Payment to Out of Network Providers

REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Payment to Out of Network Providers-OH MCD-PY-1343 04/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy 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 A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Payment to Out of Network Providers-OH MCD-P Y-1343 Effective Date: 04/01/2026 The REIMBURSEMENT Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the REIMBURSEMENT Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 2 A. SubjectPayment to Out of Network ProvidersB. BackgroundReimbursement policies are designed to assist providers when submitting claims toCareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office sta ff are encouraged to use self-service channels to verify members eligibility.It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.This policy is intended to define the reimbursement rate for claims received from providers who are not contracted (out of network) providers with CareSource.C. DefinitionsEmergency 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 resu lt in o p lacing the h ealth of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy o s erious impairment to bodily functions o s erious dysfunction of any bodily organ or partOut of Network Provider A non-participating provider that is not contracted withCareSource.D. PolicyCareSources standard procedure is to start at a 60% reimbursement rate for all out of network providers which includes the following :I. Preauthorized, medically necessary services rendered to CareSource members by out-of-network providers will be reimbursed atA. 60% of the Ohio Medicaid Fee schedule chargesB. 60% of the Ohio Medicaid Fee schedule for labsC. If a service or procedure is not priced by the Ohio Department of Medicaid fee schedule , then it will be reimbursed to the provider at 20% of billed charges. Payment to Out of Network Providers-OH MCD-P Y-1343 Effective Date: 04/01/2026 The REIMBURSEMENT Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the REIMBURSEMENT Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 3 II. Out-of-network providers have the option to negotiate a different rate than stated above.I II . Exclusions /Exceptions are reimbursed at 100% of the current FFS Medicaid rateA. Emergency health care services will be reimbursed based on state regulations.B. Provider types with reimbursement methodology mandated by state/federal regulation/statute or rule or directive.C. hospital referralsD. providers during transitions, andE. qualified family planning providers.IV. In the event of any conflict between this policy and any written agreement between the provider and CareSource, the written agreement will be the governing document.E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers , if applicable . Please refer to the individual f ee schedule for appropriate codes.F. Related Policies/RulesNAG. Review/Revision HistoryDATE ACTION Date Issued 07/02/2021 New policy Date Revised 09/29/2021 04/12/2023 01/31/2 024 11/19/2025 Added III. B. for clarification. Approved at PGC. Removed links from policy. Updated reference. Approved at Committee. Annua l review. Updated reference. Approved at Committee. Periodic review. Updated D.I.II.III and references. Approved at Committee. Date Effective 04/01/2026 Date Archived H. Ref erences1. Managed Care: Definitions, OHIO A DMIN . CODE 5160-26-01 (2022).Approved by ODM 01/05/2026

Obstetrical Care Unbundled Cost

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Obstetrical Care Unbundled Cost-OH MCD-PY-0004 04/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy 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 ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………… 2 B. Background ………………………….. ………………………….. ………………………….. ………………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 8 H. References ………………………….. ………………………….. ………………………….. …………………… 8 Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectObstetrical Care-Unbundled Cost B. BackgroundObstetrical care refers to health care treatment given in relation to pregnancy and delivery of a newborn child. This include s care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members receive in a hospital or birthing center , as well as 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 qualified provider . Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. This policy is for practitioners meet ing either of the following: Obstetrical practitioners who are not part of a free standing birthing center . Obstetrical practitioners part of a free standing birthing center when any of the following occur: o Unbundled obstetrical care is the preferred method of billing . o The member has a change of insurer during pregnancy . o The member received part of the antenatal care elsewhere (eg , from another group practice ). o The member leaves the practitioners 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 (eg , midwife to medical doctor) for a cesarean delivery . o The member has an unattended precipitous delivery . o Termination of pregnancy without delivery occurred (eg , miscarriage, ectopic pregnancy) . C. Definitions Initial and Prenatal Visit A practitioner visit to determine whether a member is pregnant. Freestanding Birthing Center (FBC) Freestanding facilities that are not considered hospitals , provid ing peripartum care for low-risk women with uncomplicated , singleton term vertex pregnancies expected to have an uncomplicated birth . High Risk Delivery Labor management and delivery for an unstable or critically ill pregnant patient. 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. Premature Birth Delivery before 37 weeks of pregnancy is completed. Prenatal Profile Initial laboratory services. Unbundled Obstetrical Care The practitioner bil ls delivery, antepartum care, and postpartum care independently. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 o Antepartum Care Basic care (eg, obtaining and updating subsequent medical history, physical examination, recording of vital signs, and routine chemical urinalysis provided monthly up to 28 weeks gestation, biweekly there after up to 36 weeks gestation, and weekly thereafter until delivery. o Delivery Admission to a facility, medical history during admission, physical examinations, and management of labor (either by vaginal delivery or by cesarean section). o Postpartum Care The time period that begins 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. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile – Evaluation and management (E/M) codes 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. Providers are encouraged to submit a PRAF any time there is a change in condition during the pregnancy. Please use code H1000 and append modifier 33 on the associated claim to indicate that an assessment for m was submitted. 2. Any eligible woman who meets any of the risk factors listed on the Pregnancy Risk Assessment Form (PRAF) is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those case management services. NOTE : CareSource follows the Ohio Department of Medicaid (ODM) guidanceregarding PRAF and can be submitted during any pregnancy stage according to ODM . Beginning 4/1/2025 ODM will allow PRAF submissions for postpartum care . C. Unbundled Obstetric Care – The practitioner w ill 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 . 