REIMBURSEMENT POL ICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Overpayment Recovery PY-1115 08/01/2021-07/31/2022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject …………………………………………………………………………………………………………….. 2 B. Bac k g r ou nd ………………………………………………………………………………………………………. 2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..3 E. Conditions of Co v er ag e ………………………………………………………………………………………..3 F. Related Policies/Rules …………………………………………………………………………………………. 5 G. Review/Revision His t or y ……………………………………………………………………………………….5 H. Ref er en ce s …………………………………………………………………………………………………………4 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding b illin g , coding a nd documentation guidelines. Coding methodology, regulatory requirements, indust ry-sta ndard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Po licy, Reimbursement of services is subject to member benefits a n d e lig ib ility on the date of service, me d ical necessity, adherence to pla n po licie s and procedures, cla ims editing lo gic, provider contractual agreement, an d applicable re f e rral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re not limite d 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, dysfunc t ion 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. Me d ica lly 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. Th is Po licy 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 t his Po licy 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 a ffilia te s ma y use reasonable discretion in interpreting and applying th is Policy to serv ice s 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), cov erage for the diagnosis and t re at me nt of a behavioral health disorder will not be subject to any limita tio n s that are less favorable than the limita tio n s that apply to medical conditions as covered under this policy.
REIMBURSEMENT POLICY STATEMENTOHIO M EDICAID Policy Name Policy Number Effective Date Payment of Out of Network Providers PY-134 3 08/15/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing lo gic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically 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 patien t 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 lowes t 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 Statem ents, 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 P olicy 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 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 ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Payment to Out of Network ProvidersOHIO MEDICAIDPY-1343 Effective Date: 08/15/2021 2 A. SubjectPayment to Out of Network Providers B. Background Reimbursement 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 esta blished 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 eligibilit y. 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 inclusion of a code in this policy does not imply any right to reimbursemen t 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 st andard 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 Medica id Fee schedule charges; and B. 60% of the Medica id Fee schedule for labs. C. If a service or procedure is not priced by Medicaid, then it will be reimbursed to the provider at 20% of billed charges. Payment to Out of Network ProvidersOHIO MEDICAIDPY-1343 Effective Date: 08/15/2021 3 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. III. Exclusions:A. Emergency Health Care Services will be reimbursed based on state regulations including but not limited to reimbursement o f all emergency services at the lessor of billed charges or 100% of the current Medicaid FFS rate. B. Negotiated reimbursement, including out of network (OON) hospital reimbursement, via Single Case Agreement. C. Provider types with reimbursement methodology mandated by state/federal regulation/statute or rule or directive including but not limited to Federally Qualified Health Centers/Rural Health Clinics and Title Xservices provided by Qualified Family Planning Providers. E. Condition s 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/Rules NA G. NA Review/Revision History DATE ACTIONDate Issued 07/02/2021 New policyDate Revised 09/29/2021 04/19/2022 Added III. B. for clarification. Approved at PGC. Updated D. III. Exclusions Date Effective 08/15/2021 Date Archived H. References 1. Rule 5160-26-01. Managed health care programs: definitions. (July 19, 2020). Ohio Laws and Administrative Rules. Retrieved 7/1/2021 from www. codes.ohio.gov . The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Chiropractic Care Spinal Manipulation PY-1328 10/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-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 co ntractual 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 diag nosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These service s 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 condition s as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Cov erage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Chiropractic Care Spinal ManipulationOH MEDICAIDPY-1328 Effective Date: 10/01/2021 2 A. SubjectChiropractic Care Spinal Manipulation B. Background Reimbursement 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 eligibi lity. 