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 S ubject: Blood Specimen Collection Fee [Venipuncture] Policy CareSource will not reimburse providers for the collection of blood samples when the provider also performs a blood laboratory service because the collection of the sample is an integral part of the lab service. Definitions Encounters are face-to-face contacts between a patient and a health provider for medically necessary services and includes the recipients visit to the center, including all services and supplies incidental to a practitioners services, if the services or supplies are of a type commonly furnished in a practitioners office, commonly furnished either without charge or included in the FQHCs claim , and furnished as an incidental, although integral part of provider services. (CareSource internal definition.) Service is a clinical diagnostic laboratory test. (CareSource internal definition.) Provider Reimbursement Guidelines Specimen collection fee CareSource will reimburse for a specimen collection fee only when the provider drawing the venous sample is not the same provider or provider affiliate that is testing the specimen. W hen submitting claims for laboratory services [88002-85999 or 87800-87906] a provider may use the following specimen collection CPT codes; however CareSource will not reimburse the provider for these specimen collection fees as they are considered to be bundled with CPT codes 88002-85999 or 87800-87906. Code Description 36415 Collection of venous blood by Venipuncture 36416 Collection of capillary blood specimen (eg. finger, heel, ear stick) 36591 Collection of blood specimen from a completely implantable venous access device 36592 Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified A physicians office is reimbursed only one specimen collection fee per encounter regardless of the number of samples drawn or tests performed from a sample. 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 Related Polic ies & References Medicare Claims Processing Manual Chapter 16 Laboratory Services 907 KAR 3. 010 Physicians services State Exceptions NONE Document Revision History Archived
Payment Policy Subject: Biofeedback Services Po l i c y CareSource will not cover biofeedback services. Re l a t e d Po l i c i es & Re f e r e n c e s OAC Chapter 5160-4-28(G) , Physician Services, Noncovered services. KAR Rule 3:005 Section 4-10(m) Services not covered. St a t e Ex c e p t i o n s KY Do c u m e n t Hi s t o r y 10/31/2013 OAC Rule renumbered from 5101:3-4-28(K), per Legislative Service Commission Guidelines. Thi s 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 1Archived
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: Behavioral Health Professional Billing Policy OHIO ONLY Po l i c yCareSource will directly reimburse physicians for covered clinical psychiatric diagnostic services, evaluative procedures and therapeutic procedures provided to eligible members age 21 and under or age 65 and older residing in a private, free-standing psychiatric hospital or Institution of Mental Disease, when billed by the provider independent ly of a hospital. CareSource is not responsible for the confinement portion of an eligible members costs when residing in a private, free-standing psychiatric hospital. De f i n i t i o n sAn Inpatient Psychiatric Facility is a facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician. (from www.ucare.org) An Institution of Mental Disease (or, IMD) is a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing di agnosis, treatment, or care of persons with mental disease, including medical attention, nursing care, and related services. (from the Social Security Act 1905(i) A Psychiatric Diagnostic Interview examination consists of elicitation of a complete medical history (to include past, family and social); psychiatric history, a complete mental status exam, establishment of a tentative diagnosis, and an evaluation of the patients ability and willingness to participate in the proposed treatment plan. (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 sPrior Authorization When psychiatric care is provided to eligible members on an out-patient basis by participating physicians, prior authorization is not required when the physician bills CareSource independent of a private, free-standing psychiatric hospital or IMD. Prior authorization is not required for eligible members when psychiatric care is provided on an inpatient basis at a private, free-standing psychiatric hospital or IMD when billed by the physician independent of these settings. Prior authorization is not required for eligible members when psychiatric care is provided on an inpatient basis at a general hospital when billed by the provider independent of this setting. 