Payment Policy S ubject: Psychiatric Day Programs P rograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4Me TM Policy CareSource will reimburse participating providers for psychiatric day programs at negotiated per diem rate for the mental health and wellness services provided as part of the day program , as described herein . Definitions None required Provider Reimbursement Guidelines The purpose of this policy is to explain the r eimbursement for providers of psychiatric day facility programs and their component treatments and services as offered to CareSource members . CareSource typically enters into specific negotiated contract s with its providers which establish a defined per diem rate for psychiatric day services. Prior Authorization Prior authorization is required for reimbursement of psychiatric day facility programs. To request prior authorization for these services, please call 1-800-488-0134. During regular business hours, the call will be answered by the CareSource Medical Management Department. If calling after regular business hours, the call will be answered by the CareSource Nurse Triage Line. C overage Psychiatric facility services offered as day (outpatient) programs vary from facility to facility in the scope and content of their services. CareSource considers that all such services a re included in the established per diem rate negotiated with each participating fa cility. However, CareSource will separately reimburse a f acility for the following outpatient hospital and professional services : Speech therapy;Physical therapy;Laboratory ;Radiology ; and,Psychiatrist services.This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Archived These services are not considered to be included in the per diem rate and instead will be reimbursed to the facility in accordance with the fee schedule established at the time of the agreement negotiated and entered into by CareSource and that facility. Related Policies & References OAC Chapter 5160-8- 05, Psychology services provided by licensed psychologists . OAC Chapter 5160-29, Outpatient health facility services. 907 KAR 1:044, Coverage provisions and requirements regarding community mental health center services. State Exceptions NONE Document History This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Archived
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment Policy Subject: Dry Eye Syndrome Testing Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4Me TM Po l i c y Effective February 1, 2014, CareSource will reimburse participating providers for dry eye syndrome testing as set forth in this policy. De f i n i t i o n s Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Dry Eye Syndrome , also known as keratoconjunctivitis sicca, (KCS), keratitis sicca, sicca syndrome, xerophthalmia, or simply, dry eyes, is an eye disease in which tear film evaporation is high or tear production is low, or there is an imbalance in the composition of the patients tears, or eyelid problems, medications, or environmental factors cause a lack of adequate tears, leading the patients eyes to dry out and become inflamed. (from www.mayoclinic.com)Medically necessary services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (from OAC 5160-10-02) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Coverage Microfluidic analysis utilizing an integrated collection and analysis device to measure tear osmolarity (one eye) is a test covered by CareSource, and using the CPT code 83861. The American Academy of Ophthalmology Preferred Practice Pattern guideline for Dry Eye Syndrome specifically recommends tear osmolarity testing for the diagnosis and management of dry eye syndrome. The tear osmolarity test is considered to be a more sensitive method of diagnosing and grading the severity of dry eye compared to corneal and conjunctival staining, tear break-up time, Schirmer test and meibomian gland grading. CareSource acknowledges that this test can only be performed at the point-of-care, as tear fluid is a fragile sample with insufficient volume to allow for collection and transfer to a reference laboratory for analysis, as stated in AMAs CPT Assistant article on the associated CPT code (83861). Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 CareSource will reimburse all participating doctors offices, including optometrists offices,performing a medically necessary tear osmolarity test , provided that the doctors office has been certified as a laboratory under the Clinical Laboratory Improvement Act (CLIA) regulations, and has a CLIA license. Re l a t e d Po l i c ies & Re f e r e n c e s St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment PolicySubject: Oxygen Delivery Systems & SuppliesPrograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program,OH M yCare , and OH Just4MeTM Po l i c yEffective January 1, 2014, CareSource provides coverage for the rental of oxygen delivery systems and supplies when a claim meets the criteria outlined in this policy. De f i n i t i o n sCurrent Procedural Terminology ( CPT ) codes are numbers assigned toevery task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org)Healthcare