ADMINISTRATIVE POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Itemized Billing-OH MCD-AD-0857 02/01/2024 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 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 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 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 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 Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Itemized Billing-OH MCD-AD-0857Effective Dat e: 02/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectItemized Billing B. BackgroundItemized bill review is the analysis of inpatient facility itemized billing statement s against CareSource policies and industry standard guidelines, as well as state and/or federal billing guidelines. CareSource may request an itemized bill for an inpatient facility claim to verify that billed revenue codes represent charges for appropriately billed items, supplies , and services. Routine items, supplies, and services are to be included in the primary inpatient room and board charge and are not separately reimbursable. C. Definitions Inpatient Hospital Claim Claims submitted for a member who has been admitted by a physician order to an inpatient hospital bed to receive inpatient services . Itemized Bill A comprehensive list of all services and goods provided during the inpatient hospital stay, listing the costs and descriptions associated with the service and/or good. D. PolicyI. CareSource follows the Centers for Medicare and Medicaid Services ( CMS ) Provider Reimbursement Manu al guidelines, chapter 22 , section s 2202.6 and 2203 : A. Routine services defined by CMS chapter and section above are services included by the provider in a daily service charge , sometimes referred to as the room and board charge. B. Routine services are composed of two broad components: (1) general routine service and (2) special care uni ts (SCU), including coronary care units (CCU) and intensive care units (ICU). Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made . II. For diagnostic-related group (DRG) high dollar claims exceeding $25,000, an itemized bill is required for review. III. The following supplies, items, and services are typically not separately billable and are not reimbursable from the general room and board charge or primary service charge. This list contains examples only and is not an all-inclusive list : A. capital/medical equipment B. fluoroscope C. hydration flushes D. implants and supplies E. inpatient private duty nursing F. oximetry G. rental equipment Itemized Billing-OH MCD-AD-0857 Effective Dat e: 02/01/2024 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 3 H. r outine suppliesIV. If upon review of the itemized bill, charges are determined to exceed state or federal reimbursement guidelines or CareSource specific policy, then reimbursement will be reduced accordingly.V. Provider exception requests to reimbursement reductions may be requested via standard provider appeal process and should include supporting documentation (e g ,medical records or op erative notes to support requested payment exception).E. Conditions of Cove rageNAF. Related Policies/RulesNAG. Review/Revision HistoryDATES ACTION Date Issued 10/14/2020 New Policy Date Revised 05/25/2022 10/11/2023 Annual Review: updated references, formatting, added section D. II Annual Review; Approved at Committee Date Effective 02/01/2024 Date Archived H. References1. Determination of c ost of s ervices. The Provider Reimbursement Manual , I. Ce nters for Medicare and Medicaid Services . Publication 15-1 . AccessedOctober 10 , 2023. www.cms.gov2. Outlier p ayments. Centers for Medicare and Medicaid Services.December 1, 2021. Accessed October 10 , 2023 . www.cms.gov3. Payments for Outlier Cases, 42 C.F.R. 412.80 – . 84 (2023).Approved by ODM 10/26/2023
ADMINISTRATIVE POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Court Mandated Health Services-OH MCD-AD-0798 02/01/2024 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 managem ent 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 services meet the standards of good medical practic e 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 Statemen ts, 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. 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 ………………………….. ………………………….. ………………………….. ….. 2 H. Re ferences ………………………….. ………………………….. ………………………….. ……………………. 2 Court Mandated Health Services-OH MCD-AD-0798 Effective Dat e: 02/01/2024 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 2 A. SubjectCourt Mandated Health ServicesB. BackgroundCourt mandated health services are treatments ordered as a result of criminal, civil , or custodial judicial proceedings. Services may include withdrawal management,medication assisted treatment , community-based services, behavioral health inpatient or outpatient treatment, medica l inpatient or outpatient treatment and /or other treatment related to one s overall health.C. DefinitionsCourt Mandated Health Services Court order issued upon the decision of a judge or the result of a judicial proceeding for health-related servi ces.D. PolicyI. Court mandated health services are subject to all existing CareSource policies and procedures , including medical necessity determination and prior authorization as necessary.II. If court ordered health services are determined as not meet ing medi cal necessity criteria, the member will be referred to care management to ensure access to the proper treatment and services and assist in coordination of necessary care.E. Conditions of CoverageNAF. Related Policies/RulesMedical Necessity DeterminationsG. Review/Revision HistoryDATES ACTION Date Issued 02 /20/2020 New Policy Date Revised 11/10/2021 08/31/2022 10/11/2023 Reviewed, No changes . Annual review. No changes. Annual review; Approved at Committee Date Effective 02/01/2024 Date Archived H. ReferencesNAApproved by ODM 10/26/2023
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Policy Development Process-OH MCD-AD-0917 01/01/2024 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 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. Re ferences ………………………….. ………………………….. ………………………….. ……………………. 4 Policy Development Process-OH MCD-AD-0917Effective Dat e: 01/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectPolicy Development Process B. BackgroundCareSource utilizes a systematic way to develop policies through a standard operating procedure that improves efficiency, increases productivity and quality, and provides consistent policy products to stakeholders and others . This is achieved through identifying a policy need, including policy intent an d triage, and then, thorough research and collaboration allows CareSource to determine its best practice for members. According to the tenets of the 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 or more restrictive than the limitations that apply to medical condi tions as covered by CareSource policies . The policy development process ensures quality and consistency among both medical/surgical and behavioral health policies. C. Definitions Administrative Policies Policies written to provide guidance to providers on the administration of behavioral and/or physical health benefits. AllMed A vendor with independent, external review specialists, who complete impartial medical reviews prior to final medical policy approval and implementation. Business Owner An individual who identifies a gap in information or benefits and recommends or requests that a topic be researched for possible creation or clarification of medical necessity criteria, reimbursement information , or administrative conditions to assist i n providing consistent and quality services to CareSource members. The business owner supports the development of a policy. Clinical Policy Governance Committee (CPGC) The