2. Delivery only – Use if only a delivery 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 Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 c. Services (This list may not be all inclusive):Services included that may NO Tbe billed separately Services 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 anesthesia Artificial rupturing of membranes prior to delivery Insertion of a cervical dilatorDelivery of placenta Minor laceration repairs Inpatient 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: 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 CPT Code Description Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 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 member who present s with the expectation of a vaginal delivery 14. caesarean delivery following unsuccessful vaginal delivery attempt after previous cesarean delivery 4. Postpartum care only If postpartum care only was provided a. Use code 59430 postpartum care only. b. Only one code 59430 can be billed per pregnancy as this includes all E/M pregnancy related 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 (not an all inclusive list ): 01. office and outpatient visits following cesarean section or vaginal delivery 02. qualified health care professional providing all or a 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 (list may not be all inclusive): 59410 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 Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 01. conditions unrelated to pregnancy (eg , respiratory tract infection )02. treatment and management of complications 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 postpartum 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 laboratory services , are reimbursable. III. Multiple GestationsA. 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 may 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. IV. High Risk Pregnancy and DeliveryA. 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 may 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. E. Conditions of CoverageIn the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. The inclusion of a cod e in this policy does not imply any right to reimbursement or guarantee of claimspayment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify a members eligibility. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 Submission of claims for reimbursement will serve as the providers certification of medical necessity for these services. Proper billing and submission guidelines must be followed, including the use of industry standard, compliant codes on all claims subm issions. Services should be billed using Current Procedure Terminology (CPT)codes, Healthcare Common Procedure 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 providers and facilities Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individualfee schedule for appropriate codes .The following list of codes is provided as a reference. This list may not be all inclusive and is subject to updates.CPT Code DescriptionUse E/M codes 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/RulesObstetrical Care-Hospital Admissions Obstetrical Care-Total Cost for Freestanding Birthing Centers Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 G. Review/Revision History DATE ACTIONDate Issued 06/10/2015Date Revised 10/18/2017 07/22/2020 09/15/202110/10/202210/11 /202311/20/202401/15/202512/17 /2025Updated codes, template New 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 Committee. Annual review. Updated references. Approved at Committee. Updated D.I.B.1. Approved at Committee. Updated D.I.C.2, conditions of coverage, and references. Approved at Committee. Date Effective 04/01/2026 Date Archived H. References1. ACOG Committee Opinion no. 579: definition of term pregnancy. Obstet Gynecol . 2013; 122(5):e1139-e1140. Reaffirmed 2025. doi:10.1097/01.AOG.0000437385.88715.4a 2. ACOG Committee Opinion no. 736: optimizing postpartum care. Obstet Gynecol .. 2018;131(5):e140-e150. Reaffirmed 2025. doi:10.1097/AOG.0000000000002633 3. ACOG Committee Opinion no. 761: cesarean delivery on maternal request. Obstet Gynecol . 2019;133(1)e73-e77. Reaffirmed 2024. doi:10.1097/AOG.0000000000003006 4. American Academy of Professional Coders. Code obstetrical care with confidence. December 1, 2011. Accessed November 12, 2025 . www.aapc.com 5. American College of Obstetricians and Gynecologists. Billing for care after the initial outpatient postpartum visit: the fourth trimester. Accessed November 12, 2025 . www.acog.org 6. American College of Obstetricians and Gynecologists. Preterm labor and birth. Updated April 2023. Accessed November 12, 2025 . www.acog.org 7. Freestanding Birth Center Services, OHIO ADMIN . CODE 5160-18-01 (2023). 8. Limitations on Elective Obstetric Deliveries, OHIO ADMIN . CODE 5160-1-10 (2015). 9. Managed Care: Definitions, OHIO ADMIN . CODE 5160-26-01 (2022). 10. Medically Indicated Late-Preterm and Early-Term Deliveries . American College of Obstetricians and Gynecologists; 2024 . Committee Opinion No. 831. Accessed November 12, 2025 . www.acog.org Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.9 11. Modifiers Recognized by Ohio Medicaid . Ohio Dept of Medicaid; 2011. RevisedNovember 3, 2025 . Accessed November 12, 2025 . www.medicaid.ohio.gov 12. Pregnant Women Eligible for Extended Coverage, 42 C .F.R. 436.122 ( 2024 ). 13. Reproductive Health Services: Pregnancy-Related Services, OHIO ADMIN . CODE 5160-21-04 ( 2025 ). 14. Reardon CC, Chen F. Critical illness during pregnancy and the peripartum period. UpToDate. Updated December 5, 2024. Accessed November 17, 2025. www.uptodate.com 15. Scope of Specialized Nursing Services, OHIO REV . CODE 4723.43 (2020). Approved by ODM on 01/ 12/2026

Coordination of Benefits

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Coordination of Benefits-OH MCD-PY-1412 03/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy 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 ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. …………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………….. ……… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. ………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ………………… 7 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………………. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………………. 7 H. References ………………………….. ………………………….. ………………………….. ………………………….. ………. 7 Coordination of Benefits-OH MCD-PY-1412Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectCoordination of Benefits B. BackgroundFederal regulations require that all identifiable financial resources be utilized prior to the expenditure of Medicaid funds for most health care services provided to Medicaid beneficiaries. Coordination of benefits (COB) is the method used to designate th e order in which multiple carriers are responsible for benefit payments, which prevents duplication of payments. Providers must utilize other payment sources to the fullest extent prior to filing a claim with CareSource. The terms “third party liability” and “other insurance” are used interchangeably to mean any source, other than Medicaid, that has a financial oblig ationfor health care coverage. If other insurance resources are not exhausted and the provider was aware of other insurance coverage, billing Medicaid may be considered fraud under the False Claim Act.The purpose of this policy is to define the order of coverage and how CareSource willcoordinate benefit payments as the secondary payer.C. Definitions CareSource Provider Agreement The contract between a provider and CareSource for the provision of services by the provider to individuals enrolled with the plan, including but not limited to contracts titled Provider Agreement and Group Practice Services Agreement. Coordination of Benefits (COB) The process of determining which health plan or insurance policy will pay first and/or determining the payment obligations of each health plan, medical insurance policy, or third-party resource when 2 or more health plans, insurance policies , or third-party resources cover the same benefits for CareSource members . Explanation of Payment (EOP) A detailed explanation of payment or denial of a claim by an insurance carrier. Primary Carrier The insurance carrier that has been determined to be responsible for primary paymen t. D. PolicyI. Submitted claims must include the total amount billed, total amount paid by the primary carrier, and balance due, along with a valid provider signature. Any balance due after receipt of payment from the primary carrier