Modifier 59 XE XP XS XU

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 an y 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 Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 12/01/2023-10/31/2024 Policy Type REIMBURSEMENT Tabl e of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 5 G. Review/Revision History …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 5 Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 59, XE, XP, XS, XUB. Background Reimbursement policies are designed to assist physicians 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. Reimbursement modifiers are two-digit codes that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, their 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 prepayment and post-payment audit. Using a modifier inappropriately 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 CareSources request. The Medicare National Correct Coding Initiat ive (NCCI) includes Procedure-to-Procedure edits that define when two Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together, but are appropriate under the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because two different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the two procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established four HCPCS modif iers to define specific subsets of modifier 59 XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances . Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59.C. DefinitionsCurrent Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. 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 Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. Policy I. 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 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment 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 their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial. IV. Standard appeal rights apply fo r both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59. VI. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available. Documentation s hould support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 s eparate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that1. Are performed at different anatomic sites, and2. Are not ordinarily performed or encountered on the same day, and3. Cannot be described by one of the more specific anatomic NCCI Procedur e to P rocedure (PTP)-associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA,T1-T9, LC, LD, RC, LM, RI).B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgica l t herapeutic procedures, or diagnostic procedures that1. Are performed during different patient encounters, and2. Cannot be described by one of the more specific NCCI PTP-associat ed m odifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91).C. Modifier XE (or 59, when applicable) may also be used when two tim ed pr ocedures are performed during the same encounter but occur one after another (the first service must be completed before t he next service begins).D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgica l t herapeutic procedures, or diagnostic procedures that1. Are performed at separate anatomic sites, or2. Are performed at separate patient encounters on the same date of service.E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedur e i s performed before a therapeutic procedure only when1. The diagnostic procedure is the basis for performing the therapeutic procedure, and2. It occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires, and3. P rovides clearly the information needed to decide whether to proceed with the therapeutic procedure, and4. Does not constitute a service that would have otherwise been required duri ng t he therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately.F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedur e is performed after a therapeutic procedure only when1. The diagnostic procedure is not a common, expected, or necessary follow-up t o the therapeutic procedure, and2. It occurs after the completion of the therapeutic procedure and is not mingl ed w ith or otherwise mixed with services that the therapeutic interventi on r equires, and3. Does not constitute a service that would have otherwise been required duri ng t he therapeutic intervention. If the post-procedure diagnostic procedure is an i nherent component or otherwise included (eg, not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately. Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 E.C onditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual f ee s chedule for appropriate codes.P roviders must follow proper billing, industry standards, and state compliant codes on a ll c laims submissions. The use of modifiers must be fully supported in the medical recor d and/ or office notes. Unless otherwise noted within the policy, this policy applies to bot h par ticipating and nonparticipating providers and facilities.In t he event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document. F. Related Policies/Rules Modifier 2 5 M odifiers G. Review/Revision History DATE ACTION Date Issued 08/17/2022 Date Revised 08/02/2023 Annual review: updated references. Approved at Committee. Date Effective 12/01/2023 Date Archived 10/31/2024This 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.References 1.General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 2023.2. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysici an P ractitioners . US Centers for Medicare and Medicaid Services; 2022. Updat ed Febr uary 9, 2023.3. MLN1783722-Proper Use of Modifiers 59 & – X{EPSU}. US Centers for Medicare & M edicaid Services; 2023.4. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicar e and M edicaid Services. Updated July 18, 2023.5. Transmittal R1422OTN-Publication 100-20-MM8863-Specific Modifiers forDistinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Approved ODM 09/07/2023