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 inclusion of a code in this policy does not imply any right to reimburse ment or guarantee claims payment.Chiropractic is a licensed healthcare profession where treatment typically involvesmanual therapy, often including spinal manipulation.C. Definitions Maintenance therapy A therapy that is performed to treat a chronic, stable condition or to prevent deterioration. Acute Subluxation Member is being treated for a new injury, defined by x-ray or physician exam which result s in an expected improvement in, or arre st of progression in the members condition. Rendering providers – A chiropractor or a mechanot herapist is eligible to provide spinal manipulation . Billing provider – A chiropractor, mechanotherapist, a profession medical group, a hospital or a fee-for-service clinic as noted by the Ohio Administrative Code . D. Policy I. CareSource follows the Ohio Administrative Code for payment of spinal manipulation . II. Payment may be made only for : A. The manual correction to correct a spin al subluxation ; B. A c ondition that is acute and episodic in nature. 1. When the maximum therapeutic benefit has been met, ongoing therapy is considered maintenance therapy and this is considered not medically necessary; and C. A subluxation of the spine that was determined by x-ray or physician exam. III. Payment may be made for the following services :A. Spinal manipulation. 1. Chiropractic manipulative treatment (CMT); spinal, one to two regions. Chiropractic Care Spinal ManipulationOH MEDICAIDPY-1328 Effective Date: 10/01/2021 3 2. Chiropractic manipulative treatment (CMT); spinal, three to four regions.3. Chiropractic manipulative treatment (CMT); spinal, five regions. B. Diag nostic imaging to determine the existence of a subluxation. 1. Spine, entire; survey study, anteroposterior and lateral. 2. Spine, cervical; anteroposterior and lateral. 3. Spine, cervical; anteroposterior and lateral; minimum of four views. 4. Spine, cervical; anteroposterior and lateral; complete, including oblique and flexion and/or extension studies. 5. Spine, thoracic; anteroposterior and lateral views. 6. Spine, thoracic; complete, with oblique views; minimum of four views. 7. Spine, thoracolumbar; anteroposterior a nd lateral views. 8. Spine, lumbosacral; anteroposterior and lateral views. 9. Spine, lumbosacral; complete, with oblique views. 10. Spine, lumbosacral; complete, including bending views. IV. A service performed must be medically necessary and related to the treatment of a specifi c medical complaint. A. To determine medical necessity, CareSource requires all of the following: 1. A primary diagnosis of subluxation a. Examples include lumbar and sac ral ; and 2. A secondary diagnosis that supports the treatment provided. a. Examples include osteoarthritis and congenial musculoskeletal deformities of the spine. B. The manual manipulation must have a direct therapeutic relationship to the members condition as documented in the medical record. The lack of documentation specifying the relationship between the members condition and treatment shall result in the service being ineligible for reimbursement. 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/Rules Medical Necessity Determinat ion Policy G. Review/Revision History DATE ACTIONDate Issued 05/2 6/2021Date Revised Date Effective 10/01/2021 Date Archived Chiropractic Care Spinal ManipulationOH MEDICAIDPY-1328 Effective Date: 10/01/2021 4 H. References1. Ohio Administrative Code. (2016, May, 8) 5160-8-11 Spinal manipulation and related diagnostic imaging services. Retrieved April 15, 2021 from www.codes.ohio.gov 2. The Association of Chiropractic Colleges. (n.d.). Chiropractic Paradigm/Scope & Practice. Retr ieved April 15, 2021 from www.chirocolleges.org The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date COVID-19 Vaccine Reimbursement PY-PHARM-0072 03/15/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement 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 Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. T his Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o 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 t o make the determination. C areSource 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. A ccording to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy . Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Archived COVID-19 Vaccine Reimbursement OHIO MEDICAID PY-PHARM-0072 Effective Date: 03/15/20212A. Subject COVID-19 Vaccine Reimbursement B. Background Reimbursement 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 submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 /NDC code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. The 2019 novel coronavirus, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes the disease known as coronavirus disease 2019 (COVID-19). The Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) for the following vaccines for the prevention of COVID-19: Pfizer-Bio NTech, Moderna, and Janssen as of February 2021. The Pfizer-BioNTech and Moderna vaccines are offered as a two-dose series. The Janssen vaccine is offered as a single-dose vaccine. The EUA allows the vaccines to be widely distributed in the United States. The Advisory Committee