should be submitted to CareSource for consideration , and the claim must include information verifying the payment amount received from the primary plan. CareSource shall coordinate payment for covered services in accordance with the terms of a members benefit plan, applicable state and federal laws, and applicable Centers for Medicare & Medicaid Services (CMS) guidance. If CareSource is not the primary carrier, Coordination of Benefits-OH MCD-PY-1412Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 providers shall bill the primary carrier for all services provide d before submi tting claims to CareSource. II. COB GuidelinesA. When CareSource coordinates benefits with the primary carrier, reimbursement will be made according to the Medicaid contracted maximum allowable minus any payment made by the primary carrier. Any items or services for which another carriers reimbursement amount is equal to or greater than the Medicaid contracted maximum allowable amount will be paid at zero. Claims that pay at zero are considered to be paid claims, not denied claims. B. When the payment from another insurance carrier is less than the Medicaid contracted amount, CareSource will pay up to the Medicaid contracted total allowed amount. The sum of the payments will not exceed the Medicaid contracted maximum allowable amount (a s indicated in the CareSource Provider Agreement ). Example 1: Charged amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $50.00 $10.00 $0 $0 $40.00 CareSource $35.00 $0.00 Summary : In this example, since the primary carriers paid amount of $40.00 is to theCareSource allowed amount of $35.00, then CareSource pays zero . Example 2: Charged Amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance Paid Primary Insurance $80.00 $50.00 $0 $0 $30.00 CareSource $40 .00 $10.00 Summary : In this example, subtract the primary paid amount of $30.00 from theCareSource allowed amount of $40.00 (lessor of the allowed amounts). Therefore, CareSource will pay $10.00. Example 3: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance Paid Primary Insurance $10 0.00 $0 $10 0.00 $0 $0 CareSource $12 5.00 $10 0.00 Coordination of Benefits-OH MCD-PY-1412Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Summary: In this example, subtract the primary paid amount of $0 from the primary allowed amount of $100.00 (lessor of the allowed amounts). Therefore, CareSource will pay $100.00. Example 4: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance Paid Primary Insurance $150.00 $0 $10 0.00 $40.00 $10.00 CareSource $12 5.00 $115 .00 Summary: In this example, subtract the primary paid amount of $10.00 from theCareSource allowed amount of $125.00 (lessor of the allowed amounts). Therefore, CareSource will pay $115.00 . III. CareSource as Secondary PayerA. Following Medicare reimbursement , Medicaid pays the remaining portion based on the following criteria: When a member becomes entitled to Medicare before the member’s termination of enrollment, the member may receive covered benefits that are also covered by Medicare. During that time, unless the provider has agreed in writing to an alternative payment methodology or different secondary claims payment rate, CareSource will reimburse Medicare secondary claims as set forth in Ohio Administrative Code (OAC) 5160-1-05.3 for both network and out-of-network providers , including application of the following exemptio ns to the Part B Medicaid maximum policy in accordance with the OAC and other guidance issued by the Ohio Department of Medicaid : 1. hospital services 2. nursing facility services included in the nursing facility per diem 3. covered supplemental medical insurance benefits under the Medicare progra m 4. dual eligible coordinated benefits for members who elect to receive Medicare Part Bbenefits through the original Medicare program B. Secondary Payer for Obstetrical Services 1. Primary payer EOP is required in order to coordinate coverage. With the primary payer EOP, CareSource will verify if the prenatal visits are a part of the primary carriers global reimbursement. If so , CareSource will not make a payment until a delivery charge is received. If the prenatal visits are excluded from the primary carriers global reimbursement, including when maternity benefits are not covered by the plan, CareSource will process the claim as the primary payer. 2. If the first claim that CareSource receives is for a global delivery, the claim will deny for invalid coding. The provider will need to re-bill within 90 days of denial using the delivery-only CPT codes, as CareSource does not recognize global obstetrical codes for claims processing. Coordination of Benefits-OH MCD-PY-1412Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 3. Once the delivery charge is received, CareSource will combine all prenatal visit charges with the delivery charges. CareSource will subtract the primary carriers payment from the lesser of the primary carrier allowed amount and the CareSource allowed amoun t (the benefit allowance for all visits and the delivery charge) and will pay any remaining liability. CareSource will not pay more than CareSources normal benefit when no other coverage exists or more than the patient responsibility after the primary in surance has paid. IV. COB Timely Filing GuidelinesA. If a provider is aware that a member has primary coverage, the provider will submit a copy of the primary payer s EOP along with the claim to CareSource within the claim s timely filing period. 1. If CareSource receives a claim for a member identified as having other coverage and a primary payer EOP was not submitted with the claim(s), CareSource will deny the claim(s) , requesting the required COB information. 2. If a claim is denied for COB information needed, the provider must submit the primary payer s EOP. If the initial timely filing period has elapsed, the EOP must be submitted to CareSource within 90 days from the primary payer s EOP date. B. If a provider has information that the primary payer s policy has terminated or was not in effect during the date of service for the claim(s), the provider must notify CareSource of the dispute within the original timely filing period or within 90 days of the providers actual receipt of the primary payer s EOP date, whichever is greater. C. If the dispute is received within the original timely filing period: 1. CareSource will confirm whether or not the primary payer was in effect during the date of service. If the policy was NOT in effect, CareSource will process the claim(s) that are within the original timely filing period or 90 days of the providers actual r eceipt of the payer s EOP date. 2. If the policy WAS in effect, the claim will remain denied for lack of primary payer s EOP. D. If the provider does not notify CareSource of the dispute within the original timely filing period or if the provider does not submit the primary payer s EOP within 90 days of the providers actual receipt of the primary payer s EOP date, the claim will re-deny as not being timely filed. V. COB Claim Submission to CareSourceA. CareSource follows The Health Insurance Portability and Accountability Act (HIPAA ) guidelines and accepts industry standard codes. It is imperative that claims are filed with the same codes that the primary payer presented on the Explanation of Benefits ( EOB ) to ensure that claims are processed correctly. Claim(s) will be denied if there is a mismatch between the codes on the received claim and the primary payer s EOP. B. CareSource applies standard claim adjustment codes . C. Claim Adjustment Group Codes are as follows: Coordination of Benefits-OH MCD-PY-1412Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 1. CO Contractual Obligation2. OA Other Adjustment 3. PI Payer Initiated Reductions 4. PR Patient Responsibility D. When filing claims with patients responsibility, the following Claim Adjustment Reason Codes should be used: 1. PR1 Deductible 2. PR2 Coinsurance 3. PR3 Copayment E. When filing claims with