Acupuncture Services

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Acupuncture Services-OH MCD-PY-0152 09/01/2023 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 s ervice, 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, i llness, 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 subj ect to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Acupuncture Services-OH MCD-PY-0152 Effective Date: 09/01/2023 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 Acupuncture Services 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 s ervices provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitt ing provider to submit the most accurate and appropriate 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. Acupunctur e is an ancient Chinese method of treatment based on the theory that stimulation of specific key points on or near the skin by the insertion of needles or by other methods improves vital energy flow . The term acupuncture describes a variety of methods and styles to stimulate specific anatomic points in the body. Acupuncture is used to relieve pain, to induce surgical anesthesia, or for therapeutic purposes. It is considered an alternative treatment and an adjunct to standard treatment . C. Definitions Acupuncturist-A n individual who holds at least a valid certificate to practice as an acupuncturist or a valid certificate to practice as an oriental medicine practitioner. Chiropractor-An individual who holds a certificate to practice acupuncture issued by s tate chiropractic board. Other Individual Medicaid Provider-A physician assistant or an advanced registered nurse practitioner who has a valid certificate as an acupuncturist . Physician-An individual who has completed medical training in acupuncture with a current and active designation or an equivalent designation from the national certification commission for acupuncture and oriental medicine. D. Policy I. CareSource reimburses for acupuncture services accor ding to the criteria found in Ohio Administrative Code (OAC) 5160-8 -51. II. CareSource does not require prior authorization for acupuncture services for the first 30 visits per calendar year for participating providers. Acupuncture Services-OH MCD-PY-0152 Effective Date: 09/01/2023 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.3III. In accordance with OAC 5160-8-51, acupuncture services are only reimbursable for the following conditions: A. Migraines B. Low back pain C. Cervical (neck) pain D. Osteoarthritis hip E. Osteoarthritis of knee F. Acute post-operative pain G. Acute nausea and vomiting (pregnancy and che motherapy-related, not inpatient) . IV. Participating providers must be one of the following: A. A physician who has completed medical training in acupuncture with a current and active designation, or an equivalent designation from the national certification com mission for acupuncture and oriental medicine. B. A chiropractor with a valid certificate to practice acupuncture. C. Other individual Medicaid provider, including an advanced practice registered nurse or a physician assistant , with a valid certificate as an acupuncturist. V. Limitations: A. No separate reimbursement will be made for both an evaluation and management service and an acupuncture service performed by the same provider to the same individual on the same day. B. No separate reimbursement will be made for services that are an incidental part of a visit , such as but not limited to providing instruction on breathing techniques, diet or exercise. C. No reimbursement will be made for additional treatment af ter an initial treatment period if any of the following occur : 1. Symptoms show no evidence of clinical improvement after an initial treatment period, or 2. Symptoms worsen over a course of treatment. NOTE: Although CareSource does not require a prior authorization for the first 30 visits for acupuncture services, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. 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 . Acupuncture Services-OH MCD-PY-0152 Effective Date: 09/01/2023 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.4The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one on one contact with the patient . 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one on one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) 97813 Acupuncture, 1 or more needles with electrical stimulation, initial 15 minutes of personal one on one contact with patient 97814 Acupu ncture, 1 or more needles with electrical stimulation, each addition 15 minutes of personal one on one contact with the patient, with re-insertion of needle (s) (List separately in addition for primary procedure). F. Related Policies/RulesN/A G. Review/Revision History DATE ACTIONDate Issued 10/31/2013 New PolicyDate Revised 10/31/2013, 06/06/2016 04/30/2020 05/25/2022 05/24/2023 New Allowed Services Removed III. D. Shoulder Pain Updated references. No changes. Approved at committee.Date Effective 09/01/2023Date Archived H. References1. Appendix DD to rule 5160-1- 60 (Non-Institutional Fee Schedule) (January 1, 2022).Retrieved May 1, 2023 from www.medicaid.ohio.gov . 2. Ohio Administrative Code OAC-5160-8- 51 Acupuncture services. (March 1, 2021) . Retrieved May 1, 2023 from www. codes.ohio.gov/oac . 3. Ohio Revised Code 4762.02 (2020) – License to Practice. Retrieved May 1, 2023 from www.codes.ohio.gov/orc .

Payment to Out of Network Providers

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 Reimburs ement 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 no t limited to, those health care services or supplies that are proper and necessary for the d iagnosis 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 sign ificant pain and discomfort. These serv ices 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 pl an con tract (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 (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than t he limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Payment to Out of Network Providers-OH MCD-PY-1343 08/01/2023-05/31/2024 Policy Type REIMBURSEMENT T able of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 3 F. Related Policies/Rules …………………………………………………………………………………………… 3 G. Review/Revision History …………………………………………………………………………………………. 3 H. References …………………………………………………………………………………………………………… 3 Payment to Out of Network Providers-OH MCD-PY-1343 Effective Date: 08/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectPayment to Out of Network Pr oviders 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. Healt h 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/ICD-10 code(s) for the product or serv ice 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 reimbursement rate for claims received from providers 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 attention 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; or o Serious dysfunction of any bodily organ or part. D. Policy CareSources 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; and 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. II. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document. Payment to Out of Network Providers-OH MCD-PY-1343 Effective Date: 08/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. III.E xclusions:A. 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 Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules NA G.Review/Revision History DATE ACTION Date Issued 07/02/2021 New policy Date Revised 09/29/2021 04/12/2023 Added III. B. for clarification. Approved at PGC. Removed links from policy. Updated reference. Approved at Committee. Date Effective 08/01/2023 Date Archived 05/31/2024This 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 tofollow CMS/State/NCCI guidelines without a formal documented Policy.H.R eferences 1.Rule 5160-26 -01. Managed health care programs: Definitions. (July 18, 2022). Ohi o Law s and Administrative Rules. Retrieved March 20, 2023 from www.codes.ohio.gov.