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 3 Reimbursement A provider of psychiatric care for eligible members should bill CareSource for such care if the physician is billing independent of a private, free-standing psychiatric hospital or IMD. When being treated on an inpatient basis through a private, free-standing psychiatric hospital or IMD, CareSource is only responsible for psychiatric care for those members age 21 and under or age 65 and older. In-patient Free-standing Psychiatric Centers Services CareSource will reimburse physicians for independent psychiatric care for eligible members who are inpatient at a private, free-standing psychiatric facility or Institution of Mental Disease, provided the physician submits a bill using place of service (POS) 51 [Inpatient Psychiatric Facility] and bills CareSource independent of the private, free-standing psychiatric hospital or IMD. CareSource is not responsible for the confinement portion of member charges while residing in a state or private, free-standing psychiatric hospital or an IMD. In-patient Psychiatric Services [Hospital setting] CareSource will reimburse for psychiatric services performed on an in-patient basis in a general hospital setting when billed by the physician independent of the hospital, regardless of the members age. Separate prior authorization is not required from CareSource, as that authorization would have been obtained for the hospital admission. Physicians must submit a bill using POS 21 [Inpatient Psychiatric Services] and the appropriate CPT code for psychiatric care rendered. When the provider uses POS 21, CareSource will reimburse the provider only if the patient was treated in the hospital setting on a full admission basis. Out-patient Psychiatric Services [Hospital setting] CareSource will reimburse physicians for psychiatric services performed for eligible members on an out-patient basis in a general hospital setting when billed by the physician independent of the hospital. Physicians must submit a bill using POS 22 (Outpatient Services) and the appropriate CPT code for psychiatric care rendered. CareSource will reimburse the provider who uses POS 22 if the eligible member was treated in the hospital setting on an observation level of care and not a full admission basis. Inpatient vs. Outpatient Independent providers of psychiatric services must ensure that they use the proper POS code when evaluating a patient in a hospital setting. If the provider assumes that a patient was admitted to a hospital on a full admission basis and bills CareSource using POS 21 [Inpatient Psychiatric Services], but the patients admission status was only observation, then the claim will be denied for incorrect POS. Likewise, if the provider assumes that a patient was only under observation at the hospital and bills CareSource using POS 22 [Outpatient Services], and the member was fully admitted to the hospital, the claim will also be denied for incorrect POS. 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 3 Re l a t e d Po l i c ies & Re f e r e n c e s OAC 5160-4- 29, Physician Services , Services provided for the diagnosis and treatment of mental and emotional disorders. St a t e Ex c e p t i o n s This payment policy applies to 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 5101:3-4-29, 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 of 2 Payment Policy Subject: All Patient Refined Diagnosis Related Groups ( APR-DRG) OHIO ONLY Po l i c yCareSource has adopted the APR-DRG inpatient classification system for all in-patient discharges occurring on or after July 1, 2013. CareSource will determine DRG codes based on diagnosis codes and other information supplied by the provider and will compute reimbursement amounts based on ODJFS assigned base rates. CareSource uses MCG (Milliman Care Guidelines) and CareSource policies for inpatient criteria. De f i n i t i o n sDiagnostic related groups (DRGs) DRGs are a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources.(from OAC 5101:3-2 -02 (B)(5)) Inpatient A patient who is admitted to a hospital based upon the written orders of a physician or dentist and whose inpatient st ay continues beyond midnight of the day of admission.(from OAC 5101:3-2 -02 (B)(1)) Inpatient services are those s ervices which are ordinarily furnished in a hospital for the care and treatment of inpatients. Inpatient services include all covered servi ces provided to patients during the course of their inpatient stay, whether furnished directly by the hospital or under arrangement, except for direct-care services provided by physicians, podiatrists, and dentists. Emergency room services are covered as an inpatient service when a patient is admitted from the emergency room.(from OAC 5101:3-2 -02 (B)(2)) Principal diagnosis is the diagnosis established after study to be chiefly responsible for causing the patients admission to the hospital.(from OAC 5101:3-2 -02 (B)(13)) 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 sAll Patient Refined Diagnosis Related Groups (APR-DRG ) codes will change significantly from the previous Diagnosis Related Groups (DGR) codes after July 1, 2 013. Providers should refer to the ODJFS website for an updated list of these codes. The APR-DRG inpatient classification system was chosen by the Ohio Department of Jobs and Family Services ( ODJFS) because it is suitable for use with a Medicaid population, especially with regard to neonatal and pediatric care, and because it incorporates sophisticated clinical logic to capture the differences in comorbidities and complications that can significantly affect hospital resource use. Each stay is assigned first to one of 314 base APR-DRGs. Then, each stay is assigned to one of four levels of severity (minor, moderate, major or extreme) that are specific to the base APR-DRG. Claims for payment for inpatient hospital services must be submitted on the UB-92 and include the data essential for assignment of a DRG. 