contractual obligation, please use Adjustment Group Code CO. Contractual obligation can be communicated on the Primary Payers EOB with several different codes. Please use the code reflected on the primary payers EOB. Some exampl es of these codes are 24, 45, 222, P24, P25, 26. (This is not an all-inclusive list). The same process should be followed when using Adjustment Group Code OA – Other Adjustment. VI. Denied COB ClaimsA. Denied COB claims will be automatically adjusted when primary insurance has been updated retroactively to show coverage was terminated at the time of service. This also has a lookback period of 12 months from the paid date or 18 months to the date of servi ce. B. Denied COB claims w ill NOT be automatically adjusted if the updated coverage information was received after 90 days from the denial for COB information. In this case, the provider must request claim adjustment within the original timely filing period or within 90 days from t he date of the EOP denial, whichever is greater. Although CareSource has implemented this COB Adjustment Policy, it is still the providers responsibility to review their accounts and submit COB claims in a timely manner for payment. VII. Disputes for Denied COB ClaimsA. Disputes w ill NOT be automatically adjusted if the updated coverage information was received after 90 days from the denial for COB information. In this case, the provider must request claim adjustment within the original timely filing period or within 90 days from t he date of the EOP denial, whichever is greater. Although CareSource is implementing this COB Adjustment Policy, it is still the providers responsibility to review accounts and submit COB claims in a timely manner for payment. B. CareSource will confirm whether or not the primary coverage was in effect during the date of service. If the policy was NOT in effect, CareSource will process the claim(s) that are within the original timely filing period. If the initial timely filing peri od has elapsed, then CareSource will process the claims that are within 90 days of the original denial. If the policy WAS in effect, the claim will remain denied for needing primary carriers EOP. If the provider does not notify CareSource of the dispute w ithin the original timely filing period, within 90 days of the CareSource denial, or if the provider does not submit the primary carriers Coordination of Benefits-OH MCD-PY-1412Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 EOP within 90 days of the Primary Carriers EOP date, the claim will re-deny as not being filed timely. 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. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 12/14/2022 New policyDate Revised 02/14/2024 11/19/2025Annual review. Updated background. Updated references. Approved at Committee.Annual review. Updated background and references. Approved at Committee. Date Effective 03/01/2026 Date Archived H. References1. Coordination of Benefits, OHIO ADMIN . CODE 5160-1-08 (2019). 2. Managed Care: Primary Care and Utilization Management, OHIO ADMIN CODE 5160 – 26-03.1 (2022). 3. Payment for “Medicare Part B” Cost Sharing, OHIO ADMIN . CODE 5160-1-05.3 (2016). ODM approved 12/ 04/2025

Transcutaneous Electrical Nerve Stimulators

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulators-OH MCD-PY-0039 03/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy 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 ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Transcutaneous Electrical Nerve Stimulators-OH MCD-PY-0039Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTranscutaneous Electrical Nerve Stimulat ors B. BackgroundTranscutaneous electrical nerve stimulation (TENS) is a device that produces a mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the members skin. C. Definitions Accessories A collective term that encompasses but is not necessarily limited to adapters, clips, additional connecting cable for lead wires, carrying pouches , and covers. Supplies A collective term that encompasses but is not necessarily limited to electrodes of any type, lead wires, conductive paste or gel, adhesive, adhesive remover, skin preparation materials, batteries , and battery charger for rechargeable batteries. Transcutaneous Electrical Nerve Stimulation (TENS) The application of mild electrical stimulation, to skin electrodes placed over a painful area that causes interference with transmission of painful stimuli. D. PolicyI. CareSource may require medical necessity review for a TENS unit. CareSource follows the Ohio Administrative Code for clinical criteria for the following devices: A. E0720 2-lead unit B. E0730 4-lead unit II. SuppliesA. Supplies are not reimbursable during the trial period. B. Supplies are not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase due to the necessity of continued treatment, the following apply: 1. Separate payment may be made for necessary supplies, which must be dispensed only when needed . 2. CareSource covers 1 unit of supplies (A4595) per month for a 2-lead TENS unit (E0720) and 2 units per month for a 4-lead TENS unit (E0730). 3. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 4. Separate payment is not provided for individual supply items. D. If a submitted claim does not include a modifier or includes an incorrect or inappropriate modifier, the claim may deny. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and Transcutaneous Electrical Nerve Stimulators-OH MCD-PY-0039Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 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.HCPCS Code DescriptionE0720 TENS unit, 2-lead, localized stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead (FOR A RECIPIENT-OWNED UNIT) Modifiers DescriptionNU Purchase of new equipmentRR Rental (use the ‘RR’ modifier when DME is to be rented) F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 08/23/2004Date Revised 02/06/2019 09/16/2020 07/15/2022 12/13/202312/18/202411/19 /2025Updated policy to align with OAC updates .Updated prior authorization requirement. PGC approved via electronic vote. Revised background information. Updated references. Annual review: rearranged criteria, updated references. Approved at Committee. Review: removed PA language, updated references, approved at Committee. Review: updated references, approved at Committee. Date Effective 03/01/2026 Date Archived H. References1. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS) : General Provisions , OHIO ADMIN . CODE 5160-10-01 (202 4). 2. DMEPOS: Transcutaneous Electrical Nerve Stimulation (TENS) Units , OHIO ADMIN . CODE 5160-10-15 ( 20 24 ). 3. Gibson W, Wand BM, Meads C, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic pain an overview of Cochrane Reviews. Cochrane Database Syst Rev . 2019;4:CD011890. doi:10.1002/14651858.CD011890.pub3 Transcutaneous Electrical Nerve Stimulators-OH MCD-PY-0039Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 4. Johnson MI, Paley CA, Wittkopf PG, et al. Characterising the features of 381 clinical studies evaluating transcutaneous electrical nerve stimulation (TENS) for pain relief: a secondary analysis of the meta-TENS study to improve future research. Medicina(Kaunas) . 2022;58(6):803. doi:10.3390/medicina58060803 5. Johnson MI, Paley CA, Jones G, et al. Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: a systemat ic review and meta-analysis of 381 studies (the meta-TENS study). BMJ Open. 2022;12(2):e051073. doi:10.1136/bmjopen-2021-051073 6. Vance CGT, Dailey DL, Chimenti RL, et al. Using TENS for pain control: update on the state of the evidence. Medicina . 2022;58(10):1332. doi:10.3390/medicina58101332 ODM Approved 11/21 /2025

Dental Services Rendered in a Hospital or Ambulatory Surgery Center