Orthotics

RE IMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Orthotics-OH MCD-PY-1151 08/01/2023 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, r egulatory 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 t he 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, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidi ty, 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 conveni ence 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 con tract (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 t o 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.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditio ns of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Orth o tics-OH MCD-PY-1151Effective Dat e: 08/01/2023The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is app roved.A. SubjectOrthoticsB. BackgroundOrthotics are braces , splints, casts and support s that may be utilized to align, prevent or correct def ormities or to improve the f unction of movable parts of the body. Reimbursement policies are designed to assist providers when submitting claims toCareSource. They are routinely updated to promote accurate coding and policy clarif ication.These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. 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 f or processing. Health care providers and of fice 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 appropriateCPT/HCPCS code(s) f or 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 reinf orce Care Source s ability to audit post payment claimsand to ensure that reimbursement was justif ied by reviewing providers documentation to conf irm medical necessity.C. Def initions Certificate of Medical Necessity (CMN) – A written statement by a practitioner attesting that a particular item or service is medically necessary f or an individual. Orthotics – The evaluation, measurement, design, f abrication, assembly, f itting, 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 f abricated or f itted medical device used to support, correct, or alleviate neuromuscular or musculoskeletal dysf unction, disease, injury, or deformity. The device is dispensed to an eligible CareSource member by an appropriate provider and can be considered f or back, spinal (lumbar, cervical, and/or thoracic), f oot, ankle, and kn ee indications. D. PolicyI. CareSource may request documentation f rom 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 f urnished by an eligible provider to an eligible CareSource member . Eligible Medicaid providers of the f ollowing types having prescriptive authority under Ohio law may certif y the medical necessity of an orthotic device: 1. A physician; 2. A podiatrist; Orth o tics-OH MCD-PY-1151Effective Dat e: 08/01/2023The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is app roved.3. An advanced practice registered nurse with a relevant specialty (e.g., clinical nurse specialist, certif ied nurse practitioner); or4. A physician assistant. B. CareSource may request the CMN af ter the claim has been submitted. C. An illegible CMN wi ll not be accepted. II. The f ollowing criteria f or reimbursement must be included:A. The DME provider must be enrolled as a DME supplier f or Medicaid. B. The ordering practitioner must conduct a f ace-to-face encounter. C. The orthotic device must have a prescription : 1. The date cannot precede the date of the f ace-to-face encounter , nor be more than 180 days af ter the encounter, 2. The date must be no more than 60 days bef ore the date the orthotic device is dispensed to the member. D. The ordering practitioner must be actively involved in managing the recipient’s medical care. A prescription written by a practitioner who has no prof essional relationship with the recipien t will be disallowed. E. The prescribed DME device must be directly related to a medical condition of the recipient that the practitioner evaluates, assesses, or actively treats during the encounter. III. Any request f or 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 f ull knowledge and consent. IV. When instruction must be given regarding saf e and appropriate use of a n 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 f or payment must have supporting document ation kept by theDME provider. VI. Payment is not available f or an orthotic device that is a duplicate or conf lict s with another device currently in the members possession, regardless of payment or supply source. Providers are responsible f or ascertaining whether duplication or conflict exists. E. Conditions of CoverageReimbursement is dependent up on, but not limited to, submitting approved HCPCS and CPT codes al ong with appropriate modif iers , if applicable . Please ref er to the individual fee schedule f or appropriate codes. F. Related Policies/RulesMedical Record Documentation Standards f or Practitioners Orth o tics-OH MCD-PY-1151Effective Dat e: 08/01/2023The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is app roved.G. Review/Revision HistoryDATE ACTIONDate Issued 06/10/2020 Date Revised 11/10/2021 04/12 /2023 Revised Policy language. Approved at PGC. Added additional background inf ormation. Updated ref erences. Approved at Committee. Date Effective 08/01/2023 Date Archived H. Ref erences1. Ohio Administrative Code. (2020, October 1). 4755-62-02 Device-related and scope of practice def initions. Retrieved March 27, 2023 from www.codes.ohio.gov. 2. Ohio Administrative Code. (20 21 , J uly 1). 5160-10-01 Durable medical equipment, prostheses, orthoses, and supplies (DMEPOS): General provisions. Retrieved March 27, 2023 f rom www.codes.ohio.gov . 3. Ohio Administrative Code. (2018, July 16). 5160-10-31 DMEPOS : Footwear and f oot orthoses. Retrieved March 27, 2023 from www.codes.ohio.gov.

