Modifier 25

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 25-OH MCD-PY-1360 11/01/ 2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims edit ing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to p lan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care 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 functi on, dysfunction 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 services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an aut horization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage) , then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particula r case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favo rable 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 ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 25-OH MCD-PY-1360Effective Dat e: 11/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 25 B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursemen t modifiers are a 2-digit code that provide a way for physicians and otherqualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifier 25 is used to report an Evaluation andManage ment (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association (AMA) Current Procedural Terminology (CPT ) book defines modifier 25 as a signi ficant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of modifier 25 pro vided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a medically necessary,significant and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by do cumentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condi tion for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Thi s modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57 for a surgical decision . For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through pre payment and post-payment edit or audit. Using a modifierinappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSource s request. CareSource uses published guidelines fromModifier 25-OH MCD-PY-1360Effective Dat e: 11/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 CPT and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly. C. Definitions American Medical Association (AMA) A professional association of physicia ns and medical students that maintains the Current Procedural Terminology coding system. Current Procedural Terminology (CPT ) Codes that are issue d, updated, and maintained by the AMA that provide a standard language for coding and billing medical servi ces and procedures. Evaluation and Management (E/M) A medical coding process established by Congress that supports medical billing and determines the type and severity of patient conditions. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier 2-character code used along with a CPT or HCPCS code to pr ovide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 25 may be flag ged for either a prepayment clinical validation or prepayment medical record coding review . A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of claim s. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submi ssion, this will also result in a claims denial. IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifier 25 may only be used to indicate that a significant, separately identifiable evaluation and manageme nt service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier 25, the code may be denied. Modifier 25-OH MCD-PY-1360Effective Dat e: 11/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 VI. Appending modifier 25 to an E/M service is considered inappropriate in th e following circumstances: A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operativ e period. B. The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure. C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedur e includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. H. The preventative E/M service is performed at the same time as a preventative care visit (eg, a prevent ative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preventative, only one should be reported. I. The routine use of the modifier is reported without supporting c linical documentation. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on allclaims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy applies to both participating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document.F. Related Policies/RulesModifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022 New PolicyDate Revised 08/02/2023 Annual Review: updated references. Approved at Committee Modifier 25-OH MCD-PY-1360Effective Dat e: 11/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 07/17 /2024 Review: updated references, approved at CommitteeDate Effective 11/01/2024 Date Archived H. References1. Appropriate use of Modifier 25. American College of Cardiology. Accessed July 8, 2024 . www.acc.org 2. Chaplain S. Are you using Modifier 25 correctly. American Academy of Professional Coders. Published March 25, 2022. Accessed July 8, 2024 . www.aapc.com 3. Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services . Centers for Medicare and Medicaid Services; 202 4. Accessed July 8, 2024 . www.cms.gov 4. CPT Modifier 25. Palmetto GBA. Accessed July 24, 2023. www.palmettogba.com 5. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag . 2004;11(9):21-22. Accessed July 8, 2024. www.aafp.org 6. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services; 2024 . Accessed July 8, 2024 . www.cms.go v Approved ODM 0 7/25/2024