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Dental Services Rendered in a Hospital or Ambulatory Surgery Center – OH MCD-PY-1244 03/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource, and its affiliates are intended to provide a general reference regarding billi ng, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. These policies are designed to assist providers and f acilities submitting claims to CareSource. The policies are routinely updated to promote accurate coding and clarificati on. These proprietary policies are not a guarantee of payment. 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. 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 any applicable referral, authorizatio n, notification, and utilization management guidelines. Medically necessary services include, but are not limited to, those heal th care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and wit hou t which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a b ody organ or part, or significant pain and discomfort. These services must meet the standards of good clinical practice in the l ocal area, are the lowest cost alternative, and are not provided for the convenience of the member or provider. Medically necessar y services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medic al Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Prior authorization is required for certain services. If authorization is not obtained prior to performing the service, CareSource may not reimburse for the pro cedure. Health care providers and their office staff are encouraged to use the self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology/He althcare Common Procedure Coding System (CPT/HCPCS) code(s) for the medical product or service being provided and the appropriate Current Dental Terminology (CDT) code(s) for the dental product or service. The inclusion of a code in this policy does not im ply any right to reimbursement or guarantee for a submitted claim payment. 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 ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 4 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 03/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDental Services Rendered in a Hospital or Ambulatory Surgery Center B. BackgroundThe decision to perform dental care in a particular place of service is based on a wide variety of factors, including the age and special health care needs (physical, intellectual, and developmental disabilities or long-term medical conditions) of the individual, in addition to the type, number , and complexity of procedures planned. These factors also determine the type of anesthesia used during the procedure. Most dental care can be provided in a dental office setting with local anesthesia or local anesthesia supplemented with non-pharmacological behavior guidance (basic toadvanced techniques) and/or pharmacological options. Basic non-pharmacological behavior guidance includes communication guidance, positive pre-visit imagery, direct observation, tell-show-do, ask-tell-ask, voice control, non-verbal communication, positive reinforcement and descriptive praise, distraction, and desensitization. Pharmacological options may include nitrous oxide, oral conscious sedation and intravenous (IV) sedation (mild, moderate, or deep) , or monitored general anesthesia by trained certified individuals in each level of sedation dentistry. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where ap propriate candidates may require the use of general anesthesia as medically necessary in a healthcare facility, such as an ambulatory surgica l center , hospital operating room , or short procedure unit (SPU). C. Definitions Ambulatory Surgical Center (ASC) Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization that meets all criteria of Ohio Administrative Code (OAC) 5160-22-01. Enhanced Ambulatory Patient Groups (EAPGs ) A patient classification system designed to explain the amount and type of resources used during an ambulatory visit. Each EAPG have similar clinical characteristics, resource use , and cost. Inpatient Hospital A nonpsychiatric facility which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. Medical Necessity Procedures, items, or services which prevent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease, or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without its use the person 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 as defined by OAC 5160-1-01. Monitored Anesthesia Care (MAC) A specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 03/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Outpatient Hospital A facility which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require admission or an overnight stay . Place of Service (POS) Codes Two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. Sedation Continuum When patients undergo procedural sedation/analgesia, they enter a sedation continuum. Several levels have been formally defined along this continuum: minimal sedation/anxiolysis, moderate sedation, deep sedation, and at the deepest level, general anesthesi a. o Minimal Sedation (Anxiolysis ) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. o Moderate Sedation/Analgesia (Conscious Sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is ad equate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. o Deep Sedation/Analgesia A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require a ssistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. o General Anesthesia A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and p ositive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. NOTE : Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initia lly intended. Individuals administering moderate sedation should be able to rescue patients who enter a state of deep sedation, while those administering deep sedation should be able to rescue patients who enter a state of general anesthesia. Rescue o f a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced cardiac life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intend ed level of sedation (such as hypoventilation, hypoxia, and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 03/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 level of sedation. Short Procedure Unit (SPU ) A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic, or medical services. D. PolicyThis policy is intended to provide guidance on the process for obtaining authorization and reimbursement for dental services performed in a place of service (ASC or hospital OR/SPU) and reimbursement for related facility charges (eg, operating room, anesthesia, medical consults). CareSource Dental Benefits for Ohio Medicaid are administered through our partnereddelegated vendor Delta Dental . Coverage for professional services performed by the dentist/oral surgeon in the POS (ASC or OR/SPU) and reimbursement for these services may be provided through the dental benefit once approved via the Delta Dental process of dental utilization review for medical necessity of services and requested place of service. Medical necessity criteria and clinical policies are in the respective Dental Office Reference Manual . OAC 5160-2-03(A)(2)(h) states that dental services are only covered in a hospital setting when the nature of the surgery or the condition of the patient precludes performing the procedure in the dentists office or other non-hospital outpatient setting and t he inpatient or outpatient service is a Medicaid covered service. As such, it would exclude any diagnostic or preventative dental services that could be performed effectively and safely in an ambulatory state, unless patient characteristics and coope ration do not allow it. CareSource Medical Benefits for Ohio Medicaid are administered directly throughCareSource. Coverage and reimbursement for f acility charges (eg, operating room,anesthesia) related to dental services performed in POS (ASC or OR/SPU), are eligible for coverage and reimbursement under the member’s medical benefit when the dental services have been approved via the Delta Dental Utilization Management process. The two-step process for dental services and facility services should be followed toobtain authorization prior to submitting claims for reimbursement:A. Step 1 – Dental authorization for services to be performed in a (OR/SPU or ASC) 1. Requests for dental services in POS (19, 21, 22, 24) are submitted by the treating dental provider to the CareSource Ohio Medicaid dental vendor, Delta Dental . The p rovider must include POS on dental claim and add in authorization notes request is for hospital or ASC setting. 