Interest Payments

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, illne ss, 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 contr act (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 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 Interest Payments-OH-MCD-PY-1324 08/01/2023-05/31/2024 Policy Type REIMBURSEMENT T able of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 2 F. Related Policies/Rules …………………………………………………………………………………………… 2 G. Review/Revision History …………………………………………………………………………………………. 3 H. References …………………………………………………………………………………………………………… 3 Interest Payments-OH-MCD-PY-1324 Effective Date: 08/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A.Subject Interest Payments B. Background Reimbursement policies are designed to assist providers when submitting claims toCareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claim s may be subject to limitations and/or qualifications. Reimbursement will bees tablished based upon a review of the actual services provided to a member and will be det ermined when the claim is received for processing. Health care providers and office staf f are encouraged to use self-service channels to verify members eligibility.It is t he responsibility of the submitting provider to submit the most accurate and appr opriate CPT/HCPCS/ICD-10 code(s) for the product or service that is bei ng pr ovided. The inclusion of a code in this policy does not imply any right t o r eimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider orCareSource to change historical data or reimbursement of an original claim.Clean Claim A clean claim is a claim that can be processed without obtaini ng addi tional information from the provider of a service or from a third party and do not in clude 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 th e pr ovider of service or third party. A clean claim also does not include a claim from a pr ovider 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 appl ication form.Prompt Payment Prompt payment is defined by Ohios Medicaid Prompt Payment rules and contract. D. Policy I. CareSource strictly adhere to all regulatory guidelines relating to interest. We follo w t he guidelines outlined in Prompt Payment regulations.I I. In alignment with the Ohio Administrative Code and the Medicaid ProviderAgreement, 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 CP Tcodes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules NA Interest Payments-OH-MCD-PY-1324 Effective Date: 08/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. G.Re view/Revision History DATE ACTION Date Issued 03/31/2021 New Policy Date Revised 01/05/2022 04/27/2022 04/12/2023 Updated language and references per Legal. No change; did for review cycle consistency No change; updated references. Approved at Committee. Date Effective 08/01/2023 Date Archived 05/31/2024 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H.R eferences 1.Electronic Code of Federal Regulations (e-CFR). CFR 447.45(b). Timely claims payment. Definitions. Retrieved March 21, 2023 from www.law.cornell.edu.2. E lectronic Code of Federal Regulations (e-CFR). CFR 447.45(d). Timely claims payment. Timely processing of claims. Retrieved March 21, 2023 from www.law.cornell.edu.3. O hio Medicaid Contract, Appendix J, 4. A clean claim is a claim that ca n be pr ocessed without obtaining additional information from the provider of a service or from a third party. Retrieved March 21, 2023 from www.managedcare.medicaid.ohio.gov.4. O hio Revised Code 5164.01(C). Definitions. Retrieved March 21, 2023 from www.managedcare.medicaid.ohio.gov

Chiropractic Care

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 Policie s. 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, provid er 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 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 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 (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 Chiropractic Care-OH MCD-PY-1328 08/01/2023-05/31/2024 Policy Type REIMBURSEMENT T able of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 3 F. Related Policies/Rules …………………………………………………………………………………………… 3 G. Review/Revision History …………………………………………………………………………………………. 3 H. References …………………………………………………………………………………………………………… 3 Chiropractic Care-OH MCD-PY-1328 Effective Date: 08/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectChiropractic Care 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/HCPCS/ICD-1 0 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. Chiropractic is a licensed healthcare profession where treatment typically involves manual 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 results in an expected improvement in, or arrest of, progression in the members conditi on. Billing Provider A chiropractor, mechanotherapist, professional 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 mechanotherapist is eligible to provide spinal manipulation. D. Policy I. CareSource follows the Ohio Administrative Code for payment of spinal manipulation. II. Payme nt may be made for the following: A. Manual correction to correct a spinal subluxation determined by x-ray or physician exam; 1. A condition that is acute and episodic in nature. When the maximum therapeutic benefit has been met, ongoing therapy is considered maintenance therapy, which is considered not medically necessary; and III. Payment may be made for the following services: A. Spinal manipulation. 1. Chiropractic manipulative treatment (CMT); spinal, one to two regions. Chiropractic Care-OH MCD-PY-1328 Effective Date: 08/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2. Chiropractic manipulative treatment (CMT); spinal, three to four regions.3. Chiropractic manipulative treatment (CMT); spinal, five regions.B. 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 an d f lexion 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. I V. All services performed must be medically necessary and related to the treatment of as pecific medical complaint.A. To determine medical necessity, CareSource requires all of the following:1. A primary diagnosis of subluxation (i.e., lumbar and/or sacral) ;2. A secondary diagnosis that supports the treatment provided (e.g.,osteoarthritis, congenial musculoskeletal deformities of the spine, etc.).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 Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules Medical Necessity Determination Policy G.Review/Revision History DATE ACTION Date Issued 05/26/2021 Date Revised 04/12/2023 Annual review: Title modified. Updated references. Approved at Committee. Date Effective 08/01/2023 Date Archived 05/31/2024This 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/Sta te/NCCI guidelines without a formaldocumented Policy.Chiropractic Care-OH MCD-PY-1328 Effective Date: 08/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. H. References1. Ohio Administrative Code. (November 1, 2022) 5160-8 -11 Chiropractic services. Retrieved March 27, 2023 from www.codes.ohio.gov.