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 Assignment of the APR-DRG and calculation of payment is based on the standard information already on the hospital claim. The CareSource claims processing system assigns the APR-DRG based on the principal diagnoses, procedures, patient age, and patient discharge status, all as submitted by the hospital. Reimbursement will be calculated and based on the patients admission date. Hospitals are advised to ensure that these fields are coded completely, accurately and defensibly. The claims processing system also calculates the payment without need for the hospital to identify the DRG. If a hospital claim contains a DRG code, CareSource will separately assess and determine the correct code. Interim Payments-A claim for inpatient services qualifies for interim payment on the thirtieth day of a consecutive inpatient stay and at thirty-day intervals thereafter. Under interim payment, hospitals will be paid on a percentage basis of charges. The percentage will represent the hospital-specific cost-to-charge ratio as described in paragraph (B)(2) of rule 5101:3-2-22 of the Ohio Administrative Code. Medicare crossover stays-There is no change in payment calculations for stays where Medicare is the primary payer and Medicaid is the secondary payer. Note, however, that No Part A claims, in which a dually eligible patient either does not have Medicare Part A or has exhausted his or her Part A hospital benefit, are priced using the new DRG method. In these situations, Medicaid acts as the primary payer. Re l a t e d Po l i c ies & Re f e r e n c e s OAC Chapter 5160-2- 02, Hospital Services, General Provisions. St a t e Ex c e p t i o n sThis payment policy applies to Ohio only. Do c u m e n t Hi s t o r y10/31/2013OAC Rule renumbered from 5101:3-2-02, 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 of 2 Payment Policy Subject: Antigen Leukocyte Cellular Antibody Testing (ALCAT) Po l i c yAs outlined in this policy, CareSource will not reimburse providers for Antigen Leukocyte Cellular Antibody Testing (ALCAT). De f i n i t i o n sAntigen Leukocyte Cellular Antibody Testing (ALCAT) food sensitivity/intolerance testing is a blood test that measures how white blood cells respond when exposed to different foods. (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 sALCAT employs semi-automated Coulter Electronics and fully automated computer analysis. Serum or whole blood testing for food intolerance or sensitivities has not been proven to be a valid, clinically reliable tool. Antigen Leukocyte Cellular Antibody Testing is a type of blood analysis for food sensitivity/intolerance which has had only limited, anecdotal clinical testing. Effectiveness studies for ALCAT have not met scientific rigor to validate its clinical usefulness. (See references below.) A LCAT does not measure IgE mediated allergenicity similar to RAST, MAST or other clinically validated diagnostic testing for food allergies or intolerance. CareSource considers blood testing for food sensitivity/intolerance, and specifically ALCAT testing, to be experimental and investigational and not medically necessary. Therefore ALCAT is not covered for food sensitivity/intolerance. Re l a t e d Po l i c i es & Re f e r e n c e s CareSource Experimental or Investigational Technologies policy. Boyce JA, Assa’ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: Report of the NIAID-sponsored expert panel. JAllergy Clin Immunol 2010;126(6 Suppl):S1-5S8. Wuthrich, B. Unproven techniques in Allergy Diagnosis. JInvestig Allergol Clin Immunol 2005; 15:86-90 Mullin, Gerard E., et al. Testing for Food Reactions: the good, the bad, and the ugly. Nutr Clin Pract 2010, Apr 25 (2): 192-8 OAC 5160-4-28 Physician Services / Noncovered services 907 KAR 3:005. Physicians’ services Section 4(10)(m) Service limitations. 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 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 10/31/2013OAC Rule renumbered from 5101:3-4-28, per Legislative Service Commission Guidelines. Archived
Payment Policy Subject: Anesthesia Programs Covered: OH Medicaid, KY Medicaid, OH MyCare, and Just4Me TM (all states)Effective Date: 6/1/2013 Policy CareSource will reimburse for medically necessary anesthesia procedures rendered within scope of practice in a physicians office, inpatient or outpatient facility . Definitions Anesthesia time is the actual number of anesthesia minutes as reported on the claim. Anesthesia time begins when the anesthetist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthetist is no longer in personal attendance, that is, when the patient may be safely placed under post-anesthetic supervision. (from OAC 51 60–4-21 (B)(4)) Base unit means the value for each anesthesia code that reflects all activities other than anesthesia time. Anesthesia activities include usual pre-operative and post-operative visits, the administration of fluids or blood incident to anesthesia care, and monitoring services.(from OAC 51 60-4-21 (B)(1) ) Base unit value. Each anesthesia code (procedure codes 00100-01999) is assigned a base unit value by the American Society of Anesthesiologists (ASA) and used for the purpose of establishing fee schedule allowances. Anesthesia services are paid on the basis of a relative value system, which include both base and actual time units. Base units take into account the complexity, risk, and skill required to perform the service. (from http://www.cms.hhs.gov) Medical direction is when a physician utilizes the assistance of a CRNA/AA, resident, intern, or fellow in the performance of the aesthesis services and is involved in no more than four concurrent anesthesia cases.