official governing body , comprised of medical and behavioral health subject matter experts, among others, charged with the approval of new or revised clinical policies relating to medical necessity determinations. The CPGC is responsible for determining whether the proposed clinical policy is clearly defined, clinically evidenced-based, assures a high level of member safety and quality of care, and articulates a business value. Medical/Clinical Policies Policies written with medical criteria, including current evidence-based research, best practice, studies, etc., which will determine what the member must meet for the provider to deliver a service. PolicyTech Policy and procedure lifecycle management software for policy development and revision d esigned to centralize, build, and simplify policy and procedure workflows. Users have t ools, such as workflow automation, document creation and review, remote access, versioning, audit-ready reporting, and employee assessments. Reimbursement Policy Policies that specify billing and claims criteria , which allow provider s to receive reimbursement for the services provided. Policy Development Process-OH MCD-AD-0917Effective Dat e: 01/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 Subject Matter Experts (SME) A person who is an authority on a particular topic or subject matter. D. PolicyI. Pre-Policy Development A. The business owner enters a policy intake into PolicyTech to start the policy development process. B. To determine the intent, need, and priority of the request, collaboration occurs between the policy writer, business owner, member benefits coder, member benefits analyst, configuration, and an appropriate business owner, such as a subject matter expert (SME) and/or medical director. C. If determined that a policy would be beneficial , a multidisciplinary team review s codes and configuration, if ap plicable, and management determines if analytics are needed in order to provide the policy team with additional data, such as financials , claims , and/or member utilization of benefits. II. Policy DevelopmentA. The policy writer researches the topic a nd develops a draft policy. This includes,but is not limited to, the following resources: 1. federal and state regulations 2. state contracts 3. standard of care guidelines (ie, MCG Health, InterQual, American Society of Addiction Medication, etc ) 4. Hayes 5. UpToDate 6. Policy Reporter 7. provider and member materials 8. professional society recommendations 9. standard of care guidelines 10. published studies 11. feedback from external sources 12. SMEs, including medical/surgical and/or behavioral 13. EncoderPro B. The draft policy is then approved in PolicyTech in several stages by subject matter experts, management, writers, applicable departments , and o thers . The final policy draft is then reviewed and approved by the following: 1. Benefits, Coding and Support 2. Configuration 3. Utilization Management 4. Independent, external medical review specialists, when applicable 5. CPGC 6. State approval, if applicable Policy Development Process-OH MCD-AD-0917Effective Dat e: 01/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 III. Post Policy DevelopmentProviders and members of the health partner community are notified of new policies and/or changes to existing policies via CareSources marketing process. A standard operating procedure gu ides a uniform, consistent process allowing for adequate notice of new criteria or revisions as outlined by state or company requirements. Upon adequate notice, policies are posted on CareSources website.E. Conditions of Coverage NA F. Related Policies/Rul esNA G. Review/Revision HistoryDATES ACTIONDate Issued 09/30/2020Date Revised 12/10/2021 09/13/2022 09/13/2023 Updated definitions, resources used for research Annual review. No substantive changes. Annual review; Approved at Committee Date Effective 01/01/2024 Date Archived H. References1. Mental Health Parity and Addiction Equity Act. US Centers for Medicare and Medicaid Services. Accessed August 21, 2023. www.cms.gov Ohio Department of Medicaid approved 10/5/2023.
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Emergency Department Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation-OH MCD-AD-1084 02/01/2024 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 s ervices 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 org an 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 se rvices 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 affiliat es 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 Administrat ive 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 A ct (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 Emergency Department Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation-OH MCD-AD-1084 Effective Dat e: 02/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectElectrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation B. BackgroundAn electrocardiogram (EKG/ECG) is a non-invasive test that records the electrical activity of the heart. It is used when a possible cardiac issue occurs , due to an emergency medical condition. An EKG/ECG may need to be performed to address the situation quickly. The recording is reviewed by a physician who provides an interpretation and written report. An EKG/ECG may be report ed as the technical aspect only, the interpretation and written report only, or both aspects together as one service. For the purpose of this policy, EKG will be used to represent both EKG and ECG. C. Definitions Electrocardiogram (EKG/ECG) – A test that re cords the electrical activity of the heart. Emergency Medical Condition – A medical condition with sudden severity and onset that , in the absence of immediate medical attention , could plac e the patient’s health in serious jeopardy , including labor and delivery, but not routine prenatal or postpartum care, or services related to an organ transplant procedure. Imaging – Several different technologies that are used to view the human body in order to diagnose, monitor, or treat medical conditions. D. PolicyI. Electrocardiogram (EKG/ECG) Interpretation A. CareSource will reimburse the first EKG interpretation claim that is received for the member on the date of service. 1. If another claim for the same EKG interpretation is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service. 2. CareSource will not reimburse for duplicate claims, for the same service on the same date of service for the same member, without the appropriate modifier. B. If a second EKG interpretation is medically necessary, on the same date of service, before the member is discharged, modifier 76 or modifier 77 must be appended to the second EKG interp retation for reimbursement. II. Imaging InterpretationA. CareSource will reimburse the first imaging interpretation claim that is received for the member on the date of service. 1. If another claim for the same imaging interpretation is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service. Emergency Department Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation-OH MCD-AD-1084 Effective Dat e: 02/01/2024 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 2. Care Source will not reimburse for duplicate claims, for the same service on the same date of service for the same member, without the appropriate modifier. B. If a second imaging interpretation is medically necessary, on the same date of service, before the member is discharged, modifier 76 or modifier 77 must be appended to the second imaging interpretation for reimbursement. III. Car eSource expects providers to work with other organizational departments to determine which department will submit the claim to prevent duplicate claim submissions. E. Conditions of CoverageCareSource expects provider to use appropriate standard billing gui delines. Modifiers and Place of service codes are listed below only as a reference. Modifier Description 26 Professional Component 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional F. Related Policies/RulesNA G. Review/Revision HistoryDATES ACTIONDate Issued 03/31/2021 New policyDate Revised 09/14/2022 09/13/2023 No changes Removed place of service language. Updated references. Approved at Committee. Date Effective 02/01/2024 Date Archived H. References1. Sattar Y, Chhabra L. Electrocardiogram. In: StatPearls [Internet]. StatPearls Publishing; 2023. Updated June 5, 2023. Accessed August 7,2023. www.ncbi.nlm.nih.gov 2. U.S. Food and Drug Administration. Medical Imaging. August 28, 2018. Accessed August 7,20 23. www.fda.gov 3. What Are Medical Coding Modifiers? American Academy of Professional Coders; 2023. Accessed August 7, 2023. www.aapc.com Approved ODM 10/12/2023