Common Procedure Coding System (HCPCS ) is a set ofhealth care procedure codes based on the American Medical Association’ sCurrent Procedural Terminology (CPT). HCPCS currently includes two leve ls of codes: Level I consists of the American Medical Association ‘s Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prost hetic de vices ,[2] and repre sen t items and suppl ies and no n-physic ian services, not covered by CPT-4 codes (Level I). (from www.wikipedia.org ) Medically necessary services are those health services that are necessary forthe diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (from OAC 5160-10-02) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior AuthorizationCareSource does not require prior authorization for medically necessary oxygen equipment and supplies for its members. ReimbursementCareSource will reimburse providers for the rental of oxygen supply systems and supplies for any member within the following parameters: This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 HCPCSCode Description Limits K0738 Trans fill oxygen system Each : 1 per month per member E1390 Oxygen concentrator, single port E1391 Oxygen concentrator, dual port E1392 Portable oxygen concentrator, rental E0424 Stationary compressed oxygen system, rental E0431 Portable gaseous oxygen system, rental E0434 Portable liquid oxygen system, rental E0439 Stationary liquid oxygen system, rental BillingThe appropriate documentation must be attached to the claim form, or sent separately to CareSource for claims submitted electronically. Re l a t e d Po l i c i e s & Re f e r e n c e sOhio Administrative Code 5160-10-03, Medical supplies and the Medicaid supply list Ohio Administrative Code 5160-10-05, Reimbursement for covered services. Ohio Administrative Code 5160-1-60, Medicaid reimbursement. St a t e Ex c e p t i o n sNONE Do c u m e n t Re v i s i o n Hi s t o r y
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing.Page 1 of 2 Payment Policy Subject: Preventive Services and Sick Visit on Same Date of Service Po l i c y CareSource will reimburse participating providers as outlined in this policy whena preventive services visit or exam and a sick visit are performed on the same date of service for a CareSource member. De f i n i t i o n s Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org)Preventive Services are exams and screenings to check for health problems, with the intention to prevent any problem discovered from becoming worse.Preventive services may include, but are not limited to, physical checkups,hearing, vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations.Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age, but are especially important for children under the ag e of 21. (CareSource internal definition) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Preventive medicine exam codes 99381-99385 and 99391-99395 should be billed with the appropriate ICD-9 diagnosis codes (if before 10/1/2014) or ICD-10diagnosis codes (after 10/1/2014). When a provider conducts a preventive medicine service or exam at the time of an acute care visit, Evaluation &Management CPT codes 99201-99204 or 99212-99214 may be submitted alongwith the appropriate ICD-9 or ICD-10 code, indicating the reason for the acute care visit, as a secondary diagnosis.Care Source will reimburse the provider for the preventive medicine CPT code at100% of the allowed amount, and will reimburse the provider for the acute careCPT code at 50% of the allowed amount. Please see the examples provided on the next page of this policy. Archived This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing.Page 2 of 2 Correct Billing Example (this example is pre-10/1/2014, using ICD-9 ) Date of Service Procedure Code Diagnosis Code Billed Amount Allowed Amount 01/15/2014 99392 V20.0 $150.00 $52.97 (100%) 01/15/2014 99213 462 $100.00 $20.19 (50%) Incorrect Billing Example(this example is pre-10/1/2014, using ICD-9 ) Date of Service Procedure Code Diagnosis Code Billed Amount Allowed Amount 01/15/2014 99392 V20.0 $150.00 $52.97 (100%) 01/15/2014 99213 V20.0 $100.00 $0.00 Re l a t e d Po l i c i e s & Re f e r e n c e s St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r yArchived
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 5 Payment Policy Subject: Family Planning Po l i c y CareSource covers family planning services for members when the services are determined to be necessary for the health and well-being of the member. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for payment will serve as the providers certification of the medical necessity for these services. De f i n i t i o n s Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Family planning services , or Pregnancy prevention/contraceptive management services , are services and supplies provided for the primary purpose of preventing or delaying pregnancy. They include services provided for the prevention of pregnancy, and related supplies. (from OAC 5160-21, Reproductive Health Services.) Infertility is defined as the condition of (i) a presumably healthy woman of childbearing age who has been unable to conceive or (ii) a presumably healthy man who has been unable to produce conception, in either case, after at least one year of trying to do so . (CareSource internal definition) Medically necessary services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (from OAC 5160-10-02) Preconception care means Medicaid-covered preventive medicine services provided prior to a pregnancy for the purpose of achieving optimal outcome of future pregnancies. (from OAC 5160-21, Reproductive Health Services.) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Prior Authorization Members may seek family planning services from any qualified CareSource participating provider without prior authorization. Coverage Family planning services must be furnished under the supervision of a physician or dispensed by a pharmacy for beneficiaries of childbearing age, including minors considered to be sexually active. Family planning services enable beneficiaries to voluntarily choose to prevent initial pregnancy or to limit the number of and spacing of their children. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 5 Covered services include an office visit for a complete exam, pharmaceuticals (including some over the counter [OTC] products), supplies and devices when such services are provided by or under the supervision of a medical doctor, osteopath, or eligible family planning provider. Family planning supplies not furnished by the provider as part of the medical services must be prescribed by a physician and purchased at a pharmacy. Exceptions are condoms and similar supplies which do not require a prescription. Family planning services may include the following. Pregnancy prevention Pregnancy testing Sterilization [Separate CareSource payment policy] Hysterectomies [Separate CareSource payment policy] Infertility services [not covered] Some of these services can be easily recognized as family planning by the CPT procedure code or drug type code (for example, intrauterine device (IUD) insertion, vasectomy, contraceptive drugs and devices). Other services such as visits, laboratory tests and X-rays are not as readily identifiable as family planning services. Claims Providers are to indicate Family Planning as a diagnosis when billing any of the services listed in this policy that relate to family planning. Providers are to complete the diagnosis code or the appropriate narrative, where applicable. In addition, providers should identify services related to the treatment of complications of family planning. Examples: Surgical procedure such as incision and drainage of pelvic abscess resulting from infection with IUD Office visit and laboratory tests needed because of uterine bleeding while on oral contraceptives Occasionally other services (including hospital, radiology, pharmaceutical, blood and blood derivatives) may be related to family planning or to its complications, and should be properly identified. Non-Comprehensive Family Planning Visits CareSource covers pregnancy prevention/contraceptive management services including evaluation and management (office) visits and consultations for the purpose of: Pregnancy prevention/contraceptive management; Pregnancy examination and testing that includes provision of information about pregnancy prevention; Pregnancy prevention/contraceptive management, including but not limited to fertility awareness and natural family planning .Natural family planning , is the use of fertility awareness-based methods to track ovulation in order to prevent pregnancy. ArchivedThis CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 3 of 5 Pregnancy determination services when pregnancy testing yields a negative or inconclusive result and provision of information about pregnancy prevention is provided; Medical/surgical services/procedures provided for the purpose of pregnancy prevention/contraceptive management (i.e., injection, fitting, insertion, removal of contraceptive devices); Laboratory tests and procedures provided for the purpose of temporary pregnancy prevention/contraceptive management; Drugs prescribed for the purpose of pregnancy prevention/ contraceptive management; Supplies provided for the purpose of pregnancy prevention/ contraceptive management.Appropriate CPT codes should be used when billing for additional time spent discussing family planning needs with a recipient during routine, non-famil y planning office visits. Pregnancy prevention/contraceptive management services Providers must include the following information on claims for pregnancy prevention/contraceptive management services: A valid current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) procedure code for each service provided; and An appropriate ICD-9 (before 10/1/2014) or ICD-10 (after 10/1/2014) diagnosis code to indicate an encounter for contraceptive management General contraceptives Condoms are considered medically necessary for men and women in the prevention of pregnancy and to reduce the risk of sexually transmitted disease. Therefore, reimbursement is available for the following codes: Codes Description A4266 diaphragm contraceptive A4267 contraceptive supply condom male A4268 