Neonatal Intensive Care Unit (NICU) Level of Care

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 07/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or suppli es that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or si gnificant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also inc lude those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Rei mbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan c ontract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may mo dify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the li mitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectNeonatal Intensive Care Unit (NICU) Level of Care B. BackgroundThis policy aligns with guidance from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) regarding NICU levels of care. This policy provides guidelines for determining the medically appropriate level of care for reimburseme nt based on available documentation. NICU admissions are reviewed to ensure that services are of an appropriate duration and level of care to promote optimal health outcomes in the most efficient manner. Clinical documentation of an ongoing NICU hospitaliz ation will be reviewed concurrently to substantiate level of care with continued authorization based on the documentation submitted. Reimbursement for the NICU stay will be based on the authorized level of care and determined by the concurrent review proce ss. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have defined and specified the capabilities for each of 4 facility levels of care (ie, a specific unit located in the hospital). These facilities ra ngefrom a Level I Newborn Observation Unit to a Level IV Regional Neonatal Intensive Care Unit. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification.The Neonatal Intensive Care Unit (NICU) is a critical care area in a facility for newbornbabies who need specialized care. The NICU designation requires a combination of advanced technology and a NICU team of licensed professionals. NICU levels of care are based on the complexity of ca re that a newborn with specifieddiagnoses and symptoms requires. All four levels of care are represented by a unique revenue code . Any inpatient revenue codes not billed as levels II-IV will be recognized as a level I. Level I = 0171 Level II = 0172 Le vel III = 0173 Level IV = 0174 While most infants admitted to the NICU are premature, others are born at term but suffer from medical conditions , such as infections or birth defects. A newborn also could be admitted to the NICU for associated maternal risk factors or complicated deliveries. Although the list of criteria used to determine the NICU levels of care in this policy is not all inclusive, it does provide an overview of the guidelines that are used. C. Definitions Intensity of care (IOC) Care based on the complexity of care that a ne wborn with specified diagnoses and symptoms requires. Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Newborn CareServices Services performed from birth to 4 weeks. Neonatal Intensive Care Services (NICU) Critical care services for a newborn. Well baby care services A basic level of care to neona tes who are low risk. D. PolicyI. As per federal mandate, newborn members are covered at an inpatient facility for a 2-day stay for vaginal deliveries and a 4-day stay for cesarean sections. These stays will be covered without clinical review (notification may be required) if they are submitted with a normal newborn DRG. II. For any newborn diagnoses/revenue codes/procedures that may be associated with care/treatment outside of routine newborn care (any revenue code 0172, 0173, 0174) , preauthori zation is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to provide documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. Wh en a newborn require s a NICU admission or a higher IOC service, a priorauthorization is required.IV. If a complication develops with the mother or baby that necessitates additionalhospital days, NICU admission, or non-well-baby service, a prior authorizati on should be submitted along with clinical information to support the stay. V. If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to newborn nursery or pediatric level of care,NICU level of care will not be assigned regardless of interventions completed during transitional time. VI. Clinical review will determine appropriate IOC utilizing MCG standards. CareSourcewill adjust IOC reimbursement if clinical documentation does not support the IOCbilled. VII. Inpatient admissions may be reviewed to ensure that all services are of anappropriate duration and level of care to promote optimal health outcomes. Clinical documentation of an ongoing neonatal hospitalization will be reviewed concurrently to substantiate the level of care and length of stay. A continued auth orization will be based on the documentation submitted and alignment with MCG Neonatal Facility Levels of Care and Neonatal Intensity of Care Criteria as well as CareSource policy. VIII. In order to avoid reimbursement delay or adjustments, providers are encour aged to reference MCG guidelines as well as the clarifications and specific details below. Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 NICU LevelRevenue Code Description MCG NICU Intensity of Care Level 1 0171: Newborn Level I Intensity of Care Criteria 1 – Routine Care (LOC-010) Level 1 – Neonatal care may be indicated for a newborn or neonate with any of the following: Physiologically stable infant (eg, no apnea, bradycardia, or unstable temperature) who is in need of care consisting of one or more of the following: o Routine newborn care o Evaluation and care of neonates with conditions that require inpatient services available at Level I o Continued inpatient care during convalescence from condition(s) treated in Level II, Ill or IV while awaiting resolution of specific issues, (eg: Sustained weight gain, poor PO feeding ) or e stablishment of safe discharge destination and plan o Uncomplicated jaundice treated only with phototherapy and requiring infrequent bilirubin checks o Absence of parenteral medications o Evaluation and management of glucose levels without IV fluids , d iagnostic work – up/surveillance, on an otherwise stable neonate where no therapy is initiated Level 2 0172: Newborn Level II Intensity of Care Criteria 2 – Continuing Care (LOC-011)Level 2 – Neonatal care may be indicated for one or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen, ( 2L/min), with other co – morbidities stable Administration of intravenous (IV) medications IV Therapy; peripheral or PICC o IV fluids inclusive of hyperalimentation (less than 50% of total nutrition) o IV heparin lock medications o IV medications in a physiologically/clinically stable infant o IV treatment of hypoglycemia at a rate less than or equal to 5 mg/kg/min or hypoglycemia that is responsive to one IV dextrose bolus (2 ml/kg or 200mg/kg) Weaning from nasogastric (NG) or naso-jejunal (NJ) tube feedings while attempting to increase oral intake Apnea, bradycardia, or desaturation, but with episodes requiring stimulation, or only self – limited episodes; OR o apnea countdown OR o events requirin g caffeine Services for neonatal abstinence syndrome (NAS) requiring medication (weaning) when the Finnegan score is 8 or less or Eat Sleep Console (ESC) scores are improving Monitor of jaundice during phototherapy requiring frequent lab draws due to high risk etiology Temperature control system, eg, incubator, radiant warmer, in otherwise stable infant Evaluation for sepsis NOT toxic appearing but on antibiotics Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Clinically stable infections completing course of IV medications Continued inpatient care du ring convalescence from condition(s) treated in Level Ill care W ithdrawal of Life support; end of life care; palliative care Level 3 0173: Newborn Level III Intensity of Care Criteria 3 – Intermediate Care (LOC-012)Level 3 – Neonatal care includes Level 2 requirements and one or more of the following: Respiratory support using one of the following: o HFNC with > 2 L/minute of blended oxygen , continuous positive airway pressure (CPAP), Nasal intermittent positive pressure ventil ation (NIPPV) o Conventional ventilation (via endotracheal tube, nasotracheal tube or tracheostomy tube) o High-frequency ventilation long-term (> one week) Presence of chest tubes Umbilical arterial catheter (UAC) for blood draws Active apnea/bradycardic episodes requiring Positive pressure ventilation (PPV ) Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia requiring greater than 5 mg/kg/min or hypoglycemia not responsive to one IV dex trose bolus 200 mg/kg or 2 ml/kg of D10W Total parenteral nutrition or IV fluids to supplement inadequate oral intake (NG or PO) greater than 50% total nutrition NAS requiring initiation/escalation of medication or inability to wean Hyperbilirubinemia wi th evidence of hemolysis requiring intravenous immunoglobulin (IV IG ) or blood transfusion Acute encephalopathy that is moderate to severe and under active investigation or has been investigated and does not meet criteria for therapeutic hypothermi a Surgica l conditions requiring general anesthesia up to 2 days post-op if indicated Surgical/Therapies for retinopathy of prematurity (ROP) Seizure activity requiring initiation, supplementation or changing of seizure medications Transfusion of blood products in absence of severe acute etiology or manifestations (eg, transfusion needed for anemia of prematurity, iatrogenic anemia) Hypotension requiring intravenous fluid bolus Level 4 0174: Newborn Level IV Intensity of Care Criteria 4 – Intensive Care (LOC-013)Level 4 – Neonatal care includes Level 3 requirements and one or more of the following clinical interventions: Perioperative care following surgical repair of severe neonatal conditions, for example: o Bowel resection for necrotizing enterocolitis (NEC) o Tracheoesophageal fistula or esophageal atresia repair o Cardiac surgery excluding PDA ligation o Myelomeningocele closure (up to 48 hours post-op) Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 o Organ transplant Medically necessary inhaled nitric oxide (iNO) Extracorporeal membrane oxygenation (ECMO) High frequency oscillatory or jet ventilation (initial week) Therapeutic cooling Exchange tran sfusion (day of procedure) Uncontrolled active seizures despite medications Ongoing cardiovascular support (inotropes, chronotropes, antiarrhythmics) Severe hemodynamic instability requiring ongoing intravenous fluid/medication support o Dialysis o IV sedati on that includes paralysis o Prostaglandin infusion Cardiopulmonary resuscitation (CPR ) in the last 24 hours (not inclusive of delivery room resuscitation) Transfusion of blood products in setting of severe acute etiology or manifestation ( eg , hemolytic anem ia, disseminated intravascular coagulation, hemorrhage) E. Conditions of Coverage I. Reimbursement is independent of the location of care and corresponds to the medical treatment provided and level of service the neonate requires. To ensure accurate reimbursement, submitted claims will be reviewed to align preauthorized levels of care and/ or clinically validate diagnoses, procedures and other claim information that impact payment. Based on review, the following may occur: Down-code revenue codes to authorized levels of care Issue a base DRG payment Adjust claim diagnoses/procedures that are not substantiated in the medical information provided and apply DRG regrouping Request for complete medical records and/or itemized statements to support the services on the claim may be made II. In the event of any conflict between this policy and any written agreement betweenthe provider and CareSource, that written agreement will be the governing document.F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/13/2023 New policy . Approved at Committee.Date Revised Date Effective 07/01/2024 Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 Date ArchivedH. References1. About preterm labor and birth. National Institutes of Health. Reviewed May 9, 2023. Accessed February 19, 2024. www.nichd.nih.gov 2. Admission to NICU. Specification Manual for Joint Commission National Quality Measures . The Joint Commission; 2022. Version 2023A . Accessed February 19, 2024. www.manual.jointcommission.org 3. Intensity of Care Criteria 1 – Routine Care: LOC-010 (ISC GRG). MCG Health. 28th ed. Accessed February 19, 2024. www .careweb.careguidelines.com 4. Intensity of Care Criteria 2 – Continuing Care: LOC-011 (ISC GRG). MCG Health. 28th ed. Accessed February 19, 2024. www.careweb.careguidelines.com 5. Intensity of Care Criteria 3 – Intermediate Care: LOC-012 (ISC GRG). MCG Health. 28th ed. Accessed February 19, 2024. www.careweb.careguidelines.com 6. Intensity of Care Criteria 4 – Intensive Care: LOC-013 (ISC GRG). MCG Health. 28th ed. Accessed February 19, 2024. www.careweb.careguidelines.com 7. Stark AR, Pursley DM, Papile L, et al. Sta ndards for levels of neonatal care: II, III, and IV. Pediatr . 2023;151(6):e2023061957. doi:10.1542/peds.2023-061957 ODM Approved 03/28/2024