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Acute Hospital Care at Home-OH MCD-AD-1213 02/01/2024 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 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 …………………………………………………………………………………………………………… 3 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 5 F. Related Polic ies/R ules ………………………………………………………………………………………….. 5 G. Review/Revision History ……………………………………………………………………………………….. 6 H. References …………………………………………………………………………………………………………. 6 Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 02/01/2024 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 Acute Hospital Care at Home B. Background The John 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 tested and demonstrated the efficacy of this model. In November 2020, t he Centers for Medicare & Medicaid Services (CMS) initiated a p rogram to allow patients to be treated outside of 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 (O DM) 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) car e ca n 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 mobi le integrated health paramedics based on the patients nursing pl an and hospital policies. This program is designed for patients who meet acute inpatient or have failed observation admission c riteria 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 Participations ( 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 member s. 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 orde r to qualify and be certified to participate in this program. This information can be accessed on the CMS website. Waiver requests will be divided into two categories based on the hospital applicants Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 02/01/2024 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.3prior experience with acute hospital care at home. Part icipating hospitals are required to submit appropriate screening protocols for medical necessity rev iew before care at home begins . C. Definitions Health 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 r equirements 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 authori zation 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 inp atient-le vel of hospital care. 5. The member must be identified and assessed by hospital staff as meeting the qualifying criteria for home admissi on 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; e. Cellulitis; Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 02/01/2024 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.4f. Urinary Tract Infection (UTI) or 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 hos pitalist , 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 clinical ly 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 remotely. 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: 01. a n 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 l ung 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 member s condition. 4. Discharge Planning Documentation should support the following discharge standards: Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 02/01/2024 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.5a. 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 w ere 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 f unctions other than as intended 7. patients suicide, or attempted suicide resulting in serious disability while being cared for in a hospital at home setting and 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 Coverage NA F. Related Polic ies/Rules N/A Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 02/01/2024 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.6G. Review/Revision History DATE ACTIONDate Issued 09/15/2021 New PolicyDate Revised 05/11/2022 08/16/2023Changed from Medical to Admin. Added UTI and 26 th ed. MCGreferences. Added new MCG. Covid-19: Hospital-at-Home. M-281-HaH (ISC). Updated references. Approved at Committee. Date Effective 02/01/2024 Date Archived H. References 1. Admission avoidance hospital at home. Sheppard, S. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD007491. Accessed on August 8 , 2023 www.cochranelibrary.com. 2. Annals of Internal Medicine. Leff, Bruce MD. Hospital at Home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Accessed on August 8, 2023 . www.acpjournals.org. 3. Centers for Medicare and Medicaid Services. Acute Hospital Care at Home Individual Waiver Only (not a blanket waiver). Accessed on August 8, 2023 . www.cms.gov. 4. Centers for Medicare and Medicaid Services. CMS Announces Comprehensive Strategy to Enhance Hospital Capacity Amid COVID-19 Surge. Accessed on August 8 , 2023 .www.cms.gov. 5. Centers for Medicare and Medicaid Services. Life Safety Code & Health Care Facilities Code Requirements. Accessed on August 8, 2023 . www.cms.gov. 6. Clarke DV, et al. Acute Hospital Care at Home: The CMS Waiver Experience. NEJM Catalyst Innovations in Care Delivery.(December 7,2021). Accessed on August 8 , 2023. www.catalyst.nejm.org. 7. John Hopkins Medicine Healthcare Solutions. Hospital at Home. Accessed on June 14, 2023 . www.johnhopkins.com. 8. MCG. 27th Edition (2023). Cellulitis: Hospital-at-Home. M-70-HaH (ISC). Accessed on August 8, 2023. www.careweb.com. 9. MCG.27th ed. (2023). Chronic Obstructive Pulmonary Disease: Hospital-at-Home. M-100-HaH (ISC. Accessed on August 8, 2023. www.careweb.com. 10. MCG.27th ed. (2023). Covid-19: Hospital-at-Home. M-281-HaH (ISC). Accessed on A ugust 8, 2023. www.careweb.com. 11. MCG.27th ed. (2023). Heart Failure: Hospital-at-Home. M-190-HaH (ISC). Accessed on August 8, 2023. www.careweb.com. 12. MCG. 27th ed. (2023). Pneumonia: Hospital-at-Home. M-282-HaH (ISC). Accessed on August 8, 2023. www.careweb.com. 13. MCG. 27th ed. (2023). Urinary Tract Infection (UTI): Hospital-at-Home. HaH: M-300-HaH (ISC). Accessed on August 8, 2023. www.careweb.com. 14. 13. MCG. 27th ed. (2023). Viral Illness, Acute: Hospital-at-Home. HaH: M-280-HaH (ISC). Accessed on August 8, 2023 .www.careweb.com. Acute Hospital Care at Home-OH MCD-AD-1213 Effective Date: 02/01/2024 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.715. Measuring Quality in Hospitals in the United States. UpToDate. Friedberg, Mark MD. (March 06, 2020). Accessed on August 8 , 2023. www.UpToDate.com. 16. Monitoring and Reporting Hospital-Acquired Conditions: A Federalist Approach. West, Nathan. (2014). Medicare and Medicaid Research Review. Volume 4, Number 4. Accessed on August 8 , 2023. www.cms.gov. 17. National Patient Safety Goals Effective January 2021 for the Hospital Program. The Joint Commission. Accessed on August 8, 2023. www.j ointcommission.org. 18. QualityNet. Acute Hospital Care at Home Resources.(April 2022). Accessed on August 8, 2023 . www.qualitynet.cms.gov . Approved ODM 10/05/2023
