB, et al. Against medical advice discharge: a narra-tive review and recommendations for a systematic approach. Am JMed . 2021;134(6):721-726. doi:10.1016/j.amjmed.2020.12.027 5. Hospital Billing Guidelines (after September 1, 202 1). Accessed January 20, 2024. www.medicaid.ohio.gov 6. Khalili M, Teimouri A, Shahramian I, et al. Discharge against medical advice in pae- diatric patients. JTaibah Univ Med Sci . 2019;14(3):262-267. doi:10.1016/j.jtumed.2019.03.001 7. Levenson J. Psychological factors affecting other medical conditions: management. UpToDate. Updated September 19, 2022. Accessed December 28, 2023. www.u p- todate.com 8. General Provisions: Hospital Services, OHIO ADMIN . CODE 5160-2-02 (2022 ). 9. Office of Policy h ospital billing guidelines . Ohio Dep t of Medicaid. Revised July 7, 2021. Accessed December 28, 2023. www.medicaid.ohio.gov 10. Patient Discharge Status Codes and Hospital Transfer Policies. Accessed January 20, 2024. www.cms.gov 11. Potentially Preventable Readmissions , OHIO ADMIN . CODE 5160-2-14 ( 20 17 ). 12. Program Withdrawal , OHIO ADMIN . CODE 5122-40-14 ( 20 19 ). Approved ODM 2/22/2024

Three-Day Window Payment

ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Three-Day Window Payment-OH MCD-AD-1001 05/01/2024 Policy Type ADMINISTRATIVE Administrative 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 which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the E vidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Cove rage) will be the controlling document used to make 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 tions that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Three-Day Window Payment-OH MCD-AD-1001Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectThree-day Window Payment B. BackgroundOhio Administrative Code 5160-2-02 states that outpatient services provided within three calendar days prior to the date of admission in hospitals will be covered as inpatient services. This includes emergency room and observation services. C. Definitions Behavioral Health (BH) Services Include m ental health and substance use disorder services. Hospitals that provide outpatient BH services must meet the Medicare conditions of participation, have accreditation by a national accrediting body, and have accreditation for the BH services provi de d. Inpatient Member who is admitted to a hospital based upon the written orders of a practitioner of physician services and whose inpatient stay continues beyond midnight of the day of admission. Inpatient Services Services which are ordinarily furn ished in a hospital for the care and treatment of patients, including all covered services provided to members during the course of their inpatient hospital stay except for direct-care services provided by a practitioner of physician services . Emergency ro om (ER) services are covered as an inpatient service when member is admitted from the ER. Outpatient Services Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a practitioner of physician services which are furnished to an outpatient by a hospital. Outpatient services do not include direct-care services provided by a practitioner of physician services . Practitioner of Physician Services Include physicians, podiatrists, dentists, clinical nurse specialists, certified nurse-midwives, certified nurse practitioners, or physician assistants. D. PolicyI. Three-Day Payment Rule A. Claims submitted for outpatient services (including emergency room and observation services) that were provided wi thin the three calendar days prior to the inpatient admission for the same member for the same hospital or wholly owned hospital system may be denied if the services are not combined into one claim. 1. The outpatient services and inpatient admission must be s ubmitted on one inpatient claim. 2. The dates of the claims should begin with the outpatient service through the inpatient discharge. B. If the hospital submits the outpatient claim separately before the inpatient claim, the inpatient claim may be deemed as a du plicate claim and may be denied payment. The inpatient hospital will need to work with the outpatient hospital to pay the outpatient visit and to have the outpatient hospital void its paid claim for Three-Day Window Payment-OH MCD-AD-1001Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 the outpatient service. The inpatient hospital should the n resubmit the claim so that it includes inpatient and outpatient services. C. If both the inpatient and outpatient services are initially paid for