REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Obstetrical Care Unbundled Cost PY-0004 01 /01 /2022 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 ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 7 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 8 Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 2 A. SubjectObstetrical Care Unbundled Cost 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.Obstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include care during the prenatal period, labor, birthing, and the postpartum period. CareSource cove rs obstetrical services members r e c e iv ein a h o s p it a l o r b ir t h in g c e n t e r a s we l l all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedu re Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating prov iders and facilities. This policy is for practitioners that meet either of the following: Obstetrical practitioners who are not part of a Free Standing Birthing Center;or Obstetrical practitioners who are part of a Free Standing Birthing Center when any of the following occur: o It is their preferred method of billing; o The member has a change of insurer during pregnancy ; o The member has received part of the antenatal care else where, e.g. from another group practice ; o The member leaves your group practice before the global obstetrical care is complete ; o The member must be referred to a provider from another group practice or a different licensure (e.g. midwife to MD) for a cesarea n delivery ; or o The member has an unattended precipitous delivery ; and o Termination of pregnancy without delivery (e.g. miscarriage, ectopic pregnancy) . Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 3 C. Definitions Freestanding birthing center (FBC) – Any facility in which deliveries routinely occur, regardless of whether the facility is located on the campus of another health care facility, and which is not licensed under Chapter 3711 of the revised code as a level one, two, or three maternity unit or a limited maternity unit . Prenatal profile – Initi al laboratory services. Initial and prenatal visit – Practitioner visit to determine member is pregnant Unbundled obstetrical care – The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. o Antepartum care – Is for basic care (including obtaining and updating subsequent medical history, physical examination, recording of vital signs, and routine chemical urinalysis) provided monthly up to 28 weeks gestation, biweekly therefore up to 36 weeks gestation, and weekly thereafter until delivery. o Delivery – Includes admission to facility, medical history during admission, physical examinations, management of labor (either vaginal delivery or by cesarean section). o Postpartum care – The period that, b egins on the last day of pregnancy and extends through the end of the month in which the 60 day period following termination of pregnancy ends. The American College of Obstetricians and Gynecologists (ACOG) recommends contact within the first 3 weeks post partum. High risk delivery – Labor management and delivery for an unstable or critically ill pregnant patient. Premature birth – Delivery before 39 weeks of pregnancy. Pregnancy – For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days or 40 weeks. D. Policy I. Obstetrical Care A. Initial Visit and Prenatal Profile 1. Evaluation and management (E/M) code s are utilized for t he initial visit , prenatal profile , and antepartum care. B. Risk Appraisal – Case Management Referral 1. Providers may complete the Pregnancy Risk Assessment Form (PRAF) and will be paid for the completion of the form a maximum of three times during the pregnancy. This form should be submitted one time during each trimester of pregnancy. Please use code H1000 on the associated claim to indicate that an assessment form was submitted. 2. Any eligible woman who meets any of the risk factors listed on the Pregnancy Risk Assessment Form (PRAF) is q ualified for case management services for pregnant women and should be referred to CareSource for further screening for those case management services. C. Unbundled Obstetric Care – The practitioner would bill antepartum care , delivery, and postpartum care independently of one another. 1. Antepartum care only do es not include delivery or postpartum care: a. Use the appropriate E/M code and trimester code(s) b. Use the appropriate modifier , if applicable Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 4 2. Delivery only Use if only a delive ry was performed a. Deliveries must be greater or equal to 20 weeks gestation to be billed as a delivery. b. Use the appropriate CPT and delivery outcome code(s): CPT Code Description59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery c. Services (This list may not be all inclusive) :Services included that may NOTbe billed separatelyServices excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or forceps Vaginal delivery after prior cesarean sectionPrevious cesarean delivery who present with expectation of vaginal deliverySuccessful vaginal delivery after previous cesarean deliveryCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean deliveryCesarean deliveryClassic cesarean section Low cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesiaArtificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as deliveryObstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 5 Delivery of placenta unless it occurs at a separate encounter from the deliveryMinor laceration repairsInpatient management after delivery/discharge services E/M services provided within 24 hours of delivery3. Delivery and postpartum care only If only delivery and postpartum care were provided a. Use the appropriate CPT and trimester code: CPT Code Description59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care b. Services included in the delivery only and postpartum care codes; and therefore are NOT allowed to be billed separately (This list may not be all inclusive): 01. Admission history 02. Admission to hospital 03. Artificial rupture of membranes 04. Care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 05. Hospital/office visits following cesarean section or vaginal delivery 06. Management of uncomplicated labor 07. Physical exam 08. Vaginal delivery with or without episiotomy or forceps 09. Caesarean delivery 10. Classic cesarean section 11. Low cesarean section 12. Successful vaginal delivery after previous cesarean delivery 13. Previous cesarean delivery who present with the expectation of a vaginal delivery 14. Caesarean delivery following unsucce ssful vaginal delivery attempt after previous cesarean delivery 4. Postpartum care only – If postpartum care only was provided:a. Use code 59430 postpartum care only. Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 6 b. Only one 59430 can be billed per pregnancy as this includes all E/M pregnancy rela ted visits provided for postpartum care.c. There is no specified number of visits included in the postpartum code. This includes h ospital and office visits following vaginal or cesarean section delivery. ACOG recommends contact within the first 3 weeks postpartum. d. Postpartum care may include; and therefore is not allowed to be billed separately for the following (This list may not be all inclusive) : 01. Office and outpatient visits following cesarean section or vaginal delivery; or 02. Qualified health care professional providing all or portion of antepartum/postpartum care, but no delivery due to referral to another physician for delivery or termination of pregnancy by abortion. e. The following are billable separately during the postpartum period (This list may not be all inclusive): 01. Conditions unrelated to pregnancy i.e. respiratory tract infection ; or 02. Treatment and management of co mplications during the postpartum period that require additional services . II. Member eligibilityA. If a member was not eligible for Medicaid for the 9 months before delivery, the practitioner must use the appropriate delivery only or delivery and postpartu m code to be reimbursed. Charges for hospital admission, history and physical or normal hospital evaluation and management services are not reimbursable. B. If a member becomes eligible for Medicaid due to a live birth, no prenatal services including laborat ory services are reimbursable . III. Multiple gestations.A. Include diagnosis code for multiple gestations . B. Modifier 51 should be added to the second and any subsequent vaginal births identifying multiple procedures were performed. C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 should be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. IV. High risk deliveriesA. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 Supervision of high-risk pregnancy. B. Modifier 22 should be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided . Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 7 E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual fee schedule for appropriate codes. The 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 E/M For antepartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59430 Postpartum care only. 59514 Cesarean delivery only 59515 Cesarean delivery only; including postpartum care 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care F. Related Policies/Rules Obstetrical Care Hospital Admissions MM-0897 Obstetrical Care Total Cost PY-0939 G. Review/Revision History DATE ACTIONDate Issued 06/10/2015Date Revised 10/18/2017 07/22/2020 09/15/2021Updated codes, templateNew title was Preferred Obstetrical Services; policy broken into two policies. Updated definitions, reorganize topics, removed total care information, updated most content and codes. Clarified who can bill unbundled charges . Revised antepartum language for clarity. Remov ed modifiers. Updated references. Approved at PGC. Date Effective 01/01/202 2 Date Archived Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 8 H. References1. The American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redefining the Postpartum Visit. Retrieved September 13, 2021 , from www.acog.org 2. American Medical Association. (1997, April). Global OB Codes: Reporting and Use. CPT Assistant . 3. American Medical Association (2015, January). Maternity Care and Delivery. CPT Assistant. 4. American Academy of Professional Coders. (2013, August 1). From Antepartum to Postpartum, Get the CPT OB Basics. Retrieved September 13, 2021 from www.aapc.com 5. Amer ican Academy of Professional Coders. (2011, December). Code Obstetrical Care with Confidence. Retrieved on September 13, 2021 from www.aapc.com 6. EncoderPro.com for Payers Professional. (2019) Retrieved September 13, 2021 , from www.encoderprofp.com 7. The Amer ican College of Obstetricians and Gynecologists. (n.d.). Coding for Postpartum Services (The 4 th Trimester). Retrieved September 13, 2021 , from www.acog.org 8. The American College of Obstetricians and Gynecologists. (n.d.). Reporting a Services with Modifier 22. Retrieved September 13, 2021 , from www.acog.org 9. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Schedu ling Induction of Labor. Retrieved September 13, 2021 , www.acog.org 10. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Planned Cesarean Delivery. Retrieved September 13, 2021 from www.acog.org 11. Americ an College of Obstetricians and Gynecologists . (2019 ), April Correct Coding Initiative Version 25.1. Retrieved September 13, 2021 from www.acog.org 12. American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Care. Retrieved Sept ember 13, 2021 , from www.acog.org 13. American College of Obstetricians and Gynecologists. (2019, January). Prete rm Labor and Birth. Retrieved A ugust 1, 2019 from www.acog.org 14. Ohio Administrative Code. (2017). 3701-4-01 Definitions . Retrieved September 13, 2021 , from www.codes.ohio.gov 15. Ohio Administrative Code. (2018). 5160-18-01 | Freestanding birth center services. Retrieved September 13, 2021 from www.codes.ohio.gov 16. Department of Ohio Medicaid. (2019, June). Modifiers Recognized by Ohio Medicaid. Retrie ved September 13, 2021 from www.medicaid.ohio.gov 17. Ohio Administrative Code. (2015). 5160-1-10 Limitations on Elective Obstetric Deliveries. Retrieved September 13, 2021 from www. codes.ohio.gov 18. Ohio Administrative Code. (2018). 4723-8-01 Definitions. Retrie ved September 13, 2021 from www. codes.ohio.gov 19. Ohio Administrative Code. (2019). 5160-26 Managed health care programs; definitions. Retrieved September 13, 2021 from www. codes.ohio.gov 20. Ohio Revised Code. (2012). 3702.141 Rules may apply to existing health care facility. Retrieved September 13, 2021 from www. codes.ohio.gov 21. Ohio Administrative Code. (2017). 5160-21-04 Reproductive health service s; pregnancy-related services. Retrieved September 13, 2021 from www. codes.ohio.gov Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 9 22. Ohio Revised Code (2017). 4723.4 3 Scope of specialized nursing services.Retrieved September 13, 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 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.
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