ADMINISTRATIVE POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-OH MCD-AD-0767 12/01/2023 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 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.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. Rev iew/Rev ision History ………………………………………………………………………………………… 5 H. References…………………………………………………………………………………………………………..5 Program Integrity Provider Prepayment Review-O HMCD-AD-0 767 Effective Date: 12/01/2023 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.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 c omparison billed services.Program Integrity (PI) – The proper management and functioning of a healt h i nsurance program to ensure it is providing quality and efficient care while usi ng f unds 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.Regist ered Health Information Administrator (RHIA) – A professional who handles patient health information. The RHIA role requires certification and must adhere t o s tandards such as the Health Insurance Portability and Accountability Act and other privacy and security rules. Registered Health Information Technician (RHIT) – A certified professional w ho s tores and verifies the accuracy and completeness of electronic health records and analyzes patient data with the goal of controlling healthcare costs and improvi ng pat ient care. Soft Denial-A denial applied to claims which are selected as part of t he pr epayment review audit . Soft denials do not require an appeal to resolve . Upl oad r ecords to the CareSource Provider Portal for the denied claim . Soft denials ar e i dentified 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. o verutilization of services B. b illing for items or services not rendered C. s election of wrong CPT/HCPCS code or supplies D. lack of medical necessity E. b illing/dispensing unnecessary services F. procedure repetition Program Integrity Provider Prepayment Review-O HMCD-AD-0 767 Effective Date: 12/01/2023 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.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. CareSource will provide a written notice to the provider/provider group advising the effective date of prepayment review.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 deni ed. 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 inMedicare 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 CodingSystem (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 asMCG 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 ServiceAdministration, and the American Association of Neuromuscular & Mental HealthServices Administration M. n ationally 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-O HMCD-AD-0 767 Effective Date: 12/01/2023 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.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 accreditati on r equirements 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 c onsecutive 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 complianc e wit h billing practices. C. If the provider fails to satisfy the requirements above, the following may be nec essary:1. If after 12 months on prepayment review the provider fails to satisfy the requirements under subsection A, CareSource may do the one of following:a. o utreach to provider to educate on claim accuracy issues b. require a corrective action plan c. d eny 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 in the following conditions:a. no billing activity for 6 months Program Integrity Provider Prepayment Review-O HMCD-AD-0 767 Effective Date: 12/01/2023 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. Relat ed Policies/Rules N/A G. Revie w/Revision History DATES ACTION Date Issued 01/08/2020 New Policy Date Revised 08/19/2020 07/20/2022 08/02/2023 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. Date Effective 12/ 01/2023 Date Archived H. Refer encesN/AApprov ed ODM 09/14/2023
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 les s favorable than the limitations that apply to medical conditions as covered under this policy. ADMINISTRATIVE POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Experimental, Investigational and Other Non – Covered Services-OH MCD-AD-0006 12/01/2023-05/31/2024 Policy Type ADMINISTRATIVE T able of Contents A.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 …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 5 Experimental, Investigational and Other Non-Covered Services-OH MCD-AD-0006 Effective Date: 11/01/2023 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 2 A. SubjectExperimental, Investigational and Other Non-Covered Services B. Background Experimental and/or investigational items or s ervices are not covered. This includes, among other things, services or procedures considered to be investigational, cosmetic, or not medically necessary, and in some cases, providers may bill members for these non-covered services or procedures. Providers are encouraged to inform members in advance when they may be financially responsible for the cost of non-covered or excluded services. To determine whether a medical technology is a proven, medically necessary service, device, or procedure, CareSource conducts literature searches and evaluates the published scientific evidence related to each technology. The published evidence is reviewed against five (5) technology assessment criteria. In order for a technology to be considered medically necessary, all five (5) criteria must be met. If any one or more of the following criteria are not met, then the technology is considered investigational: 1. The technology must have final approval from the appropriate government regulatory bodies (i.e., Food and Drug Administration [FDA]). An approval granted as an interim step (i.e., Treatment IND) in the governmental bodys regulatory process is not sufficient. 2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes and consist of well-designed and well-conducted investigations published in peer-reviewed journals. The quality of the studies and the consistency of the results are considered when evaluating the evidence. 3. The technology must improve the net health outcome (the technologys beneficial effects on health outcomes should outweigh any harmful effects on health outcomes. 4. The technology must be as beneficial as any established alternatives of a similar cost effectiveness. This means the technology should improve the net health outcome as much as or more than established alternatives. 5. The improvement must be attainable outside the investigational settings. When used under the usual conditions of medical practice, the technology should be reasonably expected to satisfy technology evaluation criteria #3 and #4. The following additional criteria apply to new diagnostic technologies (e.g., imaging studies, laboratory procedures, home monitoring devices): 1. Technical feasibility is demonstrated, including reproducibility and precision. For comparison among studies, a common standardized protocol for the new diagnostic technology is established. 2. For accurate interpretation of study results, sensitivities, specificities, and positive and negative predictive values compared to standards are established. 3. The clinical utility of a diagnostic technique, i.e., how the results of the study can be used to benefit patient management, is established. The clinical utility of both positive and negative tests must be established. Experimental, Investigational and Other Non-Covered Services-OH MCD-AD-0006 Effective Date: 11/01/2023 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 3 C. DefinitionsCPT 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 Administration (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 Service) that, at the time CareSour ce 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 Provided 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 experimental or investigational, 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. 