(from OAC 5160-4-21 (C)(3)(a)) Me dical supervision is when the physician anesthesiologist is involved in furnishing services for more than four concurrent procedures or is performing other services while directing the concurrent procedures. In situations where the physician is involved in medically supervising more than four procedures concurrently, or is performing other services while directing the concurrent procedures, the physician must be involved in the pre-surgical anesthesia services. (from OAC 51 60-4- 21 (C)(3)(b) and (4)) Monitored Anesthesia Care (MAC) is a combination of local anesthesia and certain anxiolytic and analgesic medications. When this type of anesthesia is used, the patient maintains protective reflexes and consciousness except for a brief period of time.(f rom OAC 5160-4-21 ( I))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 Archived Time unit means the continuous actual presence of the physician (or of the medically-directed resident or medically-directed CRNA/AA) and starts when he/she begins to prepare the patient for anesthesia and ends when the anesthesiol ogist (or medically-directed CRNA/AA) is no longer in personal attendance with the exception of anesthesia for neuraxial analgesia for obstetrical services. (from OAC 5160-4-21 (B)(3)) Time unit value means one unit for each fifteen minutes of reported anesthesia time. Since only the actual time of a fractional time unit is recognized, the resulting time unit value will be rounded to one decimal place. (from OAC 5160-4-21 (B )(5 )) Provider Reimbursement Guidelines Prior Authorization Prior authorization for anesthesia services may be required depending on place of service . CareSource will reimburse a qualified provider for general, regional, or supplementation of local anesthesia services (or monitored anesthesia care services as described below) provided during a surgical or diagnostic procedure. Anesthesia services include the usual pre-operative and post-operative visits, the anesthesia care during the procedure, the administration of fluid and/or blood products incident to the anesthesia or surgery, and the basic monitoring procedures. ECG, temperature, blood pressure, oximetry, capnography and mass spectometry are considered usual monitoring procedures. Unusual monitoring procedures such as intra-arterial, central venous and Swan Ganz are not included in the payment for anesthesia services and may be separately billed and reimbursed. Provider Care Source will reimburse a qualified provider for anesthesia services only if that provider is acting exclusively as an anesthetist and is not also acting as the surgeon or assistant surgeon. An exception would be if a provider employs a Certified Registered Nurse Anesthetist (CRNA) to provide anesthesia services. In that case, the provider may bill and receive reimbursement for the services of the CRNA in addition to the reimbursement for the surgical procedures performed by the attending physician. For each patient, the provider must: a) Perform a pre-anesthetic examination and evaluation; b) Pre scribe the anesthesia plan; c) Personally participate in the most demanding procedures in the anesthesia plan, including induction and emergence; d) Ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual; e) Monitor the course of anesthesia administration at frequent intervals; f) Remain physically present and available for immediate diagnosis and treatment of emergencies; and g) Provide indicated post-anesthetic care. 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 5Archived The provider may either personally perform the services itemized above, without the assistance of a CRNA/AA, resident, intern, fellow, or other qualified anesthetist , or the provider may use the assistance of a CRNA/AA, resident, intern, fellow or other qualified anesthetist in the performa nce of these services, and not perform any other services while providing medical direction. For physician-directed/supervised CRNA/AA services, providers should submit the appropriate procedure code, modifier and applicable time units for both the physici an and CRNA/AA on separate claim lines. Submit the primary anesthesia service as the first claim line. Care Source will not compensate E&M services when invoiced with anesthesia services, as the E&M service is included in the anesthesia service. Submitting a separate E&M service in place of a physician is appropriate if the only service provided was a pre-operative evaluation and no anesthesia was administered. Submitting an E&M procedure code for a pre-operative consultation is not appropriate unless the surgery is cancelled subsequent to the pre-operative visit. Care Source will reimburse for anesthesia services for a teaching anesthesiologist involved in an anesthesia procedure with a resident. The teaching physician must document in the medical records that he/she was present during all critical or key portions of the procedure. The teaching physicians physical presence during only the preoperative or post-operative visits with the patient is not sufficient to receive reimbursement. Time & the Reimbursement Formula Providers must report the start and end