the same hospital or wholly owned hospital system, retroactive recovery may be initiated for the outpatient services inclusive by the three-day window. D. Physician practices and entities s hould use modifier PD (diagnostic or related non-diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within three days or one day) to identify services subject to the payment window. E. ICD-10 diagnosis code Z01.81 Xshould be used to indicate an encounter for preprocedural examinations to flag the outpatient claim as related to an inpatient service/procedure. F. To avoid duplication for nursing facility residents: 1. The outpatient service claim should note the entire in patient stay along with the dates of the outpatient services . 2. The nursing facility claim should note the room and board days with the hospital leave days . II. The following exceptions apply:A. When a members Medicaid coverage changes payer sources (fee-for-se rvice or managed care) on the date of the inpatient admission, all outpatient services provided within three calendar days prior to the inpatient admission will be submitted to the payer source responsible for those dates of service. The inpatient claim wi ll be submitted to the payer source in effect on the date of admission. B. When a member is admitted under the inpatient hospital service program benefit plan, all outpatient services provided by either the same hospital or different hospital, prior to the in patient admission will not be included on the inpatient claim, with the exception of any outpatient services provided on the date of admission which will be included on the inpatient hospital claim if provided at the same facility as the inpatient admissio n. C. Outpatient hospital behavioral health services provided in the outpatient hospital setting w ithin three calendar days prior to the inpatient admission are exempt from the three-day window policy . E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATES ACTIONDate Issued 10/30/2019 Changed from PY. Added to the same hospital in I.A.Three-Day Window Payment-OH MCD-AD-1001Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 Date Revised 02/04/202205/10/2023 01/17/2024Annual review. Editorial changesAnnual review: added I.C, updated references, definitions. Approved at Committee. Annual review: updated references. Approved at Committee. Date Effective 05/01/2024 Date Archived H. References1. Hospital Billing Guidelines . Ohio Dep t of Medicaid. Revised July 26, 2021. Accessed January 2, 2024 . www. medicaid.ohio.gov 2. General Provisions: Hospital Services, OHIO ADMIN . CODE 5160-2-02 (2022). Approved by ODM on 1/25/2024

Retrospective Authorization Review

ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Retrospective Authorization Review-OH MCD-AD-1334 05/01/2024 Policy Type ADMINISTRATIVE Administrative 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 which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the E vidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Cove rage) will be the controlling document used to make 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 tions that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. …………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………….. ……… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. ………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ………………… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………………. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………………. 3 H. References ………………………….. ………………………….. ………………………….. ………………………….. ………. 3 Retrospective Authorization Review-OH MCD-AD-1334 Effective Dat e: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectRetrospective Authorization Review B. BackgroundA retrospective review is a request for an initial review for an authorization of care, service, or benefit for which a prior authorization (PA) is required but was not obtained prior to the delivery of the care, service, or benefit. Occasionally, situatio ns arise in which a PA cannot be reasonably obtained prior to care, service, or benefit . In these cases, CareSource will conduct a retrospective review of medical services received by members when the request is received within 30 days of the date of service or discharge. Retrospective reviews are performed by licensed clinicians who are supported by licensed physicians. A decision is rendered within 30 days of receipt of all necessarydocumentation. In the event of an adverse determination, the provider and/or member are notified of the decision and supporting