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 III 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 beneficial health outcome. Experimental, Investigational and Other Non-Covered Services-OH MCD-AD-0006 Effective Date: 11/01/2023 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 4 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, E. 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. Medical records, or G. The opinions of consulting providers and other experts in the field IV. The codes listed in this policy come from the following sources, and are typically reviewed twice a year: Center for Medicare and Medicaid Services (CMS) The American Medical Association V. The following items, procedures and services are non-covered. This list is not intended to be an all-inclusive list. Other services not inclu ded in this list may also be non-covered. The absence or removal of a code from this medical policy does not imply coverage.Codes Description Rational for non-coverage 0745T Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (eg, CT, MRI, or myocardial perfusion scan) and electrical data (eg, 12-lead ECG data), and identification of areas of avoidance As of most recent review, no FDA approval 0746T Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan As of most recent review, no FDA approval 0747T Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia As of most recent review, no FDA approval 0749T analysis of bone mineral density (BMD) utilizing data from a digital Xray, retrieval and transmis sion of digital X-ray data, assessment of bone strength and fracture risk and BMD, interpretation and report. As of most recent review, no FDA approval 0750T Bone strength and fracture-risk assessment using digital X- ray radiogrammetry-bone mineral density (DXR-BMD) As of most recent review, no FDA approval Experimental, Investigational and Other Non-Covered Services-OH MCD-AD-0006 Effective Date: 11/01/2023 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 5 Codes Description Rational for non – coverage analysis of bone mineral density (BMD) utilizing data from a digital Xray, retrieval and transmission of digital X-ray data, assessment of bone strength and fracture risk and BMD, interpretation and report; with single-view digital X-ray examination of the hand taken for the purpose of DXR-BMD 0776T Therapeutic induction of intra-brain hypothermia, including placement of a mechanical temperature-controlled cooling device to the neck over carotids and head, including monitoring (eg, vital signs and sport concussion assessment tool 5 [SCAT5]), 30 minute s of treatment The pro2cool device is not currently cleared for use by the FDA. 0778T Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle function. As of most recent review, no FDA approval 0779T Gastrointestinal myoelectrical activity study, stomach through colon, with interpretation and report As of most recent review, no FDA approval 0783T Transcutaneous auricular neurostimulation, set-up, calibration, and patient education on use of equipment. FDA approved but experimental and investigational E. C onditions of Coverage NA F. Related Policies/Rules Clinical Trial CoverageMedical Necessity Determinations policy G. Review/Revision History DATES ACTION Date Issued New Policy Date Revised 07/19/2023 Approved at Committee. Date Effective 12/01/2023 Date Archived 05/31/2024 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 doc umented Policy. H.References 1. Biological Products, 21 C.F.R. 600 (2021). Accessed June 13, 2023. www.ecfr.gov. 2. Centers for Medicare & Medicaid Services (CMS). EPSDT-A Guide for States : C overage in the Medicaid Benefit for Children and Adolescents. ExperimentalTreatments. HHS-0938-2014-F- 1347. Accessed July 14, 2023. www.hhs.gov. 3. Coverage and Authorizati on of Services, 42 C.F.R. 438.210 (2021). AccessedJune 13, 2023. www.ecfr.gov. 4. Department of Health and Human Services Centers for Medicare & Medicai d Experimental, Investigational and Other Non-Covered Services-OH MCD-AD-0006 Effective Date: 11/01/2023 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 6 Services. (2015, January 1) . Medicare Coverage of Items and Services in Category A and BInvestigational Device Exemption (IDE) Studies MLN Matters MM8921. Accessed June 13, 2023. www.cms.gov.4. ECFR. (n.d.). E-CFR Title 21 Part 312.21 Phases of an investigation. Accessed June 13, 2023. www.ecfr.gov. 5. ECFR. (2019, June 21). E-CFR Title 21 Part 812 Investigational Device Exemptions. Accessed June 13, 2023. www.ecfr.gov. 6. ECFR. (2019, June 21). E-CFR Title 21 Part 814 Premarket Approval of Medical Devices. Accessed June 13, 2023. www.ecfr.gov. 7. 42 Part 405 Subpart BMedical Services Coverage Decisions That Relate to Health Care Technology Authority. Accessed June 13, 2023. www.ecfr.gov. 8. ECFR. (2019, April 16). 42 CFR 438.210 Coverage and authorization of services. Accessed June 13, 2023. www.ecfr.gov. 9. Ohio Administrative Code (OAC). Rule 5160-1-61 Non-covered services. June 13, 2023. www. codes.ohio.gov. 10. Premarket Approval of Medical Devices, 21 C.F.R. 814 (2021). Accessed June 13, 2023. www.ecfr.gov. 11. Utilization Control, 42 C.F.R. 456.1-725 (2021). June 13, 2023. www.ecfr.gov . Approved ODM 09/07/2023
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Retrospective Authorization Review-OH MCD-AD-1334 10/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affilia tes 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 nece ssary 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 l ocal area, are the lowest cost alternative, and are not provided mainly fo r 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Retro sp ective Auth o rizatio n Review-OH MCD-AD-1334 Effective Dat e: 10/01/2023 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.2 A. SubjectRetrospective Authorization Review B. BackgroundA retrospective review is a request f or an initial review f or an authorization of care, service, or benef it 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 servi ce or discharge. Retrospective reviews are perf ormed by licensed clinicians who are supported by licensed physicians. A decision is rendered within 30 days of receipt of all necessary documentation. In the event of an adverse determination, the provider and/or memberare notif ied of the decision and supporting rationale.C. Def initions 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. Retrospective Authorization Review The process of reviewin g and making a coverage decision f or a service or procedure that has already been perf ormed (e.g., post service decision). Prior Authorization Utilization review conducted prior to an admission 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. D. PolicyI. CareSource considers retrospective authorization review appropriate when ANY of the f ollowing 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 the original prior authorized service was perf ormed . E. The need f or the new service was revealed at the time the original authorized service was perf ormed . F. The service was directly related to another service f or which prior approval has already been obtained and that has already been perf ormed. Retro sp ective Auth o rizatio n Review-OH MCD-AD-1334 Effective Dat e: 10/01/2023 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.3 II. Retrospective authorization requests must be submitted within 30 calendar days of the date of service or date of discharge or as specif ied in a provider contract. III. Unless the CareSource member is transitioning and qualif ies under the retroactive coverage re quirements , 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 conf lict between this policy and a providers 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 Date Effective 10/01/2023 Date Archived H. Ref erences1. CareSource Ohio Provider Manual-Medicaid . CareSource; 2023. Accessed June 2, 2023 . www.caresource.com.