contraceptive supply condom female A4269 contraceptive supply spermicide eg foam gel J7300 Intrauterine copper contraceptive (ParaGard T 380A) J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg (Mirena) IUDs require minimal, yet ongoing , oversight. When members experience active symptoms due to the IUD (e.g., excessive bleeding, cramping, or pelvic inflammatory disease) or need routine IUD surveillance, providers should report E/M codes for those visits as well as the appropriate diagnoses codes for IUD surveillance, current GYN symptoms, or current GYN disease processes. Some physicians also use ultrasound to confirm appropriate placement of an IUD at the time of insertion. When the healthcare provider performs this service, it is not bundled with the insertion codes. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 4 of 5 Evaluation and Management CPT-4 codes, for example 99203 or 99213, may be billed when the member is counseled regarding contraception or is examined to determine the suitability of contraceptive modalities. Implantable Contraceptives: Etonogestrel Etonogestrel, 68 mg contraceptive implant (Implanon, Nexplanon) is billed with code J7307. Implanon must be FDA approved, labeled for use in the United States, and obtained from the single-source distributor. Only providers who have completed a company-sponsored training course and have been assigned a unique Training Identification Number may purchase Implanon. The certificate of training for each provider who inserts the implant must be retained by the provider and is subject to post-audit review. Implanon may be reimbursed when service is performed by on-medical practitioners (NMPs) who have completed the required training. Implanon is not reimbursable to Pharmacy providers. Providers must maintain a written log or electronic record of all Implanon implant systems, including the recipients name, medical record or CareSource number, date of surgery, and lot number of the product, for at least three years from the date of insertion. Records are subject to post-audit reviews. When billing for code J7307 [ Etonogestrel (contraceptive) implant system, including implant and supplies ], providers must attach a copy of the invoice to the claim or document the invoice number and price in the claim. Reimbursement limited to one per recipient, any provider, per 34 months . While the duration of action of Implanon is 36 months, the 34-month limit will permit early removal and insertion of a new implant . Bill in conjunction with the appropriate ICD-9 code (before 10/1/2014) or ICD-10 code (after 10/1/2014). Providers billing code J7307 more than once in 34 months must document the necessity for the repeat implant in the claim. Implantable Contraceptives: Norplant Norplant and related services are reimbursable once per member, per five years. If removal and re-implantation at the same or different incision site is performed prior to five years from the previous implantation, reimbursement is available for the removal only. When a physician inserts an implantable contraceptive, they should use code 11981 [ Insertion, non-biodegradable drug delivery implant ]. Code 11976 [ Removal, implantable contraceptive capsules ] is for use with those members that have the older Norplant capsule systems that need to be removed. For a member who comes to the office to have an implant removed and has a contraceptive rod inserted at the same visit, codes 11976 and 11981 are appropriate; submit the claim as 11976, 11981-51 (Multiple procedures). Note: providers should report the appropriate diagnostic codes for this combination service. When a memberhas a contraceptive rod removed, report 11982 [ Removal of a non-biodegradable drug delivery implant ] or 11983 [Removal with reinsertion of a non-biodegradable drug delivery implant] . [Source: http://www.obgmanagement.com/article_pages.asp?aid=10149 .] ArchivedThis CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 5 of 5 Pregnancy testing CareSource covers pregnancy testing in the physic ians office. Code Description 81025 Pregnancy Test Kits Urine, Qualitative 84703QW Pregnancy Test Urine Instrument Infertility Services (Assisted Reproductive Technology) CareSource does not cover infertility services. Under no circumstances are the following procedures covered: Drugs prescribed in accordance with Chapter 51 60-9 (Pharmacy Services) of the Ohio Administrative Code and/or drugs administered in accordance with Chapter 51 60-4 (Physician Services) of the Ohio Administrative Code; Assisted reproductive technologies (ART); In vitro fertilization; Intrauterine insemination/artificial insemination; and Surgery, including procedures for the reversal of voluntary sterilization. Re l a t e d Po l i c i es & Re f e r e n c e s OAC Rule 5160-21 Preconception Care Services 907 KAR 1:048. Family planning services CareSource Sterilization & Hysterectomy policies St a t e Ex c e p t i o n s NONE Do c u m e n t Hi s t o r y Archived