Temporary Codes

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Temporary Codes-OH MCD-PY-1414 06/01/2023 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Temporary Codes-OH MCD-PY-1414Effective Dat e: 06/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectTemporary Codes 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 claim s 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 staf f 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 beingprovided. The i nclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Temporary codes exist in both CPT and HCPCS manuals and are updated throughout the year. Tcodes (i.e., Category III codes) are temporary CPT codes fo r emergingtechnologies, services, and procedures which support data collection to substantiate widespread use and/or provide documentation for the Food and Drug Administration (FDA) approval process. Many of these codes have not been proven medically nece ssary and are considered to be experimental or investigational based on a lack of peer-reviewed scientific literature. A variety of temporary HCPCS codes exist. Temporary HCPCS codes may be established by the Centers for Medicare and Medicaid Services (CMS ) to report drugs, biologicals, devices, and procedures, to identify services and procedures under FDA review, or address miscellaneous services, procedures, and supplies. Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) may devel op temporary HCPCS codes to report supplies and other products for which a national code has not yet been developed. Temporary HCPCS codes may also be developed by commercial payers to report drugs, services, and supplies. Coverage of these services is und er the discretion of local carriers. C. DefinitionsNA D. PolicyI. CareSource considers temporary codes medically necessary when ALL the following criteria are met: A. Documentation in the medical record supports the use of the code; B. A more specific code is not available to describe the service/procedure; C. The service provided is within the scope of the members benefit plan. II. CareSource will use current industry standard procedure codes (HCPCS CPT I and Category II codes) throughout the processing systems. HIPAA Transaction & CodeTemporary Codes-OH MCD-PY-1414Effective Dat e: 06/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.Set Rule requires providers use the procedure code(s) that are valid at the time the service is provided.III. Providers must use industry standard code sets and must use specific HCPCS CPT I and Category II codes when available unless othe rwise directed through the providers contract. IV. If specific codes are not available, unlisted codes require plan preauthorization.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. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/01/2023 New policyDate Revised Date Effective 06/01/2023 Date Archived H. References1. 2022 HCPCS Codes Level II. (n .d.). Temporary Codes for Use with Outpatient Prospective Payment System. Retrieved December 20, 2022 from www.hcpcs.codes. 2. Ameri can Academy of Professional Coders (AAPC). (2022). What is HCPCS? Retrieved December 20, 2022 from www.aapc.com. 3. American Medical Association (AMA). (2009). Practice Management Center: Understanding the HIPAA Standard Transactions: The HIPAA Transactions a nd Code Set Rule. Retrieved December 20, 2022 from www.assets.ama-assn.org. 4. Current Procedural Terminology (CPT). 2023 Professional Edition, American Medical Association: Chicago, IL.