rationale.C. Definitions Clinical Review Criteria The written screening procedures, decision abstracts, clinical protocols , and practice guidelines used by CareSource to determine the medical necessity and appropriateness of health care services. Prior Authorization Utilization review conducted prior to an admissio n or the provision of a health care service or a course of treatment in accordance with CareSources requirement that the health care service or course of treatment, in whole or in part, be approved prior to provision. Retrospective Authorization Review The process of reviewing and making a coverage decision for a service or procedure that has already been performed (eg, post service decision). D. PolicyI. CareSource considers retrospective authorization review appropriate when ANY of the following circumstances has occurred: A. A CareSource member is unable to advise the provider of plan enrollment due to a condition that renders the member unresponsive or incapacitated . B. The member is retrospectively enrolled which covers the date of ser vice . C. Urgent service(s) requiring authorization was/were performed , and it would have been to the members detriment to take the time to request authorization . D. The new service was not known to be needed at the time that the original prior authorized service was performed . E. The need for the new service was revealed at the time the original authorized service was performed . F. The service was directly related to anothe r service for which prior approval has already been obtained and that has already been performed. Retrospective Authorization Review-OH MCD-AD-1334 Effective Dat e: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 II. Retrospective authorization requests must be submitted within 30 calendar days of the date of service or date of discharge or as specified in a provider cont ract.III. Unless the CareSource member is transitioning and qualifies under the retroactive coverage requirements , retrospective reviews , which are requested greater than 30days past date of service or date of discharge, will be administratively denied. Administrative denials do not require a review by a CareSource Medical Director. IV. In the event of any conflict between this policy and a p roviders contract withCareSource, the providers contract will be the governing document.E. Conditions of CoverageNA F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATE ACTIONDate Issued 06/21/2023 New policy. Approved at Committee.Date Revised 01/17/2024 Annual review. References updated. Approved at Committee. Date Effective 05/01 /2024 Date Archived H. References1. CareSource Ohio Medicaid Provider Manual . CareSource; 2023. Accessed December 27, 2023 . www.caresource.com Approved by ODM on 1/25/2024

Readmission–Behavioral Health

Administrative 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 industry 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 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates 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 Administrative Policy Statement. If there is a conflict between the Administrative 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 make 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 limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. ADMINISTRATIVE POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Readmission Behavioral Health OH MCD-AD-1018 05/01/2024-09/30/2025 Policy Type ADMINISTRATIVE Tabl e of Contents 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 …………………………………………………………………………………………. 6 H. References …………………………………………………………………………………………………………… 6 Readmission Behavioral Health OH MCD-AD-1018 Effective Date: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 2 A. SubjectReadmission Behavioral HealthB. Background In 2019, Medicaid and the Childrens Health Insurance Program (CHIP) covered nearly 200 million behavioral health (BH) services, including 150 million BH services and almost 43 million substance use disorder (SUD) services. Following a hospitalization, readmission within 30 days is often costly, preventable, and a quality-of-care issue that can cost health plans more than $1 billion dollars annually. Readmissions result from many factors but, most often, are due to lack of transitional care or discharge planning. Members with schizophrenia, depression, medical comorbidities, and substance use disorder are more likely to be readmitted after hospitalization. For individuals hospitalized for BH conditions, including SUD, recommended