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 4 Payment Policy Subject: Chiropractic Care ALL STATES EXCEPT KENTUCKY Po l i c yCareSource will reimburse for covered services provided by a licensed chiropractor subject to the restrictions and limitations set out in this policy. De f i n i t i o n sChiropractic services are defined as the diagnosis and analysis of any interference with normal nerve transmission and expression, the procedure preparatory to and complementary to the correction thereof by an adjustment of the articulations of the vertebral column, its immediate articulation, and includes other incidental means of adjustments of the spinal column and the practice of drugless therapeutics. (from Indiana Code Title 25, Artic le 10 Chiropractors, Chapter 1) Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (from ama-assn.org) Maintenance therapy means therapy that is performed to treat a chronic, stable condition or to prevent deterioration. (from OAC 5160:8-11) Medically necessary services are those health services that are necessary for the diagnosis or treatment of dise ase, illness, or injury and meet accepted standards of medical practice. (from OAC 5160: 10-02) Subluxation means an incomplete dislocation, off centering, misalignment, fixation, or abnormal spacing of the vertebrae anatomically, as demonstrated by x-ray film or other diagnostic test. (from OAC 5160:8-11)P r o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior Authorization Prior authorization for chiropractic procedures performed within the limits of this policy is not required. However, if medically necessary chiropractic treatments are required that exceed the limits of this payment policy, then the provider should obtain prior authorization from CareSource. Determination of medical necessity and appropriateness of service is the responsibility of chiropractors within the scope of accepted medical practice and Medicaid limitations, where appropriate. Chiropractors are held responsible if excessive or unnecessary services are ordered, regardless of who actually renders these services (e.g., x-rays), or if reimbursement is received for the service. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 4 Coverage Treatment by means of manual manipulation of the spine to correct a subluxation is a covered service when determined to be medically necessary. The existence of the subluxation must be demonstrated either by a diagnostic x-ray or by physical examination. Evidence must be retained as a part of the members medical record that a subluxation exists. The 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. Spinal manipulation is the only covered chiropractic procedure. Only one of the spinal manipulation procedure codes is billable per day, per member. Clinical signs and symptoms must be consistent with the level of subluxation. If documentation other than x-rays supports the medical necessity of spinal manipulation for children, the x-ray requirement may be waived. CareSource reserves the right to request x-ray documentation if deemed necessary. X-Ray Services Diagnostic x-rays to determine the existence of a subluxation are covered with certain limitations. Two units of service, as defined below, will be covered during any six-month period. The six-month period begins on the date the diagnostic x-ray is taken and ends 180 days from the date. The covered units of service are as follows: Code Description 72010 Radiological exam, spine, entire, A&P 72020 Radiologic exam, spine, single view, specify level 72040 Radiologic exam, spine, cervical; 2 or 3 views 72050 Radiologic exam, spine, cervical; minimum of 4 views 72052 Radiologic exam, spine, cervical; complete, including oblique & flexion &/or extension studies 72069 Radiologic exam, spine, thoracolumbar, standing (scoliosis) 72070 Radiologic exam, spine; thoracic, 2 views 72074 Radiologic exam, spine; thoracic, minimum of 4 views 72080 Radiologic exam, spine; thoracolumbar, 2 views 72100 Radiologic exam, spine, lumbosacral; 2 or 3 views 72110 Radiologic exam, spine, lumbosacral; minimum of 4 views 72114 Radiologic exam, spine, lumbosacral; complete including bending views Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 3 of 4 Limitations of Coverage If the member is under the age of twenty-one, they are allowed up to thirty dates of service per twelve-month period in an outpatient setting. If the member is 21 years of age or older , they are allowed up to fifteen dates of service per twelve-month period in an outpatient setting. Other limitations includ e: 1) Services which are not personally performed by the chiropractic physician with whom CareSource has a provider agreement: a) Services provided by licensed individuals with whom CareSource does not have an individual provider agreement are not reimbursable even though the covered services are provided under the personal supervision of a licensed chiropractic physician with whom CareSource does have a provider agreement. b) Services provided by unlicensed individuals under the personal supervision of a licensed chiropractic physician are not reimbursable. c) Services provided by students during an internship are not covered services. 