Residential Treatment Services – Substance Use Disorder

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Residential Treatment Services – Substance Use Disorder – OH MCD-PY-0137 06/01/2023 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and it s 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 develo ping 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 contractu al 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 o r 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 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 co ntract (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 con trolling 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 rule s 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 covere d 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 ………………………….. ………………………….. ………………………….. ……………………. 7 Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 06/01/2023The 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 inte nsive inpatient levels of care, are considered transitional with the goal of returningthe 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 medicall y 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 disorders 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 physicians 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 3.5 – 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 personnel appropriate for members whose primary problems involve emot ional, 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 and 3.5 residen tial programs. Inpatient Services – Behavioral health or substance use disorder services provided during an inpatient admission or confinement for acute inpatient services in a hospital or treatment setting on a 24-hour basis under the direct care of a phy sician, Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 06/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.including psychiatric hospitalization, inpatient detoxification, and emergency evaluation and stabilization. Medically Managed Services – Services involving 24-hour nursing and daily medical care by an 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 sta ff 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 ther apies to provide a whole-patient approach to the treatment of substance use disorders. Per Diem – An allowance or payment made for each day of service based on the sum of the national average routine operating, ancillary , and capital costs for each pati ent day of care. Residential Level of Care – Services for behavioral health or substance use disorder issues that can include individual, family and group therapy, nursing services, medication assisted treatment, detoxification (ambulatory or subacute) , and pharmacological therapy in a congregate living community with 24-hour support. D. PolicyI. A residential program must meet all the following criteria : A. Staffed 24 hours a day B. Follo ws nationally recognized medical standards C. Certified/licensed by the Ohio Department of Mental Health and Addiction Services (OhioMHAS) to provide residential SUD treatment D. Ha s an active provider agreement with O hio Department of Medicaid (ODM) E. Employ s practitioners of SUD treatment service s who meet applicable state requirements F. Establish es individualized treatment plans G. Start s discharge planning at time of admission H. Schedule s a follow-up visit for aftercare within seven ( 7) days of discharge I. Provide s MAT or linkage to a prescriber for that service J. Ensures accessibility to all behavioral and physical health medication upon discharge . II. CareSource does not consider a residential program appropriate for the following members : A. M ember s needing intensive medical monitoring for severe or life threatening medical or physical condition s. B. Members unable to actively participate due to severe symptoms of co-existing mental or physical condit ions or severe withdrawal . Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 06/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.III. It is the responsibility of the facility to check member annual service usage to avoid a claim denial for no prior authorization. CareSource requires a prior authorization (PA) for the following: A. For the first and second admissions per calendar year, a p rior authorization is only required for an admission exceeding thirty (30) consecutive days. For example, a member goes into residential treatment for the first time in a calendar year for a period of ten days. No prior authorization is required. The sam e member goes into treatment for a second admission during the same calendar year for a period of 38 days. After day 30, the facility is required to obtain prior authorization for days 31 through 38. B. For any stay or admission exceeding two admissions per calendar year, a prior authorization is required from the first day of admission. The same member above admits for residential treatment for a third time during the same calendar year. A prior authorization for this admission is required , starting day one (1). C. Changes in level of care: 1. When step-up or step-down occur s between two SUD r esidential 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 is 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 first thirty ( 30 ) days of the first or second of the two ( 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) has exceeded thirty (30) days or this is the third or more event in a calendar year, then the step-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 two SUD residentia l facilities ( national provider identifiers (NPI) and/or tax identification 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 prior authorization for any reason, the transition admission will require that prior authorization be obtained by the receiving facility from the date of admission. 2. Same level of care admissions or transfers between two 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 two SUD residential facilitie s (NPIs and/or TINs) , the admission to the receiving facility is considered a separate Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 06/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.event and is subject to prior authoriza tion from the date of admission,beginning with the third admission in a calendar year and will accumulate as separate events . IV . DocumentationA. At least one documented face-to-face interaction must be performed by a clinical treatment team provider to the member at the SUD residential site in order to bill per diem . B. Member medical record s must show evidence of medical necessity of services and follow Ohio Administrative Code guidelines . C. The residential program has a written Affiliation Agreement , so members are connected and ensured access to outpatient care in a timely manner upon discharge , and has policies and procedures in place to monitor affiliations. V. Medical Necessity CriteriaCareSource follows The American Society of Addiction Medicine ( ASAM ) Criteria as required by the Ohio Department of Medicaid . VI. BillingA. Residential level of care admission : 1. One admission is considered one 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 hou rs are considered a termination of one admission. 4. Leaving the SUD residential treatment facility associated with significant changes in health status, such as leaving against medical advice, step-ups (including acute medical admissions) or step-downs in le vel of care, and/or incarceration are considered a termination of one 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 treatm ent plan, and the provider should continue to bill for treatment services during these times. Brief leave s of absence include but are not limite d to family visits, religious services, same day health services, and/or social support group attendance. B. The benefit follows the member, not the providers tax identification number . C. CareSource only 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 sequence from date of service may cause claims to deny inappropriately for no prior authorization . E. Claims are paid a s they are received. If a member receives services from more than one provider, claims are paid to providers who submit first, regardless of date of service. F. SUD residential is paid per diem . Per diem do es not include room and board costs and/or p ayments . Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 06/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.G. CareSource does not reimburse separately for services provided by the residential treatment service , including:1. Ongoing assessments and diagnostic evaluations 2. Crisis intervention 3. Individual, group, family psychotherapy and counseling 4. Case management 5. Substance use disorder peer recovery services 6. Urine drug screens 7. Medical services 8. Medication administration H. A member can only receive services through one 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 treatment f. Intensive home-based treatment 2. Select behavioral health services , including medication assisted treatment (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, if applicable. Please refer to the Behavioral Health Ohio fee schedule for appropriate codes. The inclusion of a code in this polic y does not imply any right to reimbursement or guarantee claims payment. F. Related Policies/RulesMedical Necessity Determinations Behavioral Health Documentation Standards G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2017Date Revised 05/15/2019 09/16/2020 12/28/202011/30/2021Updated definition, medical necessary criteria, and billing Updated definition, added note under D. I. Added D. I. C.; D.1. IV. A. 5 and IV. B. Added related policy. Revised D. IV. H. 2. Revised I. C. D. and E. Provided clarification of policy per ODM D. 1. C, D, and E; and D. IV. A. Removed codes from policy, u pdated definitions. Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 06/01/2023The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.H. References1. Centers for Medicare and Medicaid Services, Inpatient Psychiatric Facility PPS (2021, December 1). Retrieved December 28, 202 2 from www.cms.gov. 2. Ohio Administrative Code, 5160-27-01 , Eligible provider for behavioral health services. ( 20 21 , July 9). Retrieved December 28, 2022 from www.codes.ohio.gov . 3. Ohio Administrative Code, 5160-27-02 , Coverage and limitations of behavioral health services. (20 21 , July 1). Retrieved December 28, 2022 from www.codes.ohio.gov . 4. Ohio Administrative Code, 5160-27-09 , Substance use disorder treatment services . (2021, August 5). Retrieved December 28, 2022 from www. codes.ohio.gov . 5. Ohio Department of Medicaid. Medicaid Behavioral Health State Plan Services Provider Requirements and Reimbursement Manual. (202 2, December 19 ). Retrieved January 4, 2023 from www.bh.medicaid.ohio.gov . 6. Substance Abuse and Mental Health Services Administration, Medication Assisted Treatment (2021, December 16). Retrieved December 28, 2022 from www.samhsa.gov . 7. The ASAM Criteria: Treatment Criteria for Addictive, Subst ance-Related, and Co – Occurring Conditions , Third Edition. Retrieved December 28, 2022 from www.asam.org . 01/18/ /202 3 Annual review. Updated background. Added additional definitions. Date Effective 06/01/2023 Date Archived