2. The dental vendor reviews for appropriate medical necessity requirements listed in the vendors Office Reference Manual. 3. If the dental authorization is approved, the dental vendor will send an automated fax approval letter to the requesting dentist which can additionally be viewed in the Delta Dental provider portal. 4. If the dental authorization request is not approved, a Notice of Adverse Benefit Determination (Denial Notice) will be issued by the dental vendor to the submitting provider. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 03/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 B. Step 2 – Facility precertification processOnce dental procedure approval has been obtained, providers are required to administer services at CareSource participating hospitals and must obtain facility precertification. 1. For facility precertification , the facility provider (hospital or ASC) may submit the request on the CareSource Provider Portal at CareSource.com . 2. The Provider may also request a facility precertification by calling CareSource directly at 800.488.0134 and select the option to request an authorization. 3. The facility approval request should include the facility services (ie, operating room charges, anesthesia) requested, the Delta Dental Authorization Approval Letter, and authorization number. 4. The CareSource Medical Utilization Management (UM-MM) team will complete ALL the following: a. Verify that the facility is in-network. b. Review the Delta Dental pre-determination letter (PDL) or approved dental authorization and complete administrative approval for facility fee and anesthesia. c. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted. d. Fax a Facility Approval to the hospital/ASC which can also be viewed in the CareSource Provider Portal. E. Conditions of CoverageFacility reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate code modifiers, if applicable to CareSource. Please refer to the individual fee schedule for appropriate codes. Reimbursement for items assigned to a dental service EAPG type will be paid as follows: Outpatient Hospital Facility (SPU) POS (19, 22) o Use CPT code 41899 as the facility fee code. Discounting factors – payments shall be multiplied by any applicable discounting factor, rounded to the nearest whole cent. o Use CPT code 00170 for anesthesia when performing intraoral treatments, including biopsy. Time units for physician and CRNA services – both personally performed and medically directed, are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. Total minutes are listed as the units (ie, 75 minutes) 75 = 5 units (of 15 min increments). CMS Base units = 5. Maximum state allowances ma y be applicable. Payment for an anesthesia service is the lesser of the provider’s submitted charge or the Medicaid maximum, which is determined by a formula. Inpatient Hospital Facility POS (21) o All services as well as any additional room and board fees need to be pre – certified and receive medical necessity review. Services are subject to benefit provisions. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 03/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 Ambulatory Surgical Center POS (24)o Use code 41899 for facility fee. Payments for dental services will be made in accordance with the discounting factors as determined by the EAPG grouper. o Use code 00170 for Anesthesia professional services. CPT 00170 is calculated in CMS base units. The base unit = 5 units. See Hospital section above. Dental/Oral Surgery Professional ServicesThe scope of this policy is limited to medical plan coverage reimbursement codes for facility and/or general anesthesia services provided in conjunction with dental treatment, and not the actual dental or oral surgery services provided. For information on dental benefits and coding, please consult the partnered dental vendor Delta Dental Office Reference Manual for clinical guidelines, policies, and procedures. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 09/16/2020 New PolicyDate Revised 01/26/2022 02/14/202406/04/202511/19 /2025 Annual review. Removed dental codes , removed tables, simplified coding information Annual review: adjusted title, updated definitions, policy language, and references, corrected base unit typo. Approved at Committee. Review: updated references, approved at Committee. Review: updated vendor information, approved at Committee. Date Effective 03/01/2026 Date Archived H. References1. Ambulatory Surgery Center (ASC) Services: Provider Eligibility, Coverage, and Reimbursement OHIO ADMIN . CODE 5160-22-01 (202 4). 2. Anesthesia Services, OHIO ADMIN . CODE 5160-4-21 (20 24 ). 3. Committee on Quality Management and Departmental Administration. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. American Society of Anesthesiologists. Updated October 23, 20 24 . Accessed October 30, 2025 . www.asahq.org 4. Conditions and Limitations, OHIO ADMIN . CODE 5160-2-03 (2022). 5. Dental Services, OHIO ADMIN . CODE 5160-5-01 (202 4). 6. General Provisions: Hospital Services, OHIO ADMIN . CODE 5160-2-02 (202 4). 7. Hospital Billing Guidelines . Ohio Dept of Medicaid ; 2021. Accessed October 30 , 2025 . www.medicaid.ohio.gov Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 03/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 8. Management of dental patients with special health care needs. Reference Manual ofPediatr ic Dent istry . American Academy of Pediatric Dentistry ; 202 4-2025:343-350. Accessed October 30 , 2025 . www.aapd.org 9. Medicaid Medical Necessity: Definitions and Principles, OHIO ADMIN . CODE 5160-1- 01 (2022). 10. Outpatient Hospital Reimbursement, OHIO ADMIN . CODE 5160-2-75 (202 4). 11. Policy on hospitalization and operating room access for oral care of infants, children, adolescents, and individuals with special health care needs. Reference Manual of Pediatr ic Dent istry . American Academy of Pediatric Dentistry ; 2024-2025:173-175 . Accessed October 30 , 2025 . www.aapd.org 12. Policy on third-party reimbursement for management of patients with special health care needs. Reference Manual of Pediatr ic Dent istry . American Academy of Pediatric Dentistry ; 2024-2025:186-189 . Accessed October 30 , 2025 . www.aapd.org Approved ODM 11/28 /2025

Chiropractic Care

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Chiropractic Care-OH MCD-PY-1328 03/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy 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 ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Chiropractic Care-OH MCD-PY-1328Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectChiropractic Care B. BackgroundChiropractic is a healthcare field that focuses on disorders affecting the musculoskeletal and nervous systems, along with their effects on overall health. Doctors of Chiropractic (DCs) utilize a conservative approach to healthcare that includes patient as sessment, diagnosis, and treatment. In addition to manual therapies such as spinal manipulation, DCs are trained to recommend therapeutic and rehabilitative exercises and to offer advice on nutrition, lifestyle, and dietary habits. They address a variety o f conditions, including but not limited to back pain, neck pain, joint pain in the arms or legs, and headaches. The core services provided by chiropractors are a key strategy for the prevention, diagnosis, and conservative (non-drug) management of back pain and spinal disorders.This approach can help some patients minimize or avoid the need for more invasive interv entions, such as