Residential Treatment Services – Substance Use Disorder

REIMBURSEMENT POLICY STATEMENTOhio Medi caid Policy Name & Number Date Effective Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 07/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Codi ng methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management 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 local area, are the lowest cost alternative, and are not provided mainl y for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/ or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in int erpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral hea lth 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 ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectResidential Treatment Services – Substance Use Disorder (SUD) B. BackgroundSubstance Use Disorder (SUD) treatment is dependent on the needs of the member with the type, length, and intensity of treatment determined by the severity of the SUD, types of substances used, support systems available, prior life experiences, and behavioral, physical , gender, cultural, cognitive, and/or social factors. Additional factors include the availability of treatment in the community and coverage for the cost of care. The American Society of Addiction Medicines (ASAM) levels 3 and 4, or residential and int ensive inpatient levels of care, are considered transitional with the goal of returning the member to the community with a less restrictive level of care. Level 3 services include residential and/or inpatient services that are clinically managed or medical ly monitored. Level 4 services include medically managed, intensive inpatient services. Providers use the ASAM level of care criteria as a basis for the provision of SUD benefits to deliver services for the full continuum of care, which also ensures that care isdelivered consistently with industry-standard criteria. ASAM also provides key benchmarks from nationally adopted standards of care and guidelines involving evidence-based treatment measures that guide services. Treatment of substance use disorder s is dependent on an SUD diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) . C. Definitions American Society of Addiction Medicine (ASAM) A professional medical society dedicated to increasing access and improving the quality of addiction treatment, educating p rofessionals and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of pati ents with addiction. ASAMs Residential Levels of Care (LOC): o 3.1 Clinically managed, low-intensity residential program o 3.3 Clinically managed, high-intensity, population specific o 3.5 Clinically managed, high-intensity residential program for adults and/or medium intensity for adolescents o 3.7 Medical ly monitored, intensive inpatient for adults and/or high-intensity for adolescents Clinically Managed Services Services directed by nonphysician addiction specialists rather than medical personn el appropriate for members whose primary problems involve emotional, behavioral, cognitive, readiness to change, relapse, or recovery environment concerns. Intoxication, withdrawal, and biomedical concerns, if present, are safely manageable in a clinically managed service, particularly under Level 3.1 , 3.3, and 3.5 residential programs. Inpatient Services Behavioral health (BH) services provided during an inpatient admission or confinement for acute inpatient services in a hospital or treatment Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.setting on a 24-hour basis under the direct care of a physician, including psychiatric hospitalization, inpatient detoxification, and emergency evaluation and stabilization. Medically Managed Services Services involving 24-hour nursing and daily medical care by a n appropriately trained and licensed physician providing diagnostic and treatment services directly, managing the provision of those services, or both, particularly under Level 4 medically managed intensive inpatient programs. Medically Monitored Services Services provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialists, or other health and technical personnel under the direction of a licensed physician through a mix of direct patient contact, review of records, team meetings, 24-hour coverage by a physician and nursing staff , and a quality assurance program, particularly under Level 3.7 inpatient programs. Medication Assisted Treatment (MAT) The use of Food and Drug Administration (FDA) -approved medications in combination with counseling and behavioral therapies to provide a whole-patient approach to the treatment of SUD. Per Diem An allowance or payment made for each day of service based on the sum of the national average routine operating, a ncillary , and capital costs for each patient day of care. Residential Level of Care Services for BH that can include individual, family and group therapy, nursing services, medication assisted treatment, detoxification (ambulatory or subacute) , and phar macological therapy in a congregate living community with 24-hour support. D. PolicyI. A residential program is staffed 24 hours a day and follows nationally recognized medical standards. Programs must meet criteria established in the Ohio Admin istrative Code (OAC) 5122-29-09, including the following (not all-inclusive, see OAC) : A. maintains written policies and pr ocedures ensur ing appropriate referral to other levels of care, including discharge planning and follow-up communications with member and provider(s) documented in the medical record B. employ s practitioners and supervisors of service s who meet OAC 5122-29-30 C. capab le of admitting, initiating, and referring members receiving MAT and facilitating continuity of pharmacotherapy through care transitions D. deliver all component practitioner services in accordance with Chapter 5122-29 of the OAC E. provide developmentally appropr iate services that address education needs and promote family or significant other involvement if serving members under the age of 18 II. A prior authorization (P A) is require d for the following:A. For the 1st and 2nd admissions per calendar year, a PA is only required for an admission exceeding 30 consecutive days. For example, a member goes into residential treatment for the 1st time in a calendar year for a period of 10 days. No PA is required. The same member goes into treatment for a 2nd admissio n during the same calendar year for a Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.period of 38 days. After day 30, the facility is required to obtain a PA for days31 through 38. B. For any stay or admission exceeding 2 admissions per calendar year, a prior authorization is required from the 1st day o f admission. The same member above admits for residential treatment for a 3rd time during the same calendar year. A PA for this admission is required , starting day 1. C. Changes in level of care 1. When step-up or step-down occur s between two SUD r esidenti al level of care codes within the same residential provider agency and there is consecutive billing, the step-up or step-down is counted as a single event. 2. When step-up or step-down occurs between two SUD residential level of care codes and billing i s not consecutive, the events will be considered separate events . PAs may be required , depending on the members utilization in that calendar year . a. If step-up or step-down occurs during the 1st 30 days of the 1st or 2nd of the 2 allowed SUD residential events, no PA is required for the step-up or step-down. b. If the step-up or step-down occurs after a PA has been authorized, either because the length of stay (LOS) exceeded 30 days or this is the 3rd or more event in a calendar year, then the ste p-up or step-down does require a new/updated PA. D. SUD residential facility transfers 1. Prior authorization is required for a same level of care admission or transfer between 2 SUD residentia l facilities ( national provider identifiers (NPI) and/or tax ide ntification numbers [TIN ]) when the total number of days at that level of care exceeds 30 calendar days and there is not a break in stay that is greater than 24-hours between admissions indicating two separate events . If the admission has already required a PA for any reason, the transition admission will require that a PA be obtained by the receiving facility from the date of admission. 2. Same level of care admissions or transfers between 2 SUD residential facilities (NPIs and/or TINs) without a break in stay of greater than 24 hours is not considered a separate event and will not accumulate as a separate event. 3. If there is a break in stay that is greater than 24 hours between a same level of care admission or transfer between 2 SUD residenti al facilities (NPIs and/or TINs) , the admission to the receiving facility is considered a separate event and is subject to a PA from the date of admission, beginning with the 3rd admission in a calendar year and will accumulate as separate events . III. DocumentationA. At least 1 documented face-to-face interaction must be performed by a clinical treatment team provider to the member at the site in order to bill per diem . B. Medical record s must show evidence of medical necessity of services and follow OAC gui delines . C. Program s must have written Affiliation Agreement s monitored by program Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.policies and procedures to ensure member access to outpatient care in a timely manner upon discharge . IV. B illingA. Residential level of care admission 1. One admission is considered 1 length of stay (LOS). 2. Any stay under 30 consecutive days counts as a full 30-day admission. 3. Service gaps in excess of 24 hours are considered a termination of 1 admission. 4. Leaving the SUD residential treatment facility associated with signific ant changes in health status, such as leaving against medical advice, step-ups (including acute medical admissions) or step-downs in level of care, and/or incarceration are considered a termination of 1 admission . 5. Brief leave of absences (24 hours or less except in rare instances ), when supported by the members individualized treatment plan , should be documented in the members treatment plan . B. The benefit follows the member not the providers tax identification number . C. CareSource processes claims from the following: 1. provider type 95 OhioMHAS certified/licensed treatment program 2. provider specialty 954 OhioMHAS certified/licensed SUD residential facility 3. place of service code 55 residential substance abuse treatment facility D. Claims billed out of seq uence from date of service may cause inappropriate den ials for no prior authorization . E. Claims are paid as received. If a member receives services from more than 1 provider, claims are paid to providers who submit 1st , regardless of date of service. F. SUD re sidential is paid per diem , which do es not include room and board costs and/or p ayments . G. CareSource does not reimburse separately for services provided by the residential treatment service , including 1. ongoing assessments and diagnostic evaluations 2. crisis in tervention 3. individual, group, family psychotherapy and counseling 4. case management 5. substance use disorder peer recovery services 6. urine drug screens 7. medical services H. A member can only receive services through 1 level of care at a time. 1. CareSource considers the following services non-billable when a member is in residential level of care : a. therapeutic behavioral services b. psychosocial rehabilitation c. community psychiatric supportive treatment d. mental health day treatment e. assertive community t reatment f. intensive home-based treatment Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2. Select BH services , including MAT and psychiatry for example, provided to a member by practitioners not affiliated with the residential treatment program (based on billing group TIN) are considered by CareSource as billable concurrent to the SUD residential admission when the service is medically necessary , and the treatment is outside of the scope of the residential treatment program . E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers. Refer to the Behavioral Health Ohio fee schedule for codes. Code inclusion in this policy does not imply any right to reimbursement or guarantee claim (s) payment. Additional provisions for services compliant with ASAM s level of care criteria can be found in the OAC , including programs for individuals under age 18, SUD case management, and crisis services. F. Related Polic ies/RulesI. CareSource Policies A. Medical Necessity Determinations B. Behavioral Health Documentation Standards II. Regulations A. Behavioral Health Nursing Services, OHIO ADMIN . CODE 5160-27-11 (2023). B. Behavioral Health Services-Other Licensed Professionals, OHIO ADMIN . CODE 5160-8-05 (2021). C. Certifying Community Mental Health Services or Addiction Services Providers, OHIO REV . CODE 5119.36 (2023). G. Review/Revision HistoryH. References1. American Society of Addiction Medicine . The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions , 4th Ed. Hazelton Betty Ford Foundation; 2023. DATE ACTIONDate Issued 08/17/2017Date Revised 05/15/2019 09/16/202012/28/202011/30/202101/18/ 202 301/31/2024 Updated definition s, medical necessary criteria, and billing . Updated definition s. A dded note under D.I. Added D.I.C.;D.1.IV. A.5 , IV.B. Added related policy. Revised D.IV.H.2 & I.C.D. & E. Provided clarification per ODM D. 1. C, D, and E; and D. IV. A. Removed codes from policy, updated definitions. Annual review. Updated background. Added definitions. Annual review. Updated D.I.A. Deleted Sections D.II and V., 8 on VI.G. Updated Fand H. Approved at Committee. Date Effective 07/01/2024 Date Archived Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2. Coverage and Limitations of Behavioral Health Services , OHIO ADMIN . CODE 5160-27-02 (2022). 3. Eligible Provider for Behavioral Health Services , OHIO ADMIN . CODE 5160-27-01 (2023). 4. Eligible Providers and Supervisors , OHIO ADMIN . CODE 5122-29-30 (2022). 5. Inpatient psychiatric facility PPS . Centers for Medicare and Medicaid Services. Updated September 6, 2023. Accessed December 2 7, 202 3. www.cms.gov 6. Medicaid Behavioral Health State Plan Services Provider Req uirements and Reimbursement Manual . Ohio Dept of Medicaid; 2023. Accessed December 27, 2023. www.medicaid.ohio.gov 7. Residential and Withdrawal Management Substance Use Disorder Services, OHIO ADMIN . CODE 5122-29-09 (2023). 8. Statutes, regulations, and guidelines. Substance Abuse and Mental Health Services Administration. Updated September 28, 2023. Accessed December 27, 2 023. www.samhsa.gov 9. Substance-Related Disorders, Residential Behavioral Health Level of Care, Adult: B-903-RES. 27 th ed., MCG Health. Updated September 21, 2023. Accessed December 27, 2023. www.careweb.careguidelines.com 10. Substance-Related Disorders, Residential Behavioral Health Level of Care, Child or Adolescent: B-907-RES. 27 th ed., MCG Health. Updated September 21, 20 23. Accessed December 27, 2023. www.careweb.careguidelines.com 11. Substance-Related Disorders, Residential Care: B-015-RES. 27 th ed., MCG Health. Updated September 21, 2023. Accessed December 27, 2023. www.careweb.careguidelines.com 12. Substance Use Disorder Qua lified Residential Treatment Program (QRTP) for Youth, OHIO ADMIN . CODE 5122-29-09.1 (2022). 13. Substance Use Disorder Treatment Services, OHIO ADMIN . CODE 5160-27-09 (2021). 14. Withdrawal Management, Adult, Residential Care: B-031-RES. 27 th ed., MCG Health. Updated September 21, 2023. Accessed December 27, 2023. www.careweb.careguidelines.com Approved by Oh io Dep t of Medicaid 03/28/2024