post-discharge treatment includes a visit with a mental health provider within 30 days of discharge, and ideally, within 7 days of discharge. However, use of follow-up care within members with BH diagnoses, including SUD, often falls short of these recommendations. CareSource strives to improve the quality of inpatient and transitional care, including communication between the member, caregivers, providers, providing the patient with education to maintain care at home to prevent readmission, performing predischarge assessment to ensure readiness for discharge, and providing effective post discharge coordination of care. CareSource follows guidance from the Ohio Department of Medicaid (ODM) and Ohio laws and administrative rules for readmissions. C. Definitions Appropriate Care Care consistent with accepted care and industry standards. Clinical Review Review of records by a health care professional with appropriate clinical expertise in the treatment of BH conditions, including member diagnoses, living situation, supports, and severity of the condition. Diagnosis Related Groups (DRGs) A patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources in an inpatient setting used to assign cases for claims payment. Hospital Defined by Ohio Administrative Code (OAC) 5160-2-01 and includes both general acute care facilities and Institutions of Mental Disease (IMD). Planned Readmission A non-acute admission for a scheduled procedure for limited types of care when further treatment is indicated following diagnostic tests but cannot begin at the time of initial admission. Potentially Preventable Readmission An inpatient readmission as defined by OAC 5160-2 -14(c) following a prior discharge from a hospital within 30 days that is clinically related and clinically preventable to the initial admission. Readmission Behavioral Health OH MCD-AD-1018 Effective Date: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 3 Readmission An admission to the same institution within 30 days of discharge for hospitals paid under ODMs prospective payment system as described in OAC 5160-2 -65. Same Day Midnight to midnight of a single day.D. PolicyI. Readmission Criteria A. CareSource considers a readmission a return hospitalization within 30 days of a prior discharge that meets ALL the following criteria: 1. The readmission is potentially preventable by the provision of appropriate care consistent with accepted care standards in the prior discharge or during the post-discharge follow-up period. 2. The readmission is for a condition or procedure clinically related to care provided during the prior discharge or resulting from inadequate discharge planning during the prior discharge, which can include the following (not an all-inclusive list): a. during prior admission and noted in the medical record, indication of inadequately coordinated, direct communication between the hospital, MCO, outpatient provider(s), caregivers/supports, and the member regarding treatment and/or discharge planning occurred, including 01. contact names, phone numbers and addresses with dates of contact & role/responsibility in treatment regimen and discharge plan 02. organizations affiliated with contact, if applicable, including outpatient and community BH resources b. CareSources assistance was not utilized or requested connecting with appropriate outpatient resources to review recent outpatient treatment history, schedule follow-up appointments within 7 calendar days of discharge, and/or coordinate transportation to follow-up appointments c. lack of review of social determinants of health (SDoH) and request for CareSource assistance with potential barriers to care (ie homelessness, telephone availability, transportation) d. medication reconciliation did not occur e. lack of assistance with prescriptions related to treatment regimen availability at discharge, when appropriate and/or safe for the member, including 01. two weeks worth of medication provided at the time of discharge, which is not to be included in the inpatient claim and must be a separate NCPDP claim 02. transportation to the pharmacy or medication home-delivery scheduled 3. One or more readmission may be clinical related to the initial admission. If the first readmission is within 30 days after the initial admission, the 30-day timeframe may begin again at the discharge of either the initial admission or the most recent readmission clinically related to the initial admission. 