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Medical Necessity Determinations-OH MCD-AD-0005 10/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affi liates 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 n ecessary 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, increas ed 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 Administr ative 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 determinati on. 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 me dical conditions as covered under this policy.Table 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 ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Medical Necessity Determinations-OH MCD-AD-0005Effective Dat e: 10/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectMedical Necessity Determinations B. BackgroundThe term medical necessity has been used by health plans and providers to define benefit coverage. Medical necessity definitions vary among entities, including the Centers for Medicaid and Medicare Services (CMS), the American Medical Association (AMA) , st ate regulatory bodies, and most healthcare insurance providers, but definitions most often incorporate the idea that healthcare services must be reasonable and necessary or appropriate, given a patients condition and the current standards of clinical practice. Payors and insurance plans may limit coverage for service s that are reasonable andnecessary if the service is provided more frequently than allowed under a national coverage policy, a local medical policy, or a clinically accepted standard of practice. International Classification of Diseases (ICD ) guidelines instruct the clinician to choose adiagnosis code that accurately describes a clinical condition or reason for a visit and support medical necessity for services reported. To better support medical necessity for services reported, providers should apply universally accepted healthcare principles that are documented in the patients medical record, including diagnoses, coding with the highest level of specificity, specific descr iptions of the patients condition, illness, or disease and identification of emergent, acute and chronic conditions. CareSource will determine medical necessity for a requested service, procedure, or product based on the hierarchy within this policy.C. Definitions MCG Health – Developed care guidelines in strict accordance with the principles of evidence-based medicine and best practices that direct informed care. Medically Necessary/Medical Necessity – o Individuals covered by early and periodic screening, diagnosis , and treatment (EPSDT) – Procedures, items, or services that prevent, diagnose, evaluate, correct, ameliorate, or treat an adverse health condition such as an illness, injury, disease , or its symptoms, emotional or behavioral dysfuncti on, intellectual deficit, cognitive impairment, or developmental disability. o Individuals not covered by EPSDT – Procedures, items, or services that prevent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease , or i ts symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without which the person 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. o Conditions of medical necessity are met if all the following apply: Medical Necessity Determinations-OH MCD-AD-0005Effective Dat e: 10/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 1. meets generally accepted standards of medical practice2. clinically appropriate in its type, frequency, extent, duration, and deli very setting 3. appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome 4. is the lowest cost alternative that effectively addresses and treats the medical problem 5. provides unique, essential, and appropriate information if it is used for diagnostic purposes 6. not provided primarily for the economic benefit of the provider nor for the convenience of the provider or anyone else other than the recipient Mental Health Parity and Addictions Equity Act (MHPAEA) – A 2008 federal law that generally prevents group health plans and health insurance issuers that provide mental health and sub stance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations than on medical/surgical coverage. D. PolicyI. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a be havioral 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. The reviewer will determine medical necessity based on the following hierarchy: A. Ben efit contract language. B. Federal or state regulation, including state waiver regulations when applicable and Ohio Department of Medicaid (ODM) -developed criteria. C. CareSource medical policy statements, as approved by the State. D. Nationally accepted evidence-based clinical guidelines, such as MCG Health , Interqual , or American Society of Addiction Medicine, as approved by the State. E. Professional judgment of the medical or behavioral health reviewer based on the following potential resources, which may include , but are not limited to : 1. Clinical practice guidelines published by consortiums of medical organizations and generally accepted as industry standard. 2. Evidence from two (2) published studies from major scientific or medical peer-reviewed journals that are less than five (5) years old (preferred ) and less than ten ( 10 ) years (required ) to support the proposed use for the specific medical condition as safe and effective. 3. National panels and consortiums , such as NIH (National Institutes of Health), CDC (Centers for Disease Control and Prevention), AHRQ (Agency for Healthcare Researc h and Quality), NCCN (National Comprehensive Cancer Network), SAMHSA ( Substance Abuse and Mental Health Services Administration ). Studies must be approved by a United States institutional review board (IRB) accredited by the Association for the Accreditati on of Human Research Protection Programs, Inc. (AAHRPP) to protect vulnerable minors. 4. Commercial review organizations , such as Up-to-Da te and Hayes, Inc. Medical Necessity Determinations-OH MCD-AD-0005Effective Dat e: 10/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 5. Consultation from a like-specialty peer.6. Specialty and sub-specialty societies listed below . This is not an all-inclusive list: General Area Specialty SocietyAddiction American Society of Addiction Medicine , American Academy of Addiction Psychiatry Allergy & Immunology American Academy of Asthma, Allergy & Immunology American College of Allergy, Asthma & Immunology Anesthesiology American Society of Anesthesiologists Cardiology American College of Cardiology , American Heart Association Colorectal Care American Society of Colon & Rectal Surgeons Critical Care Medi cine Society of Critical Care Medicine Dermatology American Academy of Dermatology Emergency Medicine American College of Emergency Physicians , American Board of Emergency Medicine Endocrinology, Diabetes & Metabolism American College of Endocrinology American Association of Clinical Endocrinologists Family Medicine American Academy of Family Physicians Gastroenterology American Gastroenterological Association , American College of Gastroenterology Genetics American College of Medical Genetics , National Society of Genetic Counselors, American Society of Human Genetics Geriatric Medicine American Geriatrics