Payment to Out of Network Providers

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Payment to Out of Network Providers-OH MCD-PY-1343 06/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a g eneral reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In additio n to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, a uthorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or inju ry 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 i n the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage d ocuments, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidenc e of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the deter mination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equi ty Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Payment to Out of Network Providers-OH MCD-PY-1343Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectPayment to Out of Network Providers B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and w ill be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. This policy is intended to define the reimbursemen t rate for claims received fromproviders who are not contracted (out of network) providers with CareSource.C. Definitions Emergency Services Emergency health care services are used to treat an emergency medical condition. Emergency Medical Condition A medical condition that manifests itself by signs and symptoms of sufficient severity or acuity, including severe pain, such that a prudent layperson would reasonably have cause to believe constitutes a condition that the absence of immediate medical attent ion could reasonably be expected to result in o placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy o serious impairment to bodily functions o serious dysfunction of any bodily organ or part Out of Network Provider A non-participating provider that is not contracted with CareSource. D. PolicyCareSources standard reimbursement approach to out of network providers is as follows: I. Preauthorized, medically necessary services rendered to CareSource members by out-of-network providers will be reimbursed at A. 60% of the Ohio Medicaid Fee schedule charges B. 60% of the Ohio Medicaid Fee schedule for labs C. If a service or procedure is not priced by the Ohio Department of Medicaid fee schedule , then it will be reimbursed to the provider at 20% of billed charges. Payment to Out of Network Providers-OH MCD-PY-1343Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 II. In the event of any conflict between this policy and any written agreement between the provider and CareSource, th e written agreement will be the governing document.III. ExclusionsA. Emergency health care services will be reimbursed based on state regulations.B. Provider types with reimbursement methodology mandated by state/federal regulation/statute or rule or directive. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 07/02/2021 New policyDate Revised 09/29/2021 04/12/2023 01/31/2 024Added III. B. for clarification. Approved at PGC.Removed links from policy. Updated reference. Approved at Committee. Annua l review. Updated reference. Approved at Committee. Date Effective 06/01/2024 Date Archived H. References1. Managed Care : Definitions , OHIO ADMIN . CODE 5160-26-01 (2022). Approved ODM 2/29/2024

Overpayment Recovery

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Overpaymen t Recovery-OH MCD-PY-1115 06/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical nece ssity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to , those health care services or 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 functi on, dysf unction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy d oes not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services pr ovided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitatio ns 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 ………………………….. ………………………….. ………………………….. ……………………. 5 Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectOverpayment Recovery B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource . They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and wi ll be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Retrospective review of claims paid to providers assist Ca reSource with ensuringaccuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified.Fraud, waste , and abuse investigations are an exception to this policy. In theseinvestigations, the lo ok back period may go beyond 2 years.C. Definitions Claims Adjustment A claim that was previously adjudicated and is being updated for one of the following reasons: o denied as a zero payment o a partial payment o a reduced payment o a penalty applied o an additional payment o a supplemental payment Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource , and the other carrier is the primary insurance for the member. Credit Balance/Negative Balance Funds that are owed to CareSource because of a claim adjustment. Explanation of Payment (E OP ) The EOP contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Forwarding Balance (FB) An adjustm ent that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 claim has been adjusted to a different dollar amount and that funds are owed toCareSource. Improper Payment A payment that should not have been made or an overpayment was made. Examples include, but are not limited to the following : o payments made for an ineligible member o ineligible service payments o payments made for a service not received o duplicate payments Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 C.F.R. o A claim adjustme nt is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Provider Level Balancing (PLB ) Adjustments to the total check / remit amount occur in t he PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment (Beginning Segment for Payment O rder/Remittance Advice (BPR ), which means total payment within the EOP ). Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. D. PolicyI. In accordance with 42 C .F.R. 438.608, CareSource requires providers to report any overpayment that has been received by the provider. The overpayment must be returned to CareSource within 60 calendar days after the date on which the overpayment was identified and to notify CareSource in writing of the reason for the overpayment. II. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider:A. The patient’s name, date of birth, and Medicaid identification number . B. The date or dates of ser vices rendered . C. The specific claims that are subject to recovery and the amount subject to recovery, including any interest charges, which may not exceed the amount specified in Ohio law or rule . D. The specific reasons for making the recovery for each of the claims subject to recovery . E. If the recovery is a result of member disenrollment from the CareSource, the effective date of disenrollment . F. An explanation that if a written response to the notice is not received within 30 calendar days from receipt of the notice, the overpayments will be recovered from future claims . Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 G. How the provider may submit a written response disputing the overpayment .H. How the provider may submit a written request for an extended payment arrangement or settlement . III. Overpayment Recov eriesA. Lookback period is 24 months from the claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Coordination of Benefit RecoveriesA. Lookback period is 12 months from claim paid date. B. Advanced notificatio n will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims bei ng submitted within original claim timely filing guidelines. V. Retro Active Eligibility RecoveriesA. Lookback period is 24 months from date CareSource is notified by Medicaid of the updated eligibility status. B. Advanced notification will occur 30 days in advan ce of recovery. VI. Management of Claim Credit BalancesA. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. This information will be displayed on the EOP in the PLB section. B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previously but was up dated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $2 difference. b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D .I D.IV. 2. Overpayment Example Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D.IV. b. The reduced payment will trigger a 30-day advanced notifi cation with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. D. Providers are notified of negative balances through EOPs and 835s. Providers are expected to use this information to reconcile and maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances. E. Notification of negative bal ances and reconciliation of negative balances may not occur concurrently. Providers are expected to maintain their AR to account for the reconciliation of negative balances when they occur. E. Conditions of CoverageReimbursement is dependent on, but not lim ited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesCareSource Provider Manual National Agreement, Article V. Claims and Payments , 5.11 (d). G. Review/Revision HistoryDATE ACTIONDate Issued 04/29/2020 New policyDate Revised 07/21/2021 03/30/202210/26/202202 /14 /202 4 Revision: Added Management of Claims Balance information. Added compliance with 42 CFR 438.608 for requirement for provider to report identified overpayments . Approved at PGC. No changes. Updated references. Annual review. Removed V.C. Updated references. Approved at Committee. Date Effective 06/01/2024 Date Archived H. References1. Ohio Medicaid Provider Agreement for Managed Care Organization . Ohio Dept of Medicaid. Updated January 1, 2024. Accessed January 2, 2024. www.medicaid.ohio.gov 2. Payments Considered Final Overpayment, OHIO REV . CODE 3901.388 (2002). Approved ODM 2/29/2024