on Immunization Practices (ACIP) has issued interim recommendations for the use of Pfizer-BioNTech, Moderna, and Janssen COVID-19 vaccines for the prevention of CO VID-19 in the U.S. The interim recommendations are derived from the EUA of the vaccines, other data sources, general best practice guidelines for immunization, and expert opinion. The Centers of Medicare and Medicaid Services (CMS) and State Medicaid programs have released toolkits, guidance and bulletins on coverage and reimbursement. Additional considerations will be updated as additional information become available or if additional vaccine products are authorized. C. Policy This reimbursement policy outlines the reimbursement rates for COVID-19 vaccine and associated vaccine administration fees. Providers may bill CareSource through our standard claims processes. The following list(s) of codes is provided as a reference. This list may not be all inc lusive and is subject to updates. Archived COVID-19 Vaccine Reimbursement OHIO MEDICAID PY-PHARM-0072 Effective Date: 03/15/20213HCPCS CodeDescription Reimbursement 91300 SARSCOV2 VAC 30MCG/0.3ML IM (Pfizer-Biontech Covid-19 Vaccine) $0.0 0* 0001A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose (Pfizer-Biontech Covid-19 Vaccine Administration First Dose) $37.98 0002A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose (Pfizer-Biontech Covid-19 Vaccine Administration Second Dose) $37.98 91301 SARSCOV2 VAC 100MCG/0.5ML IM (Moderna Covid-19 Vaccine) $0.0 0* 0011A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose (Moderna Covid-19 Vaccine Administration First Dose) $37.98 0012A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose (Moderna Covid-19 Vaccine Administration Second Dose) $37.98 91303 SARSCOV2 VAC AD26 .5ML IM (Janssen Covid-19 Vaccine) $0.00* 0031A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5×10 10 viral particles/0.5mL dosage, single dose (Janssen Covid-19 Vaccine Administration) $37.98 Archived COVID-19 Vaccine Reimbursement OHIO MEDICAID PY-PHARM-0072 Effective Date: 03/15/20214*Providers should note that the vaccine is available at no charge to providers at this time. Therefore, CareSource will pay at zero until further notice. Providers are still ask to bill the vaccine codes for data collection purposes. Pharmacies should submit claims through their pharmacy claims platform through our pharmacy benefits manager, Express Scripts , utilizing appropriate NDC codes and POS National Council for Presription Drug Programs (NCPDP) codes for administration. Please visit the Express Scripts Pharmacist Resource Center for additional information. D. 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. E. Related Policies/Rules COVID-19 Vaccination Administrative Policy F. Review/Revision History DATE ACTIONDate Issued 12/18/2020 New policyDate Revised 03/03/2021 Policy revised to include information about Janssen COVID-19 vaccine. Reimbursement amoun ts updated. Date Effective 03/15/2021 Date Archived G. References 1. Centers for Medicare & Medicaid Services. Toolkit on COVID-19 Vaccine: Health Insurance Issuers and Medicare Advantage Plans. 2. Centers for Medicare & Medicaid Services. Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost Sharing under Medicaid, the Childrens Health Insurance Program, and Basic Health Program . 3. Ohio Department of Medicaid. COVID-19 Vaccine Administration Billing Guidelines. The Reimbursement Policy Statement detai led above has r eceived due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date COVID-19 Vaccine Reimbursement PY-PHARM-0072 12/18/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement 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 Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. T his Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o 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 t o make the determination. C areSource 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. A ccording to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy . Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Archived COVID-19 Vaccine Reimbursement OHIO MEDICAID PY-PHARM-0072 Effective Date: 12/18/20202A. Subject COVID-19 Vaccine Reimbursement B. Background Reimbursement 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 submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 /NDC code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. The 2019 novel coronavirus, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes the disease known as coronavirus disease 2019 (COVID-19). The Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) for two vaccines for the prevention of COVID-19: Pfizer-BioTech and Moderna as of December 2020. Both vaccines are offered as a two-dose series. The EUA allows the vaccines to be widely distributed in the United States. The Advisory Committee on Immunization Practices (ACIP) has issued interim recommendations for the use of Pfizer-BioNTech and Moderna COVID-19 vaccines for the prevention of COVID-19 in the U.S. The interim recommendations are derived from the EUA of the vaccines, other data sources, general best practice guidelines for immunization, and expert opinion. The Centers of Medicare and Medicaid Services (CMS) and State Medicaid programs have released