Society , National Council on the Aging Hematology American Society of Hematology Hospice and Palliative Medicine American Academy of Hospice and Palliative Medicine Infectious Disease Infectious Disease Society of America Internal Medicine American College of Physicians , American Board of Internal Medicine Nephrology American Society of Nephrology Neurology American Association of Neurological Surgeon s, American Academy of Neurology Nuclear Medicine American College of Nuclear Medicine Obstetrics & Gynecology American Congress of Obstetricians & Gynecologists , Society of Gynecologic Oncologists Oncology American Society of Clinical Oncology , American Cancer Society, Na tional Comprehensive Cancer Network Ophthalmology American Academy of Ophthalmology Orthopedic Surgery American Academy of Orthopaedic Surgeons Osteopathy American Association of Colleges of Osteopathic Medicine Otolaryngology American Academy of Otolaryngology-Head & Neck Surgery Pain Medicine American Academy of Pain Medicine Pathology College of American Pathologists , American Society for Clinical Pathology , American Society for Investigative Pathology, Association for Molecular Pathology, American Society of Cytopathology Pediatrics American Academy of Pediatrics Physical Medicine & Rehabilitation American Academy of Physical Medicine & Rehabilitation Plastic Surgery American Society of Plastic Surgeons Preventive Medicine American College of Preventive Medicine Psychiatry American Psychiatric Association , American Academy of Child & Adolescent Psychiatry , American Association for Community Psychiatry Pulmonary Disease American College of Chest Physicians , American Thoracic Society, American Lung Association, American Association of Respiratory Care Medical Necessity Determinations-OH MCD-AD-0005Effective Dat e: 10/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 Radiology American College of Radiology , American Society for Therapeutic Radiation & OncologyRheumatology American College of Rheumatology Surgery & Va scular Surgery American College of Surgeons Thoracic & Cardiac Surgery Society of Thoracic Surgeons Urology American Urological Association , American Society of Clinical Urologists E. Conditions of CoverageThe following does not guarantee coverage or claims payment for a procedure or treatment under a plan (not an all-inclusive list): I. A physician has performed or prescribed a procedure or treatment. II. The procedure or treatment may be the only available treatment for an injury, illness or behavioral health disorder. III. The physician has determined that a particular health care service is medically necessary or medically appropriate. F. Related Policie s/RulesNA G. Review/Revision HistoryDATES ACTIONDate Issued 06/15/2012Date Revised 07/15/2013 07/15/2014 05/19/2015 12/15/2015 12/11/201904/01/202001/25/202103/04/202206/21/2023 Criteria changes with specialty/sub-specialty table added to policy.Revise d language to include professional judgment in the absence of evidence-based methodology and change order of Plan hierarchy. Revised class/category . D efined evidence criteria for article submissions. Added rule, added definitions, removed hyperlinks, updated external review organizations and age restrictions. Annual review. Added ASAM. Annual review. Updated background. Reordered hierarchy, I.B-D. Annu al review . Updated hierarchy and specialty chart. Approved at Committee. Date Effective 10/01/2023 Date Archived H. References1. American Association of Professional Coders. What is medical necessity and why does it matter ? (2019, April 5). Accessed May 2, 2023 . www.aapc.com 2. American Medical Association. Definition of medical necessity . (n.d.) Accessed May 2, 2023 . www.ama.com 3. Medicaid Medical Necessity: Definitions and Principles, OHIO ADMIN . CODE 5160-1-01 (2022) .
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Readmission Behavioral Health OH MCD-AD-1018 09/01/2023 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Readmission Behavioral Health OH MCD-AD-1018Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectReadmission Behavioral Health B. BackgroundIn 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 thirty ( 30 ) days is often costly , preventable , and a quality-of-care issue that can cost health plans more than $1 billion dollars annual ly. Readmissions result from many factors but , most often , are due to lack of transitionalcare or discharge planning . Members with s chizophrenia , depression , medical comorbidities, and substance use disorder are more likely to be readmitted after hospitalization . For individuals hospitalized for BH conditions, i ncluding 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 and SUD often falls shor t of these recommendations. CareSource strives to improve the quality of inpatient and transitional care , includingcommunication between the patient, caregivers , providers and the M anaged CareOrganization (MCO) , provid ing the patient with education to maintain care at home to prevent readmission , perform ing predischarge assessment to ensure read iness for discharge , and provid ing effective post discharge coordination of care. C. Definitions Appropriate Care – Care that i s consistent with accepted care standards in the prior discharge or during the post-discharge follow-up period. Clinical Review – Review of records by a health care professional with appropriate clinical expertise in the treatment of behavioral health conditions, including member diagnoses , living situation, supports, and severity of the condition . Hospital – As defined by Ohio Administrative Code 5160-2-01 and includes both general acute care facilities and Institutions of Mental Disease (IMD). Never Events – Serious and costly errors in the provision of health care services causing serious injury or death t o patients. 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 Readmissi on – A readmission within 30 days of a prior discharge to the same or any other hospital that is clinically related and may have been prevented had appropriate care and/or discharge planning/coordination been provided during the initial hospital stay and d ischarge process. Readmission – An admission to a hospital within thirty days of the date of discharge from the same hospital. Readmission Behavioral Health OH MCD-AD-1018Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 Same Day – Midnight to midnight of a single day.D. PolicyI. CareSource considers the following p reventable , clinically related readmission s to the first admission : A. an acute complication related to lack of care provided during the initial admission B. acute decompensation of a chronic problem that was not the reason for an initial admission but was related to lack of care or care decisions provided during , or immediately after , an initial admission C. readmission for a condition /procedure clinically relat ed to care provided or resulting from inadequate or incomplete discharge planning during the prior discharge D. premature discharge due to clinical instability, inadequate medication management , and /or inadequate or incomplete discharge planning E. 