2) Spinal axis aches, strains, sprains, nerve pains, and functional mechanical disabilities of the spine are considered to provide therapeutic grounds for chiropractic manipulative treatment. Most other diseases and disorders do not provide therapeutic grounds for chiropractic manipulative treatment. Examples of non-covered diagnoses are multiple sclerosis, rheumatoid arthritis, muscular dystrophy, sinus problems and pneumonia. 3) Repeat x-rays or other diagnostic tests in members with chronic, permanent conditions will not be considered medically necessary and are not a covered service. 4) If there is no reasonable expectation that the continuation of treatment would improve or arrest deterioration of the condition within a reasonable and generally predictable period of time, coverage will be denied. 5) Continued repetitive treatments without an achievable and clearly defined goal will be considered maintenance therapy and will not be considered covered services. 6) Once the maximum therapeutic benefit has been achieved for any given condition, ongoing therapy is considered maintenance therapy which is not considered medically necessary. 7) When services are performed more frequently than generally accepted by peers, chiropractic manipulation will be considered excessive and will be denied as not medically necessary. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 4 of 4 Procedure Codes For chiropractic ser vices, CS covers the following CPT codes . Code Description 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions 98942 Chiropractic Noncovered Services Chiropractic services excluded from Medicaid coverage are all services other than manual manipulation of the spine and spinal x-rays. CareSource does not cover the following services when rendered by a chiropractor: Maintenance therapy; Laboratory test; Evaluation and management services; Physical therapy; Traction; Supplies where not included in the primary CPT code; Injections; Drugs; Diagnostic studies other than diagnostic xrays; Orthopedic devices; Equipment used for manipulation; and Any manipulation which the x-ray or other tests does not support the primary diagnosis. Consultations Fracture care Home visits Plaster casts Inpatient hospital visits Re l a t e d Po l i c i es & Re f e r e n c e s OAC Chapter 5160-8- 11 Physician Services / Covered chiropractic physician services and limitations KAR 3:125 Chiropractic Services and reimbursement St a t e Ex c e p t i o n s KENTUCKY Do c u m e n t Hi s t o r y Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 1 Payment Policy Subject: CMS NCD/LCD Policies Po l i c yCareSource will follow all CMS NCD/LCD Policies as written and outlined by CMS as they relate to medical necessity code edits, except in cases where the NCD/LCD does not account for the Medicaid population. De f i n i t i o n s”CMS, ” means the Centers for Medicaid & Medicare Services NCD/LCD , means National Coverage Determination and Local Coverage Determination, respectively. Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sIn recognition of the fact that not all CMS policies are written with Medicaid membership in mind, CareSource does evaluate all NCD/LCD policies and will determine appropriateness for Medicaid. If a determination has been made that the NCD or LCD needs to be modified, a notification will be published by CareSource on its Network Notification page [link] outlining the modifications made by CareSource. CareSource does not notify its providers each time there is a change to the medical necessity code edits; however, CareSource may make those notifications from time to time. Providers are encouraged to regularly and frequently use both the Network Notifications and the Provider Payment Portal webpages currently located at https://www.caresource.com/providers/ohio/provider-materials/updatesannouncements/ and https://www.caresource.com/providers/ohio/payment-policies/ respectively, to keep up to date with current CareSource system changes and payment policies. Re l a t e d Po l i c i es & Re f e r e n c e s NONE St a t e Ex c e p t i o n sNONE Do c u m e n t Re v i s i o n Hi s t o r yArchived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment Policy Subject: Outpatient Hospital Surgical Non Grouped Codes OHIO ONLY Po l i c yEffective January 1, 2014, CareSource will pay outpatient surgical claims for non-grouped codes as a percent of charges in accordance with the outpatient hospital and facility-specific cost to charge ratio. De f i n i t i o n sCost to Charge Ratio . Hospital and facility-specific cost-to-charge ratios are ratios that are computed from the relevant cost report and charge data determined at the time the cost report coinciding with the discharge is settled. These cost to charge ratios are applied to the covered charges for a case to determine whether the costs of the case exceed the fixed-loss outlier threshold. Payments for eligible cases are then made based on a ma rginal cost factor, which is a percentage of the costs above the threshold. CMS sets the reasonable parameters and the statewide cost-to-charge ratios in each year’s annual notice of prospective payment rates published in the Federal Register in accordanc e with 42 CFR 412.8(b). (from cms.gov) Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association.