time for the administration of anesthesia, as well as the total number of minutes that anesthesia services were rendered. For example, if the total time of anesthesia was two (2) hours and ten (10) minutes, services should be submitted at 130 minutes. Every 15-minute interval will be converted by CareSource into 1 unit, rounding up to the next unit for 8 to 14 minutes, rounding down for 1 to 7 minutes. Claims submitted in units will be rejected. During claims processing, submitted minutes will be converted to time units. The formula for calculating the reimbursement of anesthesia services will be the base unit value and the time unit value multiplied by the appropriate conversion factor , if an y, or percentage of a conversion factor, as applicable. The following formula exceptions apply: Pain-management physicians are sometimes called in to manage postoperative patients who received an epidural catheter during surgery, which is indicated with CPT code 01996 ( daily management of epidural or subarachnoid drug administration). Anesthesia code 01996 will be paid based on the base units specified in the relative value guide. No calculation for time is allowable for this anesthesia code; Services invoiced with the AD modifier will be paid at three times the appropriate conversion factor, if any . 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 5 Archived No additional reimbursement will be paid for the physical status of the patient, the age of the patient, body hypothermia, body hyperthermia, emergency conditions, or time of day. Reimbursement for monitored anesthesia care is the same as for general anesthesia when all of the conditions for reimbursement are met. There is no additional reimbursement for monitored anesthesia. CPT Codes and Modifiers The following anesthesia modifiers must be used for anesthesia services: AA Anesthesia services personally performed by the anesthesiologist. The modifier AA may be used if a teaching anesthesiologist is continuously involved in one procedure with one resident or with one student certified registered nurse anesthetist. The teaching anesthesiologist must document in the medical records that he or she was present during all critical portions of the procedure including induction and emergence. AD Medical supervision by a physician: more than four concurrent anesthesia procedures; QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals; QX CRNA with medical direction by a physician or anesthesia assistant with m edical direction by an anesthesiologist; QY Medical direction of one CRNA by an anesthesiologist; and QZ CRNA without medical direction by physician. Note: Anesthesiologist assistants may use the modifier QX for services provided under the medical direction of an anesthesiologist if they are employed by a physician or in an independent practice. An anesthesiologist may use the QY modifier if he/she provides medical direction to an anesthesiologist assistant. When it is medically necessary to provide general anesthesia services for extensive restorative dental procedures or for a covered oral surgery procedure for which there is not a surgical code, the anesthesia services must use code 00170 modified by the appropriate anesthesia modifier. For the reimbursement of anesthesia services the provider must use the anesthesia code that best describes the anesthesia procedure performed modified by the appropriate anesthesia modifier, and report the total anesthesia ti me in minutes. Surgical CPT codes that include the administration of anesthesia in the description of that CPT code will only be reimbursed when an anesthesia CPT code in the range 00100-01999 is also coded on the claim. Certain CPT codes will not be reimbursed by CareSource because it is not considered to be a surgery or incident to another surgery. For this policy, CareSource follows the guidelines provided by OAC Rule 5160-2- 21, Policies for Outpatient Hospital Services, and applies the same exceptions identified in Appendix Cof that Rule. 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 Archived NOTE: Effective June, 1 2013 CareSource is no longer making exceptions to this policy for CPT codes 64479/64480 and 64483/64484. CareSource previously excluded these codes from the logic of this policy; however this was rescinded because Primary/Secondary logic does not apply to facility coding, making that exclusion incorrect . Related Polic ies & References OAC Rule 5160-2-21 Policies for Outpatient Services / Surgical Claim Edits OAC 5160-4- 05 (E) (1) (i) OAC Rule 5160-4-21 Physician Services / Anesthesia Services 201 KAR 8:550. Anesthesia and sedation. 907 KAR 3:010. Reimbursement for physicians’ services-Sections 3 & 4 Document Revision History 10/31/2013 OAC Rules renumbered from 5101:3-2- 21, 5101:3-4-5(E)(1)(i), and 5101:3-4- 21, per Legislative Service Commission Guidelines. 1/26/2015-Updated, effective 6/1/2013 exception is no longer being made for certain CPT codes (from Network Notification (June 2012) ); updated references to OAC rules . 