prescription opioid pain medications and surgery.C. Definitions Acute Subluxation Treatment for a new injury defined by x-ray or physician exam resulting in an expected improvement in, or arre st of, progression in the members condition. Billing Provider A chiropractor, mechanotherapist, profession al medical group, hospital , or fee-for-service clinic as noted by the Ohio Administrative Code (OAC) . Maintenance Therapy A therapy that is performed to treat a chronic, stable condition or to prevent deterioration. Rendering Providers A chiropractor or a mechanot herapist eligible to provide spinal manipulation . D. PolicyI. CareSource follows the O AC for payment of spinal manipulation . II. Payment may be made for manual correction to correct a spin al subluxation determined by x-ray or physician exam for a condition that is acute and episodic in nature. When the maximum therapeutic benefit has been met, ongoing therapy is considered maintenance therapy and is not medically necessary. III. Payment may be made for the following services:A. spinal ma nipulation 1. chiropractic manipulative treatment (CMT); spinal, 1 to 2 regions 2. chiropractic manipulative treatment (CMT); spinal, 3 to 4 regions 3. chiropractic manipulative treatment (CMT); spinal, 5 regions B. diagnostic imaging to determine the existence of a subluxation 1. spine, entire; survey study, anteroposterior and lateral Chiropractic Care-OH MCD-PY-1328Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 2. spine, cervical; anteroposterior and lateral3. 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 and lateral views 8. spine, lumbosacral; anteroposterior and lateral views 9. spine, lumbosacral; complete, with oblique views 10. spine, lumbosacral; complete, including bending views IV. All services 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 (ie, lumbar and/or sacral) 2. a secondary diagnosis that supports the treatment provided ( eg , osteoarthritis, congeni tal musculoskeletal deformities of the spine) B. Manual manipulation must have a direct therapeutic relationship to the members condition as documented in the medical record. The lack of documentation specifying the relationship between the members condition and treatment shall result in the service be ing ineligible for reimbursement. 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. F. Related Policies/RulesMedical Necessity Determination Policy G. Review/Revision HistoryDATE ACTIONDate Issued 05/26/2021Date Revised 04/12/2023 01/31/202411/19 /202 5Annual review: Title modified. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Periodic review. Updated the background and references. Approved at Committee. Date Effective 03/01/2 026 Date Archived H. References1. Chiropractic Services, OHIO ADMIN . CODE 5160-8-11 (2022). Chiropractic Care-OH MCD-PY-1328Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 ODM approved 12/ 01/2025

Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-OH MCD-PY-0007 02/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy 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 ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Preventive Evaluation and Management Services and AcuteCare Visit on Same Date of Service-OH MCD-PY-0007Effective Dat e: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectPreventive Evaluation and Management Services and Acute Care Visit on Same Date of Service B. BackgroundCareSource will reimburse participating providers for medically necessary and preventive screening tests as required by federal statute through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF). C. Definitions Preventive Services Exams and screenings t hat check for health problems with the intention to prevent any problem discovered from worsening and may include, but are not limited to, physical checkups, hearing, vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider f or preventive services are encouraged at every age but are especially important for children under the age of 1 8 years . D. PolicyI. When any of the following pediatric and adolescent preventive exam codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse both codes at 100%. A. Preventive Health Service Codes 1. 99381-99384 2. 99391-99394 B. Acute Care Visit Codes 1. 9920 2-99205 2. 99212-99215 II. When any of the following adult preventive health service codes are billed on th e same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse only the preventive service code at 100%. The acute care visit service codes will not be reimbursed unless billed with the appropriate modifier to identify significant, separately identifiable services that were rendered by the same physician on the same date of service. A. Preventive Health Service Codes 1. 99385-99387 2. 99395-99397 B. Acute Care Visit Codes 1. 9920 2-99205 2. 99212-99215 III. CareSource reserves the right to request documentation to support billing both services for all claims received. The physician or other qualified health care pro vider Preventive Evaluation and Management Services and AcuteCare Visit on Same Date of Service-OH MCD-PY-0007Effective Dat e: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 may need to indicate that in the process of performing a preventive/wellness health service, an abnormality was encountered or a new or existing problem was addressed, and the problem or abnormal finding was significant enough to require additional work to perform the key components of a problem-focused (acute care)evaluation and management (E/M) service. Documentation must support the following: A. A separately identifiable service significant enough to require additional work to perform the key components of a problem-focused (acute care) E/M service. B. Acute care service may be billed based on time or medical decision making (MDM). 1. If billed based on time, documentation must reflect start/stop or total time spent. If time is used for selection, then the time spent on the preventive service cannot be counted toward the time of the work of the problem assessment, because time spent can not be counted twice. Please see the American Medical Association (AMA) Guidelines for Selecting Level of Service Based on Time. 2. If billed based on MDM, documentation must support the level of service based on AMA Medical Decision-Making Guidelines . 3. A medically appropriate history and physical exam, when performed. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule for appropriate codes. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify member eligibility. F. Related Policies/RulesModifier 25 Reimbursement policy G. Review/Revision HistoryDATE ACTIONDate Issued 11/17/2014Date Revised 11/17/2015 08/06/2019 09/14/202201/17/202 411/05/2025 Revision includes payment policy legal language Updated reimbursement rate from 50% to 100% for services that are rendered on the same date of service Annual review: removed reference to archived policies, updated codes, added reference to Modifier 25 policy Annual Review; Approved at Committee. Annual review : D.III. documentation requirements revised , Approved at Committee. Date Effective 02/01/2026 Date Archived Preventive Evaluation and Management Services and AcuteCare Visit on Same Date of Service-OH MCD-PY-0007Effective Dat e: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 H. References1. CPT Evaluation and Management (E/M) Code and Guideline Changes . American Medical Association; 2022. Accessed September 15, 2025. www.ama-assn.org 2. Healthcheck , OHIO ADMIN . CODE 5160-1-14 (2017). 3. Preventive Services, OHIO ADMIN . CODE 5160-1-16 (2017). Approved by ODM 11/17/2025

Newborn and Neonatal Intensive Care Unit (NICU) Level of Care