toolkits, guidance and bulletins on coverage and reimbursement. Additional considerations will be updated as additional information become available or if additional vaccine products are authorized. C. Policy This reimbursement policy outlines the reimbursement rates for COVID-19 vaccine and associated vaccine administration fees. Providers may bill Ca reSource through our standard claims processes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Archived COVID-19 Vaccine Reimbursement OHIO MEDICAID PY-PHARM-0072 Effective Date: 12/18/20203HCPCS CodeDescription Reimbursement 91300 SARSCOV2 VAC 30MCG/0.3ML IM (Pfizer-Biontech Covid-19 Vaccine) $0.0 0* 0001A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose (Pfizer-Biontech Covid-19 Vaccine Administration First Dose) $16.94 0002A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose (Pfizer-Biontech Covid-19 Vaccine Administration Second Dose) $28.39 91301 SARSCOV2 VAC 100MCG/0.5ML IM (Moderna Covid-19 Vaccine) $0.0 0* 0011A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosag e; first dose (Moderna Covid-19 Vaccine Administration First Dose) $16.94 0012A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, sp ike protein, preservative free, 100 mcg/0.5mL dosage; second dose (Moderna Covid-19 Vaccine Administration Second Dose) $28.39 *Providers should note that the vaccine is available at no charge to providers at this time. Therefore, CareSource will pay at zero until further notice. Providers are still ask to bill the vaccine codes for data collection purposes. Pharmacies should submit claims through their pharmacy claims platform through our pharmacy benefits manager, Express Scripts , utilizing appropriate NDC codes and POS National Council for Presription Drug Programs (NCPDP) codes for administration. Please visit the Express Scripts Pharmacist Resource Center for additional information. Archived COVID-19 Vaccine Reimbursement OHIO MEDICAID PY-PHARM-0072 Effective Date: 12/18/20204D. 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. E. Related Policies/Rules COVID-19 Vaccination Administrative Policy F. Review/Revision History DATE ACTIONDate Issued 12/18/2020 New policyDate Revised Date Effective 12/18/2020 Date Archived G. References 1. Centers for Medicare & Medicaid Services. Toolkit on COVID-19 Vaccine: Health Insurance Issuers and Medicare Advantage Plans. 2. Centers for Medicare & Medicaid Services. Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost Sharing under Medicaid, the Childrens Health Insurance Program, and Basic Health Program . 3. Ohio Department of Medicaid. COVID-19 Vaccine Administration Billing Guidelines. The Reimbursement Policy Statement detai led above has r eceived due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment Policy Subject: Free Standing Ambulatory Surgical Centers Claims for CPT Code 41899 Po l i c y CareSource will reimburse qualified free standing Ambulatory Surgical Centers at the case rate for medically necessary procedures which have no specific, listed CPT code, and which are submitted to CareSource under CPT Code 41899. De f i n i t i o n s Free Standing Ambulatory Surgical Center (ASC ) means any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission. The entity must have an agreement with CMS to par ticipate in Medicare as an ASC, and must meet the conditions set forth( From 42 CFR 416.2 Definitions) Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Unlisted Procedure Code means a medical service or procedure for which there is no specific Current Procedural Terminology. Because of advances in the field of medicine, there may be services or procedures performed by health care professionals that have not yet been designated with a specific CPT code. To report these unlisted procedures or services, a number of specific code numbers have been designated. Each of these unlisted procedure code numbers relates to a specific section of the CPT codebook and is referenced in the guidelines of that section. Unlisted codes provide the means of reporting and tracking services and proce dures until a more specific code is established in the CPT code set. When a provide r is unable to find a specific CPT code for a particular procedure, the provider may identify the service with an unlisted procedure code.(From ama-assn.org) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s The available dental CPT codes are extremely limited. Because of this, the unlisted dental procedure code of 41899 is used for dental diagnostic and/or preventive procedures, dental restorations of fillings, tooth replacements, endodontic procedures such as root canals, and many other dental procedures when performed in an ambulatory center setting. CareSource is establishing this payment policy for its providers in the absence of corresponding reimbursement guidance from its member states. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 CareSource will reimburse ASC providers at the case rate of $1,100.00 for the CPT code 41899, for one unit per member per day. Prior authorization may be required. However, for each claim the provider must retain detailed documentation including a surgical report and medical record with complete descriptions of the unlisted dental procedures performed and resources used in case an audit is necessary. Re l a t e d Po l i c i es & Re f e r e n c e s Unlisted Non-Dental Procedure Codes Study , Permedion for ODJFS, 2010 ( http://permedion.com/ASSETS/5B27856B4A214912865F46783E7BE130/Unl isted%20Procs%20Report-%20Non%20Dental.pdf .) OAC 5160-2-03 General Provisions: Hospital services, Conditions and Limitations St a t e Ex c e p t i o n s NONE Do c u m e n t Hi s t o r y 10/31/2013OAC Rule renumbered from 5101:3-2-03, per Legislative Service Commission Guidelines. Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment Policy Subject: Corneal Tissue Replacement at Free-standing Surgical Centers Policy CareSource will reimburse free-standing surgical c enters for functional corneal surgery. Corneal tissue will be reimbursed at invoice plus 10%. Definitions Corneal transplant , also known as keratoplasty, is the replacement of the cornea of a patient’s damaged eye. Provider Reimbursement Guidelines Corneal tissue replacement will be reimbursed if for functional and not cosmetic purposes. Medicare only pays for the surgical correction of astigmatism when the astigmatism has been surgically induced or resulted from ocular trauma . P rior Authorization CareSource will reimburse f ree-standing surgical centers for corneal tissue transplants when medically necessary without prior authorization when from a participating provider . Corneal tissue replacement procedures from a non-participating provider must be prior authorized. R eimbursement CareSource will perform a manual review in order to determine pricing for claims which have been billed with the corneal tissue acquisition on a Surgical Center claim. To facilitate the review process, the provider must submit specific documentation, i.e. invoice, in order for CareSource to determine the appropriate amount for reimbursement. The provider must submit a copy of the operative report and a copy of the invoice from the eye bank or organ procurement organization showing the actual cost of acquiring the tissue.Upon receiving the requested documentation, payment will be based on invoice cost + 10%.If the claim is received without the requested documentation, the reimbursement will be based on the ASC grouped rate.The cost associated with corneal tissue acquisition, HCPCS code V2785 [ Processing, preserving, and transporting corneal tissue ] is separately reimbursable from the Ambulatory Surgery Center (ASC) rate for outpatient corneal transplant procedures. Related Policies & References Medicare Claims Processing Manual-Chapter 4-Part BHospital 200.1-Billing for Corneal Tissue 907 KAR 1:350. Coverage and payments for organ transplants Archived This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 State Exceptions NONE Document Revision History Archived
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Da te Acupuncture Services PY-0152 04/01/2021-0 9/ 30 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………. 2 B. Bac k g r ou nd ………………………………………………………………………………………………… 2 C. Def initions …………………………………………………………………………………………………… 2 D. Policy ………………………………………………………………………………………………………… 2 E. Conditions of Co ve r age …………………………………………………………………………………. 3 F. Related Policies/Rules …………………………………………………………………………………… 4 G. Review/Revision History ………………………………………………………………………………… 4 H. Ref er en ce s …………………………………………………………………………………………………. 4Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding b illin g , coding a nd 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 p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable re f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of dis ease, 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 lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Ev idence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f erre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy 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 a ffilia te s ma y use reasonable discretion in interpreting and applying t his Po licy 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 limita tio n s t h at a re le ss favorable than the limita tio n s t h at apply to medical conditions as covered under this policy.2 Ac up un c ture Services OHIO MEDICAID PY-0152 Effec ti v e Date: 04/01/2021A. Subjec t Acupuncture Services B. Bac k groundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies ar e 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 ac t u al services provided to a member an d will be determined when the claim is received f or processing. Health care pr oviders and their of f ice staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the mo st ac c u r at e and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service t h at is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Acupuncture is an ancient Chinese method of treatment based on the theory that stimulation of specif ic key points on or near the skin by the insertion of needles or by other methods improves v it al energy flow, the term acupuncture describes a v ar ie t y of methods and styles to stimulate specif ic anatomic points in the body. Acupuncture is used to relieve pain, to induce surgical anesthesia, or f or therapeutic purposes. It is considered an alternative treatment and an adjunct to standard treatmentC. Def initio nsAcupuncturist-is an