Interest Payments

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Interest Payments-OH MCD-PY-1324 06/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or suppli es that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or si gnificant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also inc lude those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Rei mbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan c ontract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHP AEA), 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 ………………………………………………………………………………………… 2 F. Related Policies/R ules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments-OH MCD-PY-1324 Effective Date: 06/01/2024 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Interest Pay ments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/H CPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim is a claim that can be processed without obtaining additional information from the provider of a service or from a third party and do not include payments made to a provider of service or a third party where the timing of the payment is not directly related to submission of a completed claim by the provider of service or third party. A clean claim also does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by Ohios Medicaid Prompt Payment rules and contract. D. Policy I. CareSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations. II. In alignment with the Ohio Administrative Code and the Medicaid Provider Agreement, CareSource does not pay interest on Ohio Medicaid claims. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. Interest Payments-OH MCD-PY-1324 Effective Date: 06/01/2024 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.3F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 03/31/2021 New PolicyDate Revised 01/05/2022 04/27/2022 04/ 12/2023 01/31/2024Updated language and references per Legal. No change; did for review cycle consistency No change; updated references. Approved at Committee. No change; updated references. Approved at Committee.Date Effective 06/01/2024 Date Archived H. References1. Definitions, O HIO REV . CODE 5164.01(C) (2023 ). 2. Ohio Medicaid Contract, Appendix J, 4. Accessed January 2, 2024. www.managedcare.medicaid.ohio.gov 3. Timely Claims Payment, 42 C.F.R. 447.45(b) (2022). Approved by ODM 2/29/2024