Standard Medical Billing Guidance

Reimbursement Policy Statement: 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 – stan dard 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 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, dysfun ction 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. Med ically 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., Eviden ce 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 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 limitat ions that are less favorable than the limitations that apply to medical conditions as covered under this policy.REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Standard Medical Billing Guidance PY-PHARM-0125 – OH-MCD 07-22-2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. . 2 B. Background ………………………….. ………………………….. ………………………….. …………………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……………….. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ………. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ……. 4 H. References ………………………….. ………………………….. ………………………….. ……………………… 5 2 A. SubjectStandard Medical Billing Guidance Standard Billing Reimbursement Statement OHIO MEDICAID PY-PHARM-0125-OH-MCD Effective Date: 07-22-2022 B. BackgroundReimbursement policies are designed to assist you 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 their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submit ting provider to submit the most accurate and appropriate 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 reimbu rsement policy applies to all health care services reported using theCMS1500 Health Insurance Professional Claim Form (a/k/a HCFA), the CMS 1450 Health Insurance Institutional Claim Form (a/k/a UB04) or its electronic equivalent or any successor form. This policy applies to all products, all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Additionally, this policy applies to drugs and biologicals being used for FDA-approved indications or labels. Drugs and biologicals used for indications other than those in the approved labeling may be covered if it is determined that the u se is medically accepted, taking into consideration the major drug compendia, authoritative medical literatures and/or accepted standards of medical practice. C. Definitions Indication is defined as a diagnosis, illness, injury, syndrome, condition, or other clinical parameter for which a drug may be given. is defined as birth before 37 weeks of gestation. FDA approved Indication/Label is the official description of a drug product which includes indication (what the drug is used for); who should take it; adve rse events (side effects); instructions for uses in pregnancy, children, and other populations; and safety information for the patient. Labels are often found inside drug product packaging. Off-label/Unlabeled use of a drug is defined as a use for a non-FDA approved indication, that is, one that is not listed on the drugs official label/prescribing information. Off-label use is further defined as giving the drug in a way that deviates significantly from the labeled prescribing information for a particular indication. This includes but is not necessarily limited to, dosage, route of administration, duration and frequency of administration, and population to whom the drug would be administered. 3 Standard Billing Reimbursement StatementOHIO MEDICAID PY-PHARM-0125-OH-MCD Effective Date: 07-22-2022 Unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label. Drug compendia , defined as summaries of drug information that are compiled by experts who have reviewed clinical data on drugs. CMS (Center for Medicare and Medicaid Services) recognizes the following compendia: American Medical Association Drug Evaluations (AMA-DE), United States Pharmacopoeia-Drug Information (USP-DI) or its successor publication and American Hospital Formulary Service-Drug Information (AHFS-DI) as authoritative sources for use in the determination of a “medically-accepted indication” of drugs and biologicals used off – label in an anticancer chemotherap eutic regimen. The USP DI is a database of drug information developed by the U.S. Pharmacopoeia but maintained by Micromedex, which contains medically accepted uses for generic and brand name drug products D. PolicyCareSource requires that the use of a drug or biological must be safe and effective and otherwise reasonable and necessary. Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for indicat ions specified on the labeling. Therefore, reimbursement may be provided for the use of an FDA approved drug or biological, if: It was administered on or after the date of the FDAs approval; It is reasonable and necessary for the individual patient; and All other applicable coverage requirements are met. An unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on t he official label may be covered if it is determined that the use is medically necessary, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. The following guidelines identify three categories in which medications would not be reasonable and necessary according to accepted standards of medical practice. Not for Particular Illness Medications given for a purpose other than the treatment of a particular condition, illness, or injury are not covered (except for certain immunizations.) Route of Administration Not Indicated Medication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medication by mouth (orally ) is effective and is an accepted or preferred method of administration. Excessive Medications Medications administered for treatment of a disease which exceed the frequency or duration of dosing indicated by accepted standards of medical practice are no t covered. Effective January 1, 1994, off-label, medically accepted indications of Food and Drug Administration -(FDA) approved drugs and biologicals used in an anti-neoplastic chemotherapeutic regimen are identified under the indications described below. A 4 Standard Billing Reimbursement StatementOHIO MEDICAID PY-PHARM-0125-OH-MCD Effective Date: 07-22-2022 regimen is a combination of anti-neoplastic agents clinically recognized for the treatment of a specific type of cancer. Off-label, medically accepted indications are supported in either one or more of the compendia or in peer-reviewed medical literature. E. Conditions of CoverageA medically accepted indication is one of the following: An FDA approved, labeled indication or a use supported in the American Hospital Formulary Service Drug Information (AHFS-DI), NCCN Drugs and Biologics Compendium, Truven Health Analytics Micromedex Drug Dex , Elsevier/Gold Standard Clinical Pharmacology and Wolters Kluwer Lexi – Drugs as the ac ceptable compendia based on CMS’ Change Request 6191 (Compendia as Authoritative Sources for Use in the Determination of a “Medically Accepted Indication” of Drugs and Biologicals Used Off-Label in an Anti-Cancer Chemotherapeutic Regimen); or Articles of Local Coverage Determinations (LCDs) published by CMS. In general, a use is identified by a compendium as medically accepted if the: Indication is a Category 1 or 2A in NCCN, or Class I, Class IIa, or Class IIb in DrugDex; or, Narrative text in AHFS-DI or Clinical Pharmacology is supportive, or Indication is listed in Lexi-Drugs as Use: Off-Label and rated as Evidence Level A A use is not medically accepted by a compendium if the: Indication is a Category 3 in NCCN or a Class III in DrugDex; or, Narrative text in AHFS or Clinical Pharmacology is not supportive, or Indication is listed in Lexi-Drugs as Use: Unsupported If a use is identified as not indicated by CMS or the FDA, or if a use is specifically identified as not indicated in one or more of the compendia listed, or if it is determined, based on peer-reviewed medical literature, that a particular use of a drug is not safe and effective, the off-label use is not supported and the drug will not be co vered. F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate IssuedDate Revised Date Effective TBD Date Archived 5 Standard Billing Reimbursement StatementOHIO MEDICAID PY-PHARM-0125-OH-MCD Effective Date: 07-22-2022 1. Drugs@FDA Glossary of Terms https://www.fda.gov/drugs/drug-approvals-and-databases/drugsfda-glossary-terms 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals 3. United States Federal Food, Drug and Cosmetic Act https:/ /www.f da.gov/regulatory-information/laws – enforced-fda/federal-food-drug-and-cosmetic-act-fdc-act The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. H. References