individual who holds at le as t a valid certif icate to practice as an acupuncturist or a valid certif icate to practice as an oriental medicine practitioner. Chiropractor-is a chiropractor who holds a certif icate to practice acupuncture issued by state chiropractic board. Other Individual Medicaid Provider-is a physician assistant or an advanced registered nurse practitioner that has a valid certif icate as an acupuncturist Physician-is a physician t h at h as completed medical t raining in acupuncture with a current and active designation, or an equivalent designation f rom the national certif ication commission f or acupuncture and oriental medicine. D. Polic yI. CareSource reimburses for acupuncture services ac c o r d ing to the criteria f ound in Ohio Administrative Code (OAC) 5160-8-5 1. 3 Ac up un c ture Services OHIO MEDICAID PY-0152 Effec ti v e Date: 04/01/2021II. CareSource does not require p r ior authorization f or acupuncture services f or the f i r s t 30 visits per calendar year f or participating providers. III. In accordance with OAC 5160-8-51, acupuncture services ar e only reimbursable f or the f ollowing conditions: A. Migraines B. Low b ac k p ain C. Cervical (neck) p ain D. Shoulder p ain E. Osteoarthritis hip F. Osteoarthritis of knee G. Acute post-operative p ain H. Acute nausea an d vomiting (pregnancy an d chemotherapy-r elat e d , not inp at ie nt )IV. Participating providers mu st be one of the following: A. A physician t h at h as completed medical training in an acupuncture with a current and active designation, or an equivalent designation f rom the national certif ication commission f or acupuncture and oriental medicine. B. A chiropractor with a valid certif icate to practice ac u p u nc t ur e. C. Other individual Medicaid provider, including an advanced practice registered nurse or a physician assistant with a valid certif icate as an acupuncturist. V. Limitations: A. No separate reimbursement will be made f or both an evaluation and management service an d an acupuncture service performed by the s ame provider to the same individual on the same day. B. No separate reimbursement will be made f or services that are an incidenta l p ar t of a visit (such as but not limited to providing instruction on breathing techniques, diet or exercise). C. No reimbursement will be mad e f or additional treatment af t e r an initial treatment period if any of the f ollowing occur; 1. Symp t o ms show no evidence of clinical improvement af t e r an initial treatment period or2. Symp t o ms worsen over a course of t r eat me n t. NOTE: Although CareSource does n ot require a prior authorization f or the f irst 30 visits f or 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 Cov erageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Ple as e ref er to the individual f ee schedule f or appropriate codes. 4 Ac up un c ture Services OHIO MEDICAID PY-0152 Effec ti v e Date: 04/01/2021The 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 mo r e 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 f or primary procedure) 97813 Acupuncture, 1 or mo r e needles with electrical stimulation, initial 15 minutes of personal one on one contact with patient 97814 Acupuncture, 1 or mo r e needles with electrical stimulation, e ac h addition 15 minutes of personal one on one contact with the patient, with re-insertion of needle (s) (List separately in addition f or primary procedure). F. Related Polic ies/RulesG. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 10/31/2013 New Po licyDate Revised 10/31/2013, 06/06/2016,04/30/2020 New Allo wed Services Date Effecti ve 04/01/2021 Date Archived 09/30/2022 This Po licy is no lo nger ac tiv e and has been arc hiv ed . Please no te that there c ould be o ther Po lic ies that may hav e s ome of the s ame rules inc o rp orated and CareSource res erves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Polic y. H. Ref erenc es1. Ap p endix DD to rule 5160-1-60. (2015, January) Retriev ed 04/02/2020 f ro m www.med icaid.ohio.gov 2. Lawriter-OAC-5160-8-51 Ac up uncture serv ices. (2018, January ). Retrieved 04/02/2020 f ro m www.codes.ohio.gov/oac 3. Lawriter-ORC. Retriev ed 04/02/2020 from www.codes.ohio.gov/orc The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Respiratory Virus PY-0451 01 /01 /2021-06/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement 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 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 lowes t 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 Statem ents, 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. Table of Contents Reimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………… 3 F. Related Policies/Rules …………………………………………………………………………………………….. 3 G. Review/Revision History ………………………………………………………………………………………….. 3 H. References ……………………………………………………………………………………………………………. 