Dental Services Rendered in a Hospital or Ambulatory Surgery Center

REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 06/01/2024-08/31/2025 Policy Type REIMBURSEMENT Rei mbursement Policies prepared by CareSource, and its affiliates are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. These policies are designed to assist providers and facilities submitting claims to CareSource. The policies are routinely updated to promote accurate coding and clarification. These proprietary policies are not a guarantee of payment. This Policy does not ensure an authorization or reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service( s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the pl an contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. Rei mbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and any applicable referral, authorization, notification, and utilization management guidelines. Medically necessary services include, but are not limited to, those heal th 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 must meet the standards of good clinical practice in the local area, are the lowest cost alternative, and are not provided for the convenience of the member or provider. Medically necessar y services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Prior authorization is required for certain services. If authorization is not obtained prior to performing the service, CareSource may not reimburse for the procedure. Heal th care providers and their office staff are encouraged to use the self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCS) code(s) for the medical product or service being provided and the appropriate Current Dental Terminology (CDT) code(s) for the dental product or service. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee for a submitted claim payment. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Tabl e of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 4 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 6 G. Review/Revision History …………………………………………………………………………………………. 6H. References …………………………………………………………………………………………………………… 6Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectDental Services Rendered in a Hospital or Ambulatory Surgery Center B. Background The decision to perform dental care in a particular place of service is based on a wide variety of factors, including the age and special health care needs (physical, intellectual, and developmental disabilities or long-term medical conditions) of the individual, in addition to the type, number, and complexity of procedures planned. These factors also determine the type of anesthesia used during the procedure. Most dental care can be provided in a dental office setting with local anesthesia or local anesthesia supplemented with non-pharmacological behavior guidance (basic to advanced techniques) and/or pharmacological options. Basic non-pharmacological behavior guidance includes communication guidance, positive pre-visit imagery, direct observation, tell-show-do, ask-tell-ask, voice control, non-verbal communication, positive reinforcement and descriptive praise, distraction, and desensitization. Pharmacological options may include nitrous oxide, oral conscious sedation and intravenous (IV) sedation (mild, moderate, or deep), or monitored general anesthesia by trained certified individuals in each level of sedation dentistry. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require the use of general anesthesia as medically necessary in a healthcare facility, such as an ambulatory surgical center, hospital operating room, or short procedure unit (SPU). C. Definitions Ambulatory Surgical Center (ASC) Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization that meets all criteria of Ohio Administrative Code (OAC) 5160-22-01. Enhanced Ambulatory Patient Groups (EAPGs) A patient classification system designed to explain the amount and type of resources used during an ambulatory visit. Each EAPG have similar clinical characteristics, resource use, and cost. Inpatient Hospital A nonpsychiatric facility which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. Medical Necessity Procedures, items, or services which prevent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease, or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without its use 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 as defined by OAC 5160-1-01. Monitored Anesthesia Care (MAC) A specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 Outpatient Hospital A facility which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require admission or an overnight stay. Place of Service (POS) Codes Two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. Sedation Continuum When patients undergo procedural sedation/analgesia, they enter a sedation continuum. Several levels have been formally defined along this continuum: minimal sedation/anxiolysis, moderate sedation, deep sedation, and at the deepest level, general anesthesia.o Minimal Sedation (Anxiolysis) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. oModerate Sedation/Analgesia (Conscious Sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.oDeep Sedation/Analgesia A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.oGeneral Anesthesia A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.Note: Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation should be able to rescue patients who enter a state of deep sedation, while those administering deep sedation should be able to rescue patients who enter a state of general anesthesia. Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced cardiac life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia, and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation.Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 Short Procedure Unit (SPU) A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic, or medical services.D. Policy This policy is intended to provide guidance on the process for obtaining authorization and reimbursement for dental services performed in a place of service (ASC or hospital OR/SPU) and reimbursement for related facility charges (eg, operating room, anesthesia, medical consults). CareSource Dental Benefits for Ohio Medicaid are administered through our partnered delegated vendor DentaQuest. Coverage for professional services performed by the dentist/oral surgeon in the POS (ASC or OR/SPU) and reimbursement for these services may be provided through the dental benefit once approved via the DentaQuest process of dental utilization review for medical necessity of services and requested place of service. Medical necessity criteria and clinical policies are in the respective Dental Office Reference Manual ( DentaQuest ). OAC 5160-2-03(A)(2)(h) states that dental services are only covered in a hospital setting when the nature of the surgery or the condition of the patient precludes performing the procedure in the dentists office or other non-hospital outpatient setting and the inpatient or outpatient service is a Medicaid covered service. As such, it would exclude any diagnostic or preventative dental services that could be performed effectively and safely in an ambulatory state, unless patient characteristics and cooperation do not allow it. . CareSource Medical Benefits for Ohio Medicaid are administered directly through CareSource. Coverage and reimbursement for facility charges (eg, operating room, anesthesia) related to dental services performed in POS (ASC or OR/SPU), are eligible for coverage and reimbursement under the member's medical benefit when the dental services have been approved via the DentaQuest Utilization Management process. The two-step process for dental services and facility services should be followed for obtaining authorization prior to submitting claims for reimbursement:A. Step 1-Dental authorization for services to be performed in a (OR/SPU or ASC)1. Requests for dental services in POS (19, 21, 22, 24) are submitted by the treating dental provider to the CareSource Ohio Medicaid dental vendor, DentaQuest. The provider must include POS on dental claim and add in authorization notes request is for hospital or ASC setting. 2. The dental vendor reviews for appropriate medical necessity requirements [listed in the DentaQuest Office Reference Manual Section 14.05 Criteria forAuthorization of Operating Room (OR) Cases].3. If the dental authorization is approved, the dental vendor will send an automated fax approval letter to the requesting dentist which can additionally be viewed in the DentaQuest provider portal. 4. If the dental authorization request is not approved, a Notice of Adverse Benefit Determination (Denial Notice) will be issued by the dental vendor to the submitting provider. Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 B. Step 2-Facility precertification processOnce dental procedure approval has been obtained, providers are required to administer services at CareSource participating hospitals and must obtain facility precertification. 1. For facility precertification , the facility provider (hospital or ASC) may submit the request on the CareSource Provider Portal at CareSource.com.2. The Provider may also request a facility precertification by calling CareSource directly at 800.488.0134 and select the option to request an authorization. 3. The facility approval request should include the facility services (ie, operating room charges, anesthesia) requested, the DentaQuest Authorization Approval Letter, and authorization number. 4. The CareSource Medical Utilization Management (UM-MM) team will complete ALL the following: a. Verify that the facility is in network. b. Review the DentaQuest pre-determination letter (PDL) or approved dental authorization and complete administrative approval for facility fee and anesthesia. c. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted. d. Fax a Facility Approval to the hospital/ASC which can also be viewed in the CareSource Provider Portal.E. Conditions of Coverage Facility reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate code modifiers, if applicable to CareSource. Please refer to the individual fee schedule for appropriate codes. Reimbursement for items assigned to a dental service EAPG type will be paid as follows: Outpatient Hospital Facility (SPU) POS (19, 22) o Use CPT code 41899 as the facility fee code. Discounting factors-payments shall be multiplied by any applicable discounting factor, rounded to the nearest whole cent. o Use CPT code 00170 for anesthesia when performing intraoral treatments, including biopsy. Time units for physician and CRNA services-both personally performed and medically directed, are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. Total minutes are listed as the units (ie, 75 minutes) 75 = 5 units (of 15 min increments). CMS Base units = 5. Maximum state allowances may be applicable. P ayment for an anesthesia service is the lesser of the provider's submitted charge or the Medicaid maximum, which is determined by a formula. Inpatient Hospital Facility POS (21) o All services as well as any additional room and board fees need to be pre-certified and receive medical necessity review. Services are subject to benefit provisions. Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 6 Ambulatory Surgical Center POS (24)o Use code 41899 for facility fee. Payments for dental services will be made in accordance with the discounting factors as determined by the EAPG grouper.o Use code 00170 for Anesthesia professional services. CPT 00170 is calculated i n C MS base units. The base unit = 5 units. See under Hospital section above.D ental/Oral Surgery Professional Services The scope of this policy is limited to medical plan coverage reimbursement codes for facility and/or general anesthesia services provided in conjunction with dental treatment, and not the actual dental or oral surgery services provided. For information on dental benefits and coding, please consult the partnered dental vendor DentaQuest Office Reference Manual for clinical guidelines, policies, and procedures. F.Related Policies/Rules NA G. Review/Revision History DATE ACTION Date Issued 09/16/2020 New Policy Date Revised 01/26/2022 02/14/2024 Annual review. Removed dental codes, removed tables, simplified coding information Annual review: adjusted title, updated definitions, policy language, and references, corrected base unit typo. Approved at Committee. Date Effective 06/01 /2024 Date Archived 08/31/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H.R eferences 1. Ambulatory Surgery Center (ASC) Services: Provider Eligibility, Coverage, and R eimbursement O HIO ADMIN . C ODE 5160-22-01 (2020).2. Anesthesia Services, O HIO ADMIN . C ODE 5160-4- 21 (2017).3. Committee on Quality Management and Departmental Administration. Continuum ofDepth of Sedation: Definition of General Anesthesia and Levels ofSedation/Analgesia. American Society of Anesthesiologists. Updated October 23,2019. Accessed February 7, 2024. www.asahq.org 4. C onditions and Limitations, O HIO ADMIN . C ODE 5160-2- 03 (2022).5. Dental Services, O HIO ADMIN . C ODE 5160-5- 01 (2022).6. General Provisions: Hospital Services, O HIO ADMIN . C ODE 5160-2- 02 (2022).7. Hospital Billing Guidelines . Ohio Dept of Medicaid; 2021. Accessed January 31,2024. www.medicaid.ohio.gov 8. M anagement of dental patients with special health care needs. Reference Manual ofPediatric Dentistry . American Academy of Pediatric Dentistry; 2023:337-344. Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 7 Accessed February 13, 2024. www.aapd.org 9. Medicaid Medical Necessity: Definitions and Principles, O HIO ADMIN . C ODE 5160-1-01 (2022).10. Outpatient Hospital Reimbursement, O HIO ADMIN . C ODE 5160-2- 75 (2020).11. Policy on hospitalization and operating room access for oral care of infants, children,adolescents, and individuals with special health care needs. Reference Manual ofPediatric Dentistry . American Academy of Pediatric Dentistry; 2023:169-170. Accessed February 13, 2024. www.aapd.org 1 2. Policy on third-party reimbursement for management of patients with special healt h c are needs. Reference Manual of Pediatric Dentistry . American Academy ofPediatric Dentistry; 2023:181-184. Accessed February 13, 2024. www.aapd.org Approved ODM 03/07/2024