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 r eferral, 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, illnes s, 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 provider. Medically necessary services also include those services defined in an y 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 05/01/2023-05/31/2024 Policy Type REIMBURSEMENT T able of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 6 F. Related Policies/Rules ……………………………………………………………………………………………. 6 G. Review/Revision History …………………………………………………………………………………………. 6 H. References …………………………………………………………………………………………………………… 7 Coordination of Benefits-OH MCD-PY-1412 Effective Date: 05/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A.Subject Coordination of Benefits B. Background The purpose of this guideline is to define the order of coverage and how CareSource will c oordinate benefit payments as the secondary payer. C. Definitions CareSource Provider Agreement The contract between provider and plan for t he pr ovision of services by provider to individuals enrolled with the plan, including but not limited to contracts titled Provider Agreement and Group Practice Service s A greement. 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 forCare Source members. Explanation of Payment (EOP) A detailed explanation of payment or denial of a c laim by an insurance carrier. Primary Carrier The insurance carrier that has been determined to be responsibl e f or primary payment. D. Policy I. Submitted claims must include 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 cover ed se rvices 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 al l services they provide before they submit their claims to CareSource.Any balance due after receipt of payment from the primary carrier should be s ubmitted to CareSource for consideration. The claim must include informati on v erifying the services billed and the payment amount received from the primary carrier. II. COB GuidelinesA. 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 whic h anot her carriers reimbursement amount is equal to or greater than the Medicai d c ontracted maximum allowable amount will be paid at zero. Claims that pay at zero are considered to be paid claims, not denied claims. Coordination of Benefits-OH MCD-PY-1412 Effective Date: 05/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 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 the CareSource 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 the CareSource allowed amount of $40.00 (lessor 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 primary allowed amount of $100.00 (lessor of the allowed amounts). Therefore, in this example, CareSource will pay $100.00. 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 the CareSource allowed amount of $125.00 (lessor of the allowed amounts). Therefore, in this example, CareSource will pay $115.00.Coordination of Benefits-OH MCD-PY-1412 Effective Date: 05/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. III. CareSource as Secondary Payer A. Following Medicar e reimbursement the remainder portion for Medicaid pays 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 b oth 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; and 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 they are, 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 us ing 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 pay 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 we have identi fied 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. Coordination of Benefits-OH MCD-PY-1412 Effective Date: 05/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 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 us 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: 1. PR1 Deductible 2. PR2 Coin surance 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 Coordination of Benefits-OH MCD-PY-1412 Effective Date: 05/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 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 1 8 m onths to the date of service. B. Denied COB claims will NOT be automatically adjusted if the updated cover age i nformation was received after 90 days from the denial for COB information. I n t his 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 ClaimsA. Disputes will NOT be automatically adjusted if the updated coverage informati on w as received after 90 days from the denial for COB information. In this case, t he pr ovider must request claim adjustment within the original timely filing period or within 90 days from the date of the EOP denial, whichever is greater. Altho ugh C areSource 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 w ill confirm whether or not the primary coverage was in effect duri ng t he 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 elaps ed, then we will process the claims that are within 90 days of t he or iginal 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 th e di spute 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 CP Tcodes along with appropriate modifiers, if applicable. Ple ase refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules NA G. Review/Revision History DATE ACTION Date Issued Not Set Date Revised Date Effective 05/01/2023 Date Archived 05/31/2024 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/ NCCI guidelines without a formal documented Policy. Coordination of Benefits-OH MCD-PY-1412 Effective Date: 05/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. H. References1. Ohio Administrative Code. Coordination of Benefits. Rule 5160-1-08. Retrieved November 22, 2022 from www.codes.ohio.gov. 2. Ohio Administrative Code. Managed health care programs: primary care and utilization management. Rule 5160-26-03.1. Retrieved November 22, 2022 from www.codes.ohio.gov. 3. Ohio Administrative Code. Payment for "Medicare Part B" cost sharing. Ohio Administrative Code Rule 5160-1-05.3. Retrieved November 21, 2022 from www. codes.ohio.gov. This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC.

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