3 Molecular Diagnostic Testing for Respiratory Virus OHIO MEDICAID PY-0 451 Effective Date: 01/01/20212A. Subject Molecular Diagnostic Testing for Respiratory Virus B. Background Reimbursement 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 submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusi on of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropri ate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Molecular Diagnostic testing for the respiratory viruses known as Adenovirus, Influenza Virus, Coronavirus, Metapneumovirus, Parainfluenza Virus, Respiratory Syncytial Virus (RSV) and Rhinovirus can be utilized in the presence of symptoms such as cough, fever, headache, fatigue, rhinorrhea, pharyngitis and a general unwell feeling, that would create a clinical picture of a respiratory virus. Molecular Diagnostic testing for respiratory viruses is not indicated for every patient that presents with these signs and symptoms, as treatment is generally the same for all of the viruses and resolve with little to no pharmacological treatment, except in immunocompromised patients. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – A genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) . Molecular Diagnostic Testing for Respiratory Virus OHIO MEDICAID PY-0 451 Effective Date: 01/01/20213D. Policy I. Prior a uthorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. A. Documentation must be submitted with the prior authorization indicating that the lower cost test was performed and a negative result was confirmed. II. Conventional testing, such as rapid antigen direct tests, direct fluorescent antibody testing and cultures, are viewed as low cost and must be utilized before the higher cost Molecular Diagnostic Testing by PCR. 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. F. Related Policies/Rules G. Review/Revision History DATE ACTIONDate Issued 12/01/2018Date Revised 12/02/2020 Updated the prior authorization requirement. Removed CPT and ICD-10 codes. Updated definitions and references. Date Effective 01/01/2021 Date Archived 06/30/2021 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 Polic y. H. References 1. NREVSS | Home | National Respiratory and Enteric Virus Surv System | CDC (2020, November 1 9). Retrieved 11/20/ 2020 from www.cdc.gov 2 . Polymerase Chain Reaction (PCR) (2017, November 09). Retrieved 11/20/2020 from www.ncbi.nlm.nih.gov . The Reimbursement Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the ReimbursementP olic y Sta te m ent Polic y a nd i s a pp ro ved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Gastrointestinal Illness PY-04 48 01/01 /2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, indust ry-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 not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment o f disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical 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 mand ate, 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 (ofte n 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 doc ument 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 und er this policy.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 ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Molecular Diagnostic Testing for Gastrointestinal IllnessOHIO MEDICAIDPY-0448 Effective Date: 01/01/2021 2 A. SubjectMolecular Diagnostic Testing for Gastrointestinal Illness B. Background Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requir es small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Gastrointestinal illness, as addressed in this policy, include Clostridium difficile, E. Coli, Salmonella, Shigella, Norovirus and Giardia. These infection and illnesses of the intestine can cause symptoms such a s diarrhea, nausea, vomiting and abdominalcramping. There are three basic modes of transmission: in food, in water and person to person. While some of these illnesses will resolve on their own, others can spread throughout the body and require treatment t o prevent a more devastating illness.All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvemen t Amendments of 1988 (CLIA). Waived testsinclude test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, t his does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – A genetic amp lification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary – Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. Policy I. Prior Authorization is required for the Molecular Diagnostic Testing by PCR ad dressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for the follow ing gastrointestinal illnesses:A. Salmonella B. Shigella C. Norovirus Molecular Diagnostic Testing for Gastrointestinal IllnessOHIO MEDICAIDPY-0448 Effective Date: 01/01/2021 3 D. GiardiaIII. Conventional testing, such as stool and saliva samples , for these illnesses is viewed as low cost . No t all cases of acute diarrhea are indicative of these illnesses, therefore, institutions should utilize conventional testing first, before using the higher cost Molecular Testing by PCR . 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/Rules N/A G. Review/Revision History DATE ACTIONDate Issued 12/01/2018Date Revised 11/07/2018 10/28/2020 Updated the prior authorization requirement. Removed CPT and ICD-10 codes.Date Effective 01/01/2021Date Archived H. References 1. Multiplexed Molecular Diagnostics for Respiratory, Gastrointestinal, and Central Nervous System Infections. (2016, July 20 ). Retrieved 10/26/2020 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5091344/ . The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
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