Coordination of Benefits

Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Coordination of Benefits-OH MCD-PY-1412 06/01/2024-02/28/2026 Policy Type REIMBURSEMENT Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 6 F. Related Policies/Rules ……………………………………………………………………………………………. 7 G. Review/Revision History …………………………………………………………………………………………. 7 H. References …………………………………………………………………………………………………………… 7 Coordination of Benefits-OH MCD-PY-1412 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectCoordination of Benefits B. Background Federal regulations require that all identifiable financial resources be utilized prior to the expenditure of Medicaid funds for most health care services provided to Medicaid beneficiaries. Coordination of benefits (COB) is the method used to designate the order in which multiple carriers are responsible for benefit payments, which prevents duplication of payments. Providers must utilize other payment sources to the fullest extent prior to filing a claim with CareSource. The terms "third party liability" and "other insurance" are used interchangeably to mean any source, other than Medicaid, that has a financial obligation for health care coverage. If other insurance resources are not exhausted and the provider was aware of other insurance coverage, billing Medicaid may be considered fraud under the False Claim Act. This policy assists in defining the order of coverage. The purpose of this policy is to define the order of coverage and how CareSource will coordinate benefit payments as the secondary payer. C. Definitions CareSource Provider Agreement The contract between a provider and CareSource for the provision of services by the provider to individuals enrolled with the plan, including but not limited to contracts titled Provider Agreement and Group Practice Services Agreement. Coordination of Benefits (COB) The process of determining which health plan or insurance policy will pay first and/or determining the payment obligations of each health plan, medical insurance policy, or third-party resource when two or more health plans, insurance policies, or third-party resources cover the same benefits for CareSource members. Explanation of Payment (EOP) A detailed explanation of payment or denial of a claim by an insurance carrier. Primary Carrier The insurance carrier that has been determined to be responsible for primary payment. D. Policy I. Submitted claims must include the total amount billed, total amount paid by primary carrier, and balance due, along with a valid provider signature. Any balance due after receipt of payment from the primary carrier should be submitted to CareSource for consideration, and the claim must include information verifying the payment amount received from the primary plan. CareSource shall coordinate payment for covered services in accordance with the terms of a members benefit plan, applicable state and federal laws, and applicable Centers for Medicare & Medicaid Services (CMS) guidance. If CareSource is not the primary carrier, providers shall bill the primary carrier for a ll services provided before submitting claims to CareSource. Coordination of Benefits-OH MCD-PY-1412 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. II. COB Guidelines A. When CareSource coordinates benefits with the primary carrier, reimbursement will be made according to the Medicaid contracted maximum allowable minus any payment made by the primary carrier. Any items or services for which another carriers reimbursement amount is equal to or greater than the Medicaid contracted maximum allowable amount will be paid at zero. Claims that pay at zero are considered to be paid claims, not denied claims. B. When the payment from another insurance carrier is less than the Medicaid contracted amount, CareSource will pay up to the Medicaid contracted total allowed amount. The sum of the payments will not exceed the Medicaid contracted maximum allowable amount (as indicated in the CareSource Provider Agreement ). Example 1: Charged amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $50.00 $10.00 $0 $0 $40.00 CareSource $35.00 $0.00 Summary : In this example, since the primary carriers paid amount of $40.00 is to theCareSource allowed amount of $35.00, then CareSource pays zero. Example 2: Charged Amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $80.00 $50.00 $0 $0 $30.00 CareSource $40.00 $10.00 Summary : In this example, subtract the primary paid amount of $30.00 from theCareSource allowed amount of $40.00 (lesser of the allowed amounts). Therefore, in this example, CareSource will pay $10.00. Example 3: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $100.00 $0 $100.00 $0 $0 CareSource $125.00 $100.00 Summary: In this example, subtract the primary paid amount of $0 from the primaryallowed amount of $100.00 (lesser of the allowed amounts). Therefore, in this example, CareSource will pay $100.00.Coordination of Benefits-OH MCD-PY-1412 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. Example 4: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $150.00 $0 $100.00 $40.00 $10.00 CareSource $125.00 $115.00 Summary: In this example, subtract the primary paid amount of $10.00 from theCareSource allowed amount of $125.00 (lesser of the allowed amounts). Therefore, in this example, CareSource will pay $115.00. III. CareSource as Secondary Payer A. Following Medicare reimbursement, Medicaid pays the remaining portion based on the following criteria: When a member becomes entitled to Medicare before the member’s termination of enrollment, the member may receive covered benefits that are also covered by Medicare. During that time, unless the provider has agreed in writing to an alternative payment methodology or different secondary claims payment rate, CareSource will reimburse Medicare secondary claims as set forth in Ohio Administrative Code Rule 5160-1- 05.3 for both network and out-of-network providers, including application of the following exemptions to the Part BMedicaid maximum policy in accordance with the Ohio Administrative Code (OAC) and other guidance issued by the Ohio Department of Medicaid: 1. hospital services 2. nursing facility services included in the nursing facility per diem 3. covered supplemental medical insurance benefits under the Medicare program 4. dual eligible coordinated benefits for members who elect to receive their Medicare Part Bbenefits through the original Medicare program B. Secondary Payer for Obstetrical Services 1. Primary payer EOP is required in order to coordinate coverage. With the primary payer EOP, CareSource will verify if the prenatal visits are a part of the primary carriers global reimbursement. If so, CareSource will not make a payment until a delivery charge is received. If the prenatal visits are excluded from the primary carriers global reimbursement, including when maternity benefits are not covered by the plan, CareSource will process the claim as the primary payer. 2. If the first claim that CareSource receives is for a global delivery, the claim will deny for invalid coding. The provider will need to re-bill within 90 days of denial using the delivery-only CPT codes, as CareSource does not recognize global obstetrical codes for claims processing. 3. Once the delivery charge is received, CareSource will combine all prenatal visit charges with the delivery charges. CareSource will subtract the primary carriers payment from the lesser of the primary carrier allowed amount and the CareSource allowed amount (the benefit allowance for all visits and the delivery charge) and will pay any remaining liability. CareSource will not payCoordination of Benefits-OH MCD-PY-1412 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. more than CareSources normal benefit when no other coverage exists or more than the patient responsibility after the primary insurance has paid. IV. COB Timely Filing Guidelines A. If a provider is aware that a member has primary coverage, the provider will submit a copy of the primary payers EOP along with the claim to CareSource within the claims timely filing period. 1. If CareSource receives a claim for a member that is identified as having other coverage and a primary payer EOP was not submitted with the claim(s), CareSource will deny the claim(s), requesting the required COB information. 2. If a claim is denied for COB information needed, the provider must submit the primary payers EOP. If the initial timely filing period has elapsed, the EOP must be submitted to CareSource within 90 days from the primary payers EOP date. B. If a provider has information that the primary payers policy has terminated or was not in effect during the date of service for the claim(s), the provider must notify CareSource of the dispute within the original timely filing period or within 90 days of the providers actual receipt of the primary payers EOP date, whichever is greater. C. If the dispute is received within the original timely filing period: 1. CareSource will confirm whether or not the primary payer was in effect during the date of service. If the policy was NOT in effect, CareSource will process the claim(s) that are within the original timely filing period or 90 days of the providers actual receipt of the payers EOP date. 2. If the policy WAS in effect, the claim will remain denied for lack of primary payers EOP. D. If the provider does not notify CareSource of the dispute within the original timely filing period or if the provider does not submit the primary payers EOP within 90 days of the providers actual receipt of the primary payers EOP date, the claim will re-deny as not being timely filed. V. COB Claim Submission to CareSource A. CareSource follows The Health Insurance Portability and Accountability Act (HIPAA) guidelines and accepts industry standard codes. It is imperative that claims are filed with the same codes that the primary payer presented on the Explanation of Benefits (EOB) to ensure that claims are processed correctly. Claim(s) will be denied if there is a mismatch between the codes on the received claim and the primary payers EOP. B. CareSource applies standard claim adjustment codes. C. Claim Adjustment Group Codes are as follows:1. CO Contractual Obligation 2. OA Other Adjustment 3. PI Payer Initiated Reductions 4. PR Patient Responsibility D. When filing claims with patients responsibility, the following Claim Adjustment Reason Codes should be used: Coordination of Benefits-OH MCD-PY-1412 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 1. PR1 Deductible 2. PR2 Coinsurance 3. PR3 Copayment E. When filing claims with contractual obligation, please use Adjustment Group Code CO. Contractual obligation can be communicated on the Primary Payers EOB with several different codes. Please use the code reflected on the primary payers EOB. Some examples of these codes are 24, 45, 222, P24, P25, 26. (This is not an all-inclusive list). The same process should be followed when using Adjustment Group Code OA-Other Adjustment. VI. Denied COB Claims A. Denied COB claims will be automatically adjusted when primary insurance has been updated retroactively to show coverage was terminated at the time of service. This also has a lookback period of 12 months from the paid date or 18 months to the date of service. B. Denied COB claims will NOT be automatically adjusted if the updated coverage information was received after 90 days from the denial for COB information. In this case, the provider must request claim adjustment within the original timely filing period or within 90 days from the date of the EOP denial, whichever is greater. Although CareSource has implemented this COB Adjustment Policy, it is still the providers responsibility to review their accounts and submit COB claims in a timely manner for payment. VII. Disputes for Denied COB Claims A. Disputes will NOT be automatically adjusted if the updated coverage information was received after 90 days from the denial for COB information. In this case, the provider must request claim adjustment within the original timely filing period or within 90 days from the date of the EOP denial, whichever is greater. Although CareSource is implementing this COB Adjustment Policy, it is still the providers responsibility to review their accounts and submit COB claims in a timely manner for payment. B. CareSource will confirm whether or not the primary coverage was in effect during the date of service. If the policy was NOT in effect, CareSource will process the claim(s) that are within the original timely filing period. If the initial timely filing period has elapsed, then CareSource will process the claims that are within 90 days of the original denial. If the policy WAS in effect, the claim will remain denied for needing primary carriers EOP. If the provider does not notify CareSource of the dispute within the original timely filing period, within 90 days of the CareSource denial, or if the provider does not submit the primary carriers EOP within 90 days of the Primary Carriers EOP date, the claim will re-deny as not being filed timely.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. Coordination of Benefits-OH MCD-PY-1412 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. F. Related Policies/RulesNA G. Review/Revision History DATE ACTIONDate Issued 12/14/2022 New policyDate Revised 02/14/2024 Annual review. Updated background. Updated references. Approved at Committee. Date Effective 06/01/2024 Date Archived 02/28/2026 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H. References1. Coordination of Benefits, O HIO ADMIN . C ODE 5160-1- 08 (2019). 2. Managed Care: Primary Care and Utilization Management, OHIO ADMIN CODE 5160-26-03.1 (2022). 3. Payment for "Medicare Part B" Cost Sharing, O HIO ADMIN . C ODE 5160-1- 05.3 (2016). Approved ODM 03/07/2024