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Newborn and Neonatal Intensive Care Unit (NICU) Level of Care – OH MCD-PY-1430 02/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 Newborn and Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Date: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectNewborn and Neonatal Intensive Care Unit (NICU) Level of Care B. BackgroundThis policy aligns with guidance from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) regarding NICU levels of care. This policy provides guidelines for determining the medically appropriate level of care for reimbursement based on available documentation. NICU admissions are reviewed to ensure that services are of an appropriate duration and level of care to promote optimal health outcomes in the most efficient manner. Clinical documentation of an ongoing NICU hospitalization will be reviewed concurrently to substantiate level of care with continued authorization based on the documentation submitted. Reimbursement for the NICU stay will be based on the authorized level of care and determined by the concurrent review process. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have defined and specified the capabilities for each of 4 facility levels of care (ie, a specific unit located in the hospital). These facilities range from a Level I Newborn Observation Unit to a Level IV Regional Neonatal Intensive Care Unit. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification.The Neonatal Intensive Care Unit (NICU) is a critical care area in a facility for newborn babies who need specialized care. The NICU designation requires a combination of advanced technology and a NICU team of licensed professionals. Newborn and NICU levels of care are based on the complexity of care that a newbornwith specified diagnoses and symptoms require. All four levels of care are represented by a unique revenue code. Any inpatient revenue codes not billed as levels 2-4 will be recognized as level 1. Newborn nursery=0170 Level 1=0171 Level 2=0172 Level 3=0173 Level 4=0174 While most infants admitted to the NICU are premature, others are born at term but suffer from medical conditions , such as infections or birth defects. A newborn also could be admitted to the NICU for associated maternal risk factors or complicated deliveries. Although the list of criteria used to determine the NICU levels of care in this policy are not all inclusive, it does provide an overview of the guidelines that are used. Newborn and Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Date: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. Definitions Intensity of Care (IOC) The complexity of care that a newborn with specified diagnoses and symptoms require s. Newborn CareServices Services performed from birth to 4 weeks. Neonatal Intensive Care Services (NICU) Critical care services for a newborn. Well Baby Care Services A basic level of care to neonates who are low risk. D. PolicyI. Per federal mandate, newborn members are covered at an inpatient facility for a 2 – day stay for vaginal deliveries and a 4-day stay for cesarean sections. These stays will be covered without clinical review (notification may be required) if they are submitted with revenue codes 0170/0171 and a normal newborn DRG. II. For any newborn diagnoses/revenue codes/procedures that may be associated with care/treatment outside of routine newborn care (any revenue code 0172, 0173, 0174) , authorization is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to submit documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. When a newborn require s a NICU admission or a higher IOC service, anauthorization is required.IV. If a complication develops with the mother or baby that necessitates additionalhospital days, NICU admission, or non-well-baby service, an authorization should be submitted along with clinical information to support the stay. V. If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to Newborn Nursery or pediatric level of care, NICU level of care will not be assigned regardless of interventions completed during transitional time.VI. Clinical review will determine appropriate IOC utilizing MCG standards. Care Source will adjust IOC reimbursement if clinical documentation does not support the IOC billed. VII. Inpatient admissions may be reviewed to ensure that all services are of an appropriate duration and level of care to promote optimal health outcomes. Clinical documentation of an ongoing neonatal hospitalization will be reviewed concurrently to substantiate the level of care and length of stay. A continued authorization will be based on the documentation submitted and alignment with MCG Neonatal Facility Levels of Care and Neonatal Intensity of Care Criteria , as well as CareSource policy.Newborn and Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Date: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 VIII. In order to avoid reimbursement delay or adjustments, providers are encouraged to reference MCG guidelines as well as the clarifications and specific details below .Note: Newborn nursery babies that do not require advanced levels of care are billed using revenue code 0170. NICU Level Revenue Code Description MCG NICU Intensity of Care Level 1 0171: Newborn Level I Intensity of Care Criteria 1 Routine Care ( LOC-010 ) Neonatal care may be indicated for the p hysiologically stable infant (eg, no apnea, bradycardia, or unstable temperature) requiring care consisting of 1 or more of the following: Routine newborn care Evaluation and care of neonates with conditions that require inpatient services available at Level I Continued inpatient care during convalescence from condition(s) treated in Level II, Ill or IV while awaiting resolution of specific issues (eg , sustained weight gain, poor PO feeding ), or establishment of safe discharge destination and plan Uncomplicated jaundice treated only with phototherapy and requiring infrequent bilirubin checks Absence of parenteral medications Evaluation and management of glucose levels without IV fluids , d iagnostic work – up/surveillance, on an otherwise stable neonate where no therapy is initiated Level 2 0172: Newborn Level IIIntensity of Care Criteria 2 Continuing Care (LOC-011 )Neonatal care may be indicated for 1 or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen ( 2L/min), with other co – morbidities stable Administration of intravenous (IV) medications IV Therapy; peripheral or PICC o IV fluids inclusive of hyperalimentation ( 2 L/minute of blended oxygen , continuous positive airway pressure (CPAP), nasal intermittent positive pressure ventilation ( NIPPV ) o conventional ventilation (via endotracheal tube, nasotracheal tube or tracheostomy tube) o high-frequency ventilation long-term (> one week) Presence of chest tubes Umbilical arterial catheter (UAC) for blood draws Active apnea/bradycardic episodes requiring PPV Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia requiring > 5 mg/kg/min of IV treatment or hypoglycemia not responsive to 1 IV dextrose bolus (200 mg/kg or 2 ml/kg of D10W ) Total parenteral nutrition or IV fluids to supplement inadequate oral intake (NG or PO) > 50% total nutrition NAS requiring initiation/escalation of medication or inability to wean Hyperbilirubinemia with evidence of hemolysis requiring IVIG or blood transfusion Acute encephalopathy that is moderate to severe and under active investigation or has been investigated and does not meet criteria for therapeutic hypothermia Surgical conditions requiring general anesthesia up to 2 days post-op , if indicated Surgical/Therapies for retinopathy of prematurity (ROP) Seizure activity requiring initiation, supplementation , or changing of seizure medications Transfusion of blood products in absence of severe acute etiology or manifestations (eg, transfusion needed for anemia of prematurity, iatrogenic anemia) Hypotension requiring IV fluid bolus Level 4 0174: Newborn Level IV Intensity of Care Criteria 4 Intensive Care (LOC-013 ) Includes Level 3 requirements and 1 or more of the following: Perioperative care following surgical repair of severe neonatal conditions, for example: o bowel resection for necrotizing enterocolitis (NEC) o tracheoesophageal fistula or esophageal atresia repair o cardiac surgery excluding PDA