4. The readmission is the same or to any other hospital. Readmission Behavioral Health OH MCD-AD-1018 Effective Date: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 4 B. Readmissions subject to administrative record review exclude the following circumstances: 1. An original, patient-initiated against medical advice (AMA) discharge with circumstances of discharge and readmission documented in the medical record. 2. Planned readmissions. 3. The original discharge was for the purpose of securing treatment of a major or metastatic malignancy, major trauma, neonatal and obstetrical admission, transplant, human immunodeficiency virus (HIV), and other non-events. 4. Transfers from out of network to in-network facilities or transfers to receive care not available at the first facility. II. Review of Medical Necessity Review of medical necessity for the initial or subsequent inpatient stays is conducted pre-service delivery using related medical necessity criteria. The review process and determination are separate from any readmission review process and determination. A. Prior authorization is not a guarantee of payment and is subject to administrative review at CareSources discretion. B. Inpatient medical necessity review requests submitted without complete clinical or medical records necessary for adequate review will be denied, resulting in the denial of any related claim(s). III. Readmission Reviews and Payment Processes A. Readmission Review Process CareSource will conduct post-service clinical readmission reviews by examining medical records to determine if a readmission was a preventable, clinically related readmission. Reviews may be conducted pre-or post-payment. Pertinent and complete medical records for both admissions must be included with claim submission to determine appropriateness of the admission(s). Failure to provide complete medical records for a post-service clinical readmission review will result in an automatic denial of the claim for the readmission. B. Payment Process CareSource manages the provider payment process for readmissions according to guidelines found in OAC 5160-2-65. 1. 30-Day Readmissions a. If a clinical readmission review determines that the readmission was unavoidable or unrelated to the first admission, related claims will be treated as, and adjudicated as, two separate admissions.b. If a clinical readmission review determines that the readmission is related to the first admission and is a preventable, clinically related readmission, then the two admissions must be collapsed into one claim and resubmitted by the institution for payment, which will be reimbursed as one DRG payment. Any days between admissions should be billed as non-covered days. CareSource may recoup any payments made for readmission(s) that need collapsed into a single claim.Readmission Behavioral Health OH MCD-AD-1018 Effective Date: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 5 2. 1-calendar day readmissions (same day or next day readmissions) will be reimbursed as one diagnosis related group (DRG) payment. If an institution submits claims for both admissions, the second claim processed will be rejected. The two admissions must be collapsed into one claim and resubmitted for payment. 3. Sentinel events are not reimbursable. Per Ohio Department of Medicaid, the following are related to inpatient behavioral health admissions. For psychiatric admissions, the DRG assigned to the claim 740, 750-760 (ICD-10) and diagnoses codes, including F0150-F99, G4700, G479, H9325, Q900-Q902, Q909-Q917, Q933-Q935, Q937, Q9388-Q9389, Q939, Q992, R37, R4181, R41840-R41841, R41843-R41844, R440, R442-R443, R450-R457, R4581-R4582, R45850-R45851, R4586-R4587, R4589, R4681, R4689, R480-R482, R488-R489, R54, Z72810-Z72811, Z87890, or Z91830.Psychiatric Diagnosis Related Groups (DRGs)740 Mental Illness Diagnosis w O.R. procedure 750 Schizophrenia 751 Major depressive disorders & other/unspecified psychoses 752 Disorders of personality & impulse control 753 Bipolar disorders 754 Depression, except major depressive disorder 755 Adjustment disorders & neuroses, except depressive diagnoses 756 Acute anxiety & delirium states 757 Organic mental health disturbances 758 Behavioral disorders 759 Eating disorders 760 Other mental health disorders Detoxification DRGs (principal diagnosis codes beginning with Fonly) 773 Opioid abuse & dependence 774 Cocaine abuse & dependence 775 Alcohol abuse & dependence 776 Other drug abuse & dependence E. Conditions of CoverageNA F. Related Policies/Rules I. CareSource Policies A. Behavioral Health Service Record Documentation Standards B. Sentinel Events and