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 , inc luding the following (not all-inclusive) : 1. contact names, phone numbers and addresses with dates of contact & role/responsibility in treatment regimen and discharge plan 2. organizations affiliated with contact, if applicable, including outpatient and communit y behavioral health resources 3. CareSources assistance was requested connecting with appropriate outpatient resources to review recent outpatient treatment history, schedu le follow-up appointments within 7 calendar days of discharge, and /or coordinat e tran sportation to follow-up appointments 4. review of social determinants of health (SDoH) and request for CareSource assistance with potential barriers to care ( i.e., homelessness, telephone availability, transportation, etc.) 5. medication reconciliation did not occur 6. prescriptions related to treatment regimen availabi lity at discharge , including: a. two weeks worth of medication was provided to the member at the time of discharge , which is not to be included in the inpatient c laim and must be a separate NCPDP claim b. transportation to th e pharmacy or medication home-delivery was scheduled II. The following are excluded from a readmission review :A. an original discharge that was patient-initiated against medical advice (AMA) with circumstances of such discharge and readmission documented in the medical record B. planned readmissions C. readmission s to other hospitals/ facilities outside the hospital system (i.e., different Tax Identification Number) Readmission Behavioral Health OH MCD-AD-1018Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 D. readmissions to another hospital from within the same hospital system (i.e.,same Tax Identification Number), except for 1-day readmission (refer to IV. B. 2.) E. transfers from out-of-network to in-network facilities F. transfers to receive care not available at the first facility or unit G. readmissions for members are under the age of 21 H. readmissions for patient s with conditions related to cancer, transplants, HIV infection, pregnancy, or poisoning in addition to behavioral health condition s III. Review of Medical NecessityReview of medical necessity for the initial or subsequent inpatient stay is conducted pre-service delivery using related medical necessity criteria. The review process and determination is 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 den ied, resulting in the denial of any related claim (s) . IV. Readmission Reviews and Payment Process esA. Readmission Review Process CareSource will conduct post-service clinical readmission review s by reviewing medical records to determine if a readmission was a preventable , clinically related readmission . Reviews may be conducted pre-and/or post-payment. Pertinent and complete medical records for both admissions must be included with claim submission to determine appropriateness of t he admission(s). Failure to provide complete medical records for a post-service clinical readmission review will result in an automatic denial of t he claim for the readmission . B. Payment Process 1. 30-Day Readmissions a. If a clinical readmission review determines that readmission was unavoidable or unrelated to the first admission , related claims will be treated as , and adjudicate d as , two separate admiss ions. 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 p ayment , 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 claims for readmission(s) that need to be collapsed into a single claim. 2. 1-calendar day readmissions (i.e., same day or next day readmissions) will be reimbursed as one DRG payment. If a n institution submits claims for both admissions, the second claim processed will be rejected. The two ad missions must be collapsed into one claim and resubmitted for payment. 3. Never events are not reimbursable. Readmission Behavioral Health OH MCD-AD-1018Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 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 diagnos es code s, includ ing F0150-F99, G4700, G479, H9325, Q900 – Q902, Q 909-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 WO.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/RulesBehavioral Health Service Record Documentation Standards Sentinel Events and Provider Preventable Conditions G. Review/Revision HistoryDATES ACTIONDate Issued 12/01/2021 Approved at PGC.Date Revised 05/24/2023 Annual review. Updated background, definitions, reference list. Added related policies. Approved at Committee. Date Effective 09/01/2023 Date Archived Readmission Behavioral Health OH MCD-AD-1018Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.6 H. References1. Center s for Medicare and Medicaid Service s. Eliminating serious, preventable, and costly medical errors-never events. (2006). Retrieved May 17, 2023 from www.cms.gov . 2. Centers for Medicare and Medicaid Services. Hospital readmission reduction program. (2018) . Ret rieved May 17, 2023 from www.cms.gov . 3. Centers for Medicare and Medicaid Services. Medicare claims processing manual. (2018). Retrieved May 17, 2023 from www.cms.gov. 4. Cook JA, Burke-Miller JK, Jonikas JA, Aranda F, Santos A . Factors associated with 30-day readmissions following medical hospitalizations among medicaid beneficiaries with schizophrenia, bipolar disorder, and major depressive disorder. Psychiatry Research . 2020;291 (113168). doi.org/10.1016/j.psychres.2020.113168 . 5. Elisa D, Cristiana M, Vincenzo V, Paola R. Factors associated with 30-days and 180 – days psychiatric readmissions: A sna pshot of a metropolitan area. Psychiatry Research . 2020; 292 (113309 ). doi.org/10.1016/j .psychres.2020. 6. Goldfield N , et al . Identifying potentially preventable readmissions. Health Care Financing Review . 2008;30(1): 75-91 . 7. Mark T, et al . Hospital readmission among medicaid patients with an index hospitalization for mental and/or substance use disorder. JBehav Health Serv Res. 2013; 40(3) :207-21. 8. McIlvennan C, Eapen Z, Allen L. Hospital readmissions reduction program. Circulation . 2015; 131(20) :1796-803. 9. Ohio Administrative Code. (2017). 5160-2-01. Eligible providers. 10. Ohio Administrative Code. (2022). 5160-2-02 General provisions: Hospital services. 11. Ohio Administrative Code. (2022). 5160-2-13 Utilization review. 12. Ohio Administrative Code. (2017). 5160-2-14 Potentially preventable readmissions. 13. Ohio Administrative Code. (2022). 5160-2-65 Inpatient hospital reimbursement. 14. Ohio Department of Medicaid. RRichardson. Hospital Inpatient Readmission Policy. (2020). Retrieved May 1 7, 2023 from www.medicaid.ohio.gov. 15. Ohio Department of Medicaid. Medicaid Programs. (n.d.) Retrieved May 1 7, 2023 from www.medicaid.ohio.gov. 16. Ohio Department of Medicaid. Office of Policy. Hospital Billing Guidelines (dod and dos on or after September 1, 2021). (2021). Retrieved May 1 7, 2023 from www.medicaid. ohio.gov. 17. Reif S, Acevedo A, Garnick D. & Fullerton C. Reducing behavioral health inpatient readmissions for people with substance use disorde rs: Do follow-up services matter? (2017). Retrieved May 17, 2023 from www.ps.psychiatryonline.org . 18. The Moran Comp any. Medicare psychiatric patients & readmissions in the inpatient psychiatric facility prospective payment system . (2013). Retrieved May 17, 2023 from www.nabh.org .
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