Chiropractic Care

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Chiropractic Care-OH MCD-PY-1328 06/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, i ndustry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edic al necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t lim ited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illn ess, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or pro vider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This P olicy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to serv ices provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any li mitations 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/R ules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Chiropractic Care-OH MCD-PY-1328Effective Dat e: 06/1/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectChiropractic Care B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and o ffice staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is beingprovi ded. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Chiropractic is a licensed healthcare profession where treatment typically involvesmanual therapy, often including spinal manipulation.C. Definitions Acute Subluxation Member is being treated for a new injury defined by x-ray or physician exam which result s in an expected improvement in, or arre st of, progression in the members condition. Billing Provider A chiropractor, mechanotherapist, profession al medical group, hospital , or fee-for-service clinic as noted by the Ohio Administrative Code. Maintenance Therapy A therapy that is performed to treat a chronic, stable condition or to prevent deterioration . Rendering Providers A chiropractor or a mechanot herapist who is eligible to provide spinal manipulation . D. PolicyI. CareSource follows the Ohio Administrative Code for payment of spinal manipulation . II. Payment may be made for manual correction to correct a spin al subluxation determined by x-ray or physician exam for a condition that is acute and episodic in nature. When the maximum therapeutic benefit has been met, ongoing therapy is considered maintenance therapy and is not medically necessary. III. Payment may be made for the following services:A. Spinal ma nipulation 1. chiropractic manipulative treatment (CMT); spinal, one to two regions 2. chiropractic manipulative treatment (CMT); spinal, three to four regions Chiropractic Care-OH MCD-PY-1328Effective Dat e: 06/1/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 3. chiropractic manipulative treatm ent (CMT); spinal, five regionsB. Diagnostic imaging to determine the existence of a subluxation 1. spine, entire; survey study, anteroposterior and lateral 2. spine, cervical; anteroposterior and lateral 3. spine, cervical; anteroposterior and lateral; minimum of four views 4. spine, cervical; anteroposterior and lateral; complete, including oblique and flexion and/or extension studies 5. spine, thoracic; anteroposterior and lateral views 6. spine, thoracic; complete, with oblique views; minimum of four views 7. spine, thoracolumbar; anteroposterior and lateral views 8. spine, lumbosacral; anteroposterior and lateral views 9. spine, lumbosacral; complete, with oblique views 10. spine, lumbosacral; complete, including bending views IV. All services performed must be medically ne cessary and related to the treatment of a specifi c medical complaint. A. To determine medical necessity, CareSource requires all of the following: 1. a primary diagnosis of subluxation (ie, lumbar and/or sacral) 2. a secondary diagnosis that supports the treatment provided ( eg , osteoarthritis, congenial musculoskeletal deformities of the spine) B. Manual manipulation must have a direct therapeutic relationship to the members condition as documented in the medical record . The lack of documentation specifying the relationship between the members condition and treatment shall result in the service being ineligible for reimbursement. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting appro ved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesMedical Necessity Determination Policy G. Review/Revision HistoryDATE ACTIONDate Issued 05/26/2021Date Revised 04/12/2023 01/31/2024Annual review: Title modified. Updated references.Approved at Committee. Annual review. Updated references . Approved at Committee. Date Effective 06/01/2024 Date Archived H. References1. Chiropractic Services, OHIO ADMIN . CODE 5160-8-11 (2022). Chiropractic Care-OH MCD-PY-1328Effective Dat e: 06/1/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Approved ODM 2/29/2024

Orthotics

Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Orthotics-OH MCD-PY-1151 05/01/2024-09/30/2025 Policy Type REIMBURSEMENT 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 …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 4Orthotics-OH MCD-PY-1151 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectOrthoticsB. Background Orthotics are braces, splints, casts, and supports that may be utilized to align, prevent, or correct deformities or to improve the function of movable parts of the body. Reimbursement policies are designed to assist providers when submitting claims to CareSource. These are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. The purpose of this policy is to reinforce CareSources ability to audit post-payment claims and ensure that reimbursement was justified by reviewing a providers documentation to confirm medical necessity. C. Definitions Certificate of Medical Necessity (CMN) A written statement by a practitioner attesting that a particular item or service is medically necessary for an individual. Orthotics The evaluation, measurement, design, fabrication, assembly, fitting, adjusting, servicing, or training in the use of an orthotic device, or the repair, replacement, adjustment, or service of an existing orthotic device. Orthotic Device A custom fabricated or fitted medical device used to support, correct, or alleviate neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity. The device is dispensed to an eligible CareSource member by an appropriate provider and can be considered for back, spinal (lumbar, cervical, and/or thoracic), foot, ankle, and knee indications. D. Policy I. CareSource may request documentation from the ordering physician and the dispensing durable medical equipment (DME) provider to confirm medical necessity of the orthotic device. A. The orthotic device must be a covered orthotic device and ordered and furnished by an eligible provider to an eligible CareSource member. Eligible Medicaid providers of the following types with prescriptive authority under Ohio law may certify the medical necessity of an orthotic device: 1. a physician Orthotics-OH MCD-PY-1151 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 2. a podiatrist 3. an advanced practice registered nurse with a relevant specialty (eg, clinical nurse specialist, certified nurse practitioner) 4. a physician assistant B. CareSource may request the CMN after the claim has been submitted. C. An illegible CMN will not be accepted. II. The following criteria for reimbursement must be included: A. The DME provider must be enrolled as a DME supplier for Medicaid. B. The ordering practitioner must conduct a face-to-face encounter. C. The orthotic device must have a prescription. 1. The date cannot precede the date of the face-to-face encounter, nor be more than 180 days after the encounter. 2. The date must be no more than 60 days before the date the orthotic device is dispensed to the member. D. The ordering practitioner must be actively involved in managing the members medical care. A prescription written by a practitioner who has no professional relationship with the member will be disallowed. E. The prescribed DME device must be directly related to a medical condition of the member that the practitioner evaluates, assesses, or actively treats during the encounter. III. Any request for an orthotic device must originate with an eligible CareSource member, the members authorized representative, or a medical practitioner acting as prescriber and must be made with the members full knowledge and consent. IV. When instruction must be given regarding safe and appropriate use of an orthotic device, it is the responsibility of the provider to ensure that the member or someone authorized to assist the member has received such instruction. V. Each claim submitted for payment must have supporting documentation kept by the DME provider. VI. Payment is not available for an orthotic device that is a duplicate or conflicts with another device currently in the members possession, regardless of payment or supply source. Providers are responsible for ascertaining whether duplication or conflict exists.E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules Medical Record Documentation Standards for Practitioners Orthotics-OH MCD-PY-1151 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 G. Review/Revision HistoryDATE ACTIONDate Issued 06/10/2020 Date Revised 11/10/2021 04/12/2023 01/31/2024 Revised Policy language. Approved at PGC. Added additional background information. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Date Effective 05/01/2024 Date Archived 09/30/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H. References1. Device-Related and Scope of Practice Definitions, O HIO ADMIN . C ODE 4755-62-02 (2020).2. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS): General Provisions, O HIO ADMIN . C ODE 5160-10-01 (2024). 3. DMEPOS: Footwear and Foot Orthoses, O HIO ADMIN . C ODE 5160-10-31 (2024). Approved by ODM on 2/22/2024

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