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 5 of 5 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: Abortion Po l i c yCareSource will cover abortions for eligible CareSource members under strict federal guidelines, which require that the life of the mother would be endangered if the fetus were carried to term, or if the mother was a victim of rape or incest. Abortions are not covered if used for family planning purposes. De f i n i t i o n s42 C.F.R. 441.201, Title 42-Public Health defines the standards under which abortion procedures can be performed for federally funded health care. A therapeutic abortion is the termination of a pregnancy where fetal heart tones are present at the time of the abortive procedure. The termination of a pregnancy may be induced medically (prostaglandin suppositories, etc.) or surgically (dilation and curettage, etc.). This includes the delivery of a non-viable (incapable of living outside the uterus) but live fetus, if labor was augmented by pitocin drip, laminaria suppository, etc. (from ncdhhs.gov) 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 Authorization Prior authorization is required for the administration of an abortion procedure to validate medical necessity per federal regulations. The consent form must be submitted with the request for authorization. Reimbursement Reimbursement is available for abortions only when the abortion is required to be covered under federal law subject to limitations and restrictions set out in 42 CFR Subpart CSec.50.301, 50.302, 50.303, 50.304, 50.306, 42 CFR 441.200 Sec 441.200, 441.201, 441.202, 441.203, 441.206, 441.207, 441.208, 405 . All appropriate documentation must be attached to the claim and to claims for directly related services before CareSource can reimburse for any claim. CareSource will reimburse for drugs or devices to prevent implantation of the fertilized ovum, and for medical procedures for the termination of an ectopic pregnancy. The requirements stated below do not apply to those abortions that are treatments for incomplete, missed, or septic abortions. Reimbursement for abortion services, other than those identified above, is restricted to the following circumstances when the appropriate certification is made: Instances in which the woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed; or 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 Instances in which the pregnancy was the result of an act of rape and the patient, the patients legal guardian or the person who made the report to the law enforcement agency, certifies in writing that a report was filed,prior to the performance of the abortion, with a law enforcement agency having the requisite jurisdiction, unless the patient was physically unable to comply with the reporting requirement and that fact is certified by the physician performing the abortion; orInstances in which the pregnancy was the result of an act of incest and the patient, the patients legal guardian or the person who made the report certifies in writing that a report was filed, prior to the performance of the abortion, with either a law enforcement agency having the requisite jurisdiction, or, in the case of a minor, with a county children services,unless the patient was physically unable to comply with the reporting requirement and that fact is certified by the physician performing the abortion.Certification Before reimbursement for an abortion can be made, the physician performing the abortion must certify that one of the three circumstances outline above has occurred. The certification must be made on the appropriate state-specific certification form. All certifications must contain the name and address of the patient. The certification form must be properly executed and submitted to CareSource, including appropriate signatures. Claims for payment will be denied if the required consent is not attached or if incomplete or inaccurate documentation is submitted. Reimbursement will not be made for associated services such as anesthesia, laboratory tests, or hospital services if the abortion service itself cannot be reimbursed. Re l a t e d Po l i c i es & Re f e r e n c e s 42 C.F.R. [Code of Federal Regulations] 441, Subpart Eor Subpart FOAC Chapter 5160-17-01 Abortions 907 KAR 1:054. Primary care center and federally-qualified health center services KRS [Kentucky Revised Statutes] 205.010(3), 205.510(5), and 212.275(3) National Coalition (NC) Division of Medical Assistance-Medicaid and Health Choice-Clinical Coverage Policy No.: 1E-2 – Therapeutic and Non-therapeutic Abortions (Revised Date: March 1, 2012) 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 y10/31/2013OAC Rule renumbered from 5101:3-17-01, 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 of 1 Payment Policy Subject: Acupuncture Services Po l i c yCareSource will not reimburse for acupuncture services. De f i n i t i o n s”Acupuncture ” is a system of complementary medicine that involves pricking the skin or tissues with needles, used to alleviate pain and to treat various physical,mental, and emotional conditions.(from oxforddictionaries.com) 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 sAcupuncture is considered investigational and unproven and is not a covered benefit. 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- 28(J) Physician Services / Noncovered services. KA RRule 3:005 Section 4-10 Services not covered. Ohio Department of Job and Family Services, Ohio Medical Assistance ProviderAgreement for Managed Care Plan Appendix G: Coverage and Services. 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 y10/31/2013OAC Rule renumbered from 5101:3-4-28(J), per Legislative Service Commission Guidelines.Archived
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