(From ama-assn.org) Grouped c odes/Non g rouped codes. Grouped codes are CPT codes that are included in a standardized cost model by which different services and procedures are categorized together for the grouping of payments , and for an accurate reflection of the cost of services provided. Some CPT codes fall outside of these cost/payment groupings, and those CPT codes are commonly referred to as non grouped codes. (CareSource internal definition) Outpatient surgical service , means a claim that does not include chemotherapy, or emergency room codes modified by modifier-22, and that carries a CPT code that is in the range 10021-69990, and that is also published as a grouped outpatient surgical code. (from OAC 5010:3-2 -21) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sIf a claim is submitted to CareSource that carries a CPT code that is in the range 10021-69990 that is not a grouped outpatient surgical code because the procedure is primarily performed on an inpatient basis, the claim will be paid a per cent of charges, to be determined by the Medicaid outpatient per cent as follows:Archived This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 For outpatient services, the ratio used for outpatient non-groupables is the Medicaid-reported outpatient cost to charge ratio. Claims for outpatient surgery services must include all outpatient services performed on that date of service. Re l a t e d Po l i c i es & Re f e r e n c e s OAC 5160-2- 22, Hospital Services, Reasonable cost and cost-related reimbursement for hospital services. Ohio Department of Job and Family Services 02930 , Cost Report, Schedule H, Settlement Summary, Sections I and II St a t e Ex c e p t i o n s THIS POLICY IS FOR OHIO ONLY Do c u m e n t Re v i s i o n Hi s t o r y 10/31/2013OAC Rule renumbered from 5101:3-2-22, per Legislative Service Commission Guidelines. Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 o f 2 Payment Policy Subject: Vaccine [Immunization] Services ALL STATES EXCEPT KENTUCKY Po l i c yCareSource will reimburse providers for the administration of Medicaid-approved vaccines as well as for the vaccines themselves, except in the case of immunizations provided to VFC-eligible members. In these cases, only the administration fee will be reimbursed. De f i n i t i o n sThe Vaccines for Children Program ( VFC ) is a federally funded program that works to raise childhood immunization levels in the United States by supplying health care providers with free vaccines for children 18 years old and younger who might not otherwise be vaccinated because of inability to pay. CDC buys vaccines at a discount and distributes them to grantees, which in turn distribute them at no charge to those private physicians’ offices and public health clinics registered as VFC providers. To be eligible for the VFC program, a child must meet one of the following criteria: Medicaid-eligible;Without health insuranceUnderinsured, for example, the child has health insurance that does not cover; immunizations; orIdentified by parent or guardian as American Indian or Alaskan nativeThe VFC program currently offers free vaccines against the following diseases: DiphtheriaHemophilus influenza type B (Hib)Hepatitis B(HepB)Measles, mumps and rubella (MMR)Pertussis (Whooping cough)PolioTetanusVaricella (Chickenpox)Pneumococcal disease Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sReimbursement-VFC Providers To bill for VFC vaccine administration the provider must use the appropriate procedure code for the specific vaccine being administered. Providers are not to bill for more than the VFC vaccine administration on the date of service. If the only service provided during the encounter is vaccine administration, the provider may not bill for an office visit. An office visit can only be billed if a separate, identifiable service is performed during the same visit. Archived This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 o f 2 When the provider gives face-to-face counseling for the patient and family during the administration of a vaccine to a patient aged 18 years or younger, code 90460 or a combination of codes 90460 and 90461 are reported, regardless of whether the vaccine is administered orally or through injection. The medical record documentation must support that the physician provided the vaccine counseling. Procedure Codes Description 90460 Immunization administration through 18 years of age via any route of administration, with face to face counseling by physician or other qualified health care professional; first or only component of vaccine/toxoid . 