Provider Preventable Conditions II. Regulations A. Ohio Administrative Code Readmission Behavioral Health OH MCD-AD-1018 Effective Date: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 6 1. A ppeals and Reconsideration of Departmental Determinations RegardingHospital Inpatient and Outpatient Services, O HIO ADMIN . C ODE 5160-2- 12 ( 2022).2. Classification of Hospitals, O HIO ADMIN . C ODE 5160-2- 05 (2023).3. Conditions and Limitations, O HIO ADMIN . C ODE 5160-2- 03 (2022).4. Hospitals, O HIO ADMIN . C ODE Chapter 3701-59-01 to 06 (2024).B. Ohio Revised CodeInspecting and Licensing of Hospitals for Mentally Ill Persons, O HIO REV . C ODE 5119.33 (2023).C. Code of Federal Regulations1. Condition of Participation: Discharge Planning, 42 C.F.R. 482.43 (2024).2. Inpatient Psychiatric Services for Individuals Under Age 21 in Psychiatri c Fac ilities or Programs, 42 C.F.R. 441 Subpart D (2024).3. Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases,42 C.F.R. 441 Subpart C (2024).4. Special Contract Provisions Related to Payment, 42 C.F.R. 438.6 (2024). G.Review/Revision History DATES ACTION Date Issued 12/01/2021 Approved at PGC. Date Revised 05/24/2023 01/17/2024 Annual review. Updated background, definitions, reference list. Added related policies. Approved at Committee. Updated definitions, added DRG. Added OAC references to policy body. Updated References. Approved at Committee. Date Effective 05/01/2024 Date Archived 09/30/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H.R eferences 1.Cook JA, Burke-Miller JK, Jonikas JA, et al. Factors associated with 30-day readmissions following medical hospitalizations among medicaid beneficiaries with schizophrenia, bipolar disorder, and major depressive disorder. Psych Res . 2020; 291:113168. doi:10.1016/j.psychres.2020.1131682. Eligible Providers, O HIO ADMIN . C ODE 5160-2-01 (2023).3. Elisa D, Cristiana M, Vincenzo V, et al. Factors associated with 30-days and 180-days psychiatric readmissions: a snapshot of a metropolitan area. Psych Res . 2020; 292:113309. doi:10.1016/ j.psychres.2020 4. E xcluded Hospital Units: Common Requirements, 42 C.F.R. 412.25 (2024).5. Gaynes BN, Brown C, Lux LJ, et al. Management Strategies to Reduce PsychiatricReadmissions . Agency for Healthcare Research and Quality; 2015. Technical BriefsNo 21. Accessed December 28, 2023. www.ncbi.nlm.nih 6. G eneral Provisions: Hospital Services, O HIO ADMIN . C ODE 5160-2- 02 (2022).7. Goldfield N, McCullough E, Hughes, J, et al. Identifying potentially preventabl e r eadmissions. Health Care Financ Rev . 2008;30(1):75-91. Accessed January 5 , 2024. www.ncbi.nlm.nih.gov Readmission Behavioral Health OH MCD-AD-1018 Effective Date: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 7 8. Hospital readmission reduction program. Centers for Medicare and Medicaid Services. Updated September 6, 2023. Accessed December 28, 2023. www.cms.gov 9. Inpatient Hospital Reimbursement, OHIO ADMIN . C ODE 5160-2-65 (2024). 10. Program, Specialty Services, and Discharge Planning Requirements, OHIO ADMIN . C ODE 5122-14-12 (2017). 11. Mark TL, Tomic KS, Kowlessar N, et al. Hospital readmission among medicaid patients with an index hospitalization for mental and/or substance use disorder. JBehav Health Serv Res . 2013;40(2):207-221. doi:10.1007/s11414-013-9323-5 12. McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction program. Circulation . 2015;131(20):1796-1803. doi:10.1161/CIRCULAT.114.010270 13. Mitchell SE, Reichert M, Howard JM, et al. Reducing readmission of hospitalized patients with depressive symptoms: a randomized trial. Ann Fam Med . 2022;20(3):246-254. doi:10.1370/afm.2801 14. Richardson R. Hospital Inpatient Readmission Policy . Ohio Dept of Medicaid; 2020. Accessed December 28, 2023. www.medicaid.ohio.gov 15. Office of Policy Hospital Billing Guidelines . Ohio Dept of Medicaid. Revised July 26, 2021. Accessed December 28, 2023. www.medicaid.ohio.gov 16. Potentially Preventable Readmissions, O HIO ADMIN . C ODE 5160-2-14 (2017). 17. Reif S, Acevedo A, Garnick DW, et al. Reducing behavioral health inpatient readmissions for people with substance use disorders: do follow-up services matter? Psychiatr Serv . 2017;68(8):810-818. doi:10.1176/appi.ps.201600339 18. Tassie J. Potentially Preventable Readmissions Program Changes . Ohio Dept of Medicaid; 2018. Hospital Handbook Transmittal Letter 3352-19-02. Accessed December 28, 2023. www.medicaid.ohio.gov 19. Utilization Review, O HIO ADMIN . C ODE 5160-2-13 (2022). Approved by Ohio Dept. of Medicaid 01/25/2024.