90461 Immunization administration through 18 years of age via any route of administration, with face to face counseling by physician or other qualified health care professional; each additional vaccine/toxoid component . In order to be reimbursed for the administration fee, the corresponding vaccine must be billed on the same claim/date. Similarly, the vaccine should not be billed without the administration code. Reimbursement-Non-VFC Providers The codes 90633, 90634, 90645, 90646, 90647, 90648, 90656, 90658, 90660, 90703, 90707, 90710, 90714, 90715, 90716, 90718, 90732, 90733, and 90734 for individuals eighteen years or younger will be covered under the VFC program. For adults over 18 years of age, these codes will be reimbursed at the lesser of the providers billed charge or the Medicaid maximum. Immunizations are reimbursable as a physician or clinic service only if the immunization was provided in a nonhospital setting. Immunizations administered in a hospital setting are reimbursable only to a hospital billing on an institutional claim form/transaction. When the physician or qualified health care professional does not perform the vaccine counseling to the patient or family, or when vaccines are administered to patients older than 18 years, codes 90471 90474 are reported instead of codes 90460 90461. Codes 9047190474 are reported as appropriate based on their current guidelines (i.e., either 90471 or 90473 is reported for the first vaccine administered to a patient on a calendar date, and codes 90472 and 90474 are reported for each additional vaccine given on the same date based on its route of administration). Re l a t e d Po l i c i es & Re f e r e n c e s OAC Chapter 5160-4- 12 Physician Services / Immunizations 907 KAR 1:680. Vaccines for Children Program CareSource Preventative Care Healthchek and EPSDT Policy St a t e Ex c e p t i o n s KENTUCKY Do c u m e n t Re v i s i o n Hi s t o r y December, 2013 Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 3 Payment PolicySubject: Provider Issue Resolution ProcessP o l i c yIt is the CareSource policy to ensure that all providers of medical services to CS members are reimbursed timely for all properly submitted medical claims. CareSource has an appeal process for resolution of denied claims and disputes of payment amounts. De f i ni t i on sRetrospective review is the evaluation of medical necessity and appropriate billing for services that have already been rendered. (from mibcn.com/glossary) Pr o v i d er R e i m b u r s e m e nt G u i d e l i n e sMedical Claims AdministrationProviders have 180 days from the date of service or, in the case of an inpatient admission from date of discharge, to submit a medical claim. This timeline includes submitting corrected medical claims. Providers may appeal a payment amount or payment deni al any time within 365 days of the payment notification. Services not previously reviewed for medical necessity are categorized as retrospective reviews and are reviewed and determination is made by the Medical Management Department within 30 calendar d ays of receipt. InquiriesCareSource wants providers to receive the best service each time they contact CS and to ensure the proper internal CS teams are called on to do so.Providers should direct claims inquiries and appeals to the provider web portal at https://providerportal.caresource.com. This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 3 General provider inquiries can be directed to these sources outlined below:Category Source(s)Member Eligibility Check IVRProvider Portal: providerportal.caresource.comCoordination of Benefits Provider Portal: providerportal.caresource.com Prior Authorization Provider Portal: providerportal.caresource.com or 1-800-488-0134, please listen for the selection.Internal CareSource ResourcesProvider Relations is responsible for contracting and contract related needs such as PCP capacity changes, provider demographics changes, orientation for new providers to our network, and ongoing provider education. A Provider Relations Representative cannot expedite claim s through processing. However, a Provider Relations Representative is are available to assist providers with root cause analysis, to monitor trend issues and to educate providers on new offerings and enhancements from CareSource. The Provider Service C enter is trained and equipped to respond to claims and other non-contract related inquiries. The Provider Service Center serves as the main point of contact for all CS providers. the Provider Service Center documents all calls and inquiries. Call/Inquiry documentation is reported to CS management team who reviews for trends and other provider needs and responds accordingly. If you have a question about: Then: The status of a claim and it has been less than 45 days since submission.Use the Claims Inquiry function on the Provider Portal for the status on the processing of your claim.A claim that is in pended or P9 status.There is no action required on your part. This means the claim needs manual intervention and is being reviewed.A claim that has been pending or inP9 status for more than 60 days.Call the Provider Services Representative for the status on this claim.A claim that has been processed but the provider disagrees with how the claim processed, and the claim was correctly submitted. Submit a formal appeal within 365 days from the date of payment or denial. This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 3 of 3 R e l a t e d Po l i c i e s & R e f e r e n c e sCareSource Provider Manual St a t e E xc ep t i o n sNONE Do c um e n t Hi s t or y
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