Provider Home Visits

ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Provider Home Visits-OH MCD-AD-1165 05/01/2024 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilizatio n and technology assessment guidelines, other medical management industry 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 nece ssary 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, dysfunctio n of a body organ or part, or significant pain and discomfo rt. 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 i n any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates 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 Administrative Policy Statement. If there is a conflict between the Administrative 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 make 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 limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Provider Home Visits-OH MCD-AD-1165Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectProvider Home Visits B. BackgroundProvider home visits are medical care visits rendered in the home setting to an individual for the examination, diagnosis, and/or treatment of an injury or illness. For the purposes of this policy, home is defined as the individual’s place of residence, including private residence/domicile, assisted living facility, group home, custodial care facility, long-term care facility, or skilled nursing facility. C. Definitions Home An individual’s place of residence, including private residence/domicile, assisted living facility, group homes, custodial care facility, long-term care facility, or skilled nursing facility. Network ( Participating ) Provider Any provider, group of providers, or entity that has a network provider contract with CareSource to provide services to members . Place of Service (POS) A two-digit code that indicates the setting in wh ich a service was provided. Provider A hospital, health care facility, physician, dentist, pharmacy, or otherwise licensed or certified appropriate individual or entity that is authorized to or may be entitled to reimbursement for health care-related ser vices rendered to a CareSource mem ber. Out of Network ( Non-Participating ) Provider Any provider, group of providers, or entity that has a network provider contract with CareSource to provide services to its members. Services Services that occur in the members place of residence that normally would be performed in an office/outpatient setting, such as evaluation and management (E&M) visits, wound care, podiatry care, eye care, etc. D. PolicyI. CareSource reimburses participating or non-participating providers for services performed in a members place of residence that usually can be performed at an office visit. A. CareSource will reimburse providers according to the Medicaid fee schedule. B. Durable medical equipment (DME) services in the place o f residence are subject to medical necessity review and should be provided by in network (participating) provider . C. Ancillary services , such as labs and x-ray services , in the place of residence are subject to medical necessity review and should be prov ided by in network (participating) provider. II. Claim submission must include the appropriate Current Procedural Terminology (CPT) codes along with any applicable modifier with the appropriate place of service (POS) code.A. Place of service (POS) for provider services in the members place of residence should include one of the following: Provider Home Visits-OH MCD-AD-1165Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.1. POS 12 Home2. POS 13 Assisted Living 3. POS 14 Group Home 4. POS 31 Skilled Nursing Facility (SNF) 5. POS 32 Long-term Facility 6. POS 33 Custodial Care/Rest Home III. CareSource reimburses for services that occur in the members place of residence that normally would be performed in an office/outpatien t setting, such as E&M visits,wound care, podiatry care, eye care, etc. A. CareSource members do not need to be confined to a place of residence to receive services rendered by a provider. B. The CareSource members medical record must document the me dical necessity of the visit made in place of residence. C. A visit cannot be billed by a provider unless the provider was actually present in the members place of residence. IV. Services performed in the members place of residence may be subject to review.CareSource may request documentation of services performed. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. If medical necessity is not confirmed based on the documentation su bmitted, recoupment may occur. E. Conditions of CoverageNA F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATE ACTIONDate Issued 01/01/2019 New policyDate Revised 02/16/2022 05/10/202301/17/2024Converted from PY-0444 to AD-1165. Change d physician to provider to more inclusive. Approved at PGC. Annual review. Update reference. Approved at Committee. Annual review. Updated references. Added related policy. Approved at Committee. Date Effective 05/01/2024 Date Archived H. References1. Managed Care: Definitions, OHIO ADMIN . CODE 5160-26-01 (2022). 2. Ohio Medicaid Provider Agreement for Managed Care Organization. Ohio Dept of Medicaid. Updated January 1, 2024. Accessed January 2, 2024. www.medicaid.ohio.gov 3. Ohio Medicaid Provider Manual . CareSource; 2023. Accessed January 2, 2024. www.c aresource.com Provider Home Visits-OH MCD-AD-1165Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4. Place of service codes for professional claims. Centers for Medic are & MedicaidServices. Updated September 2023. Accessed January 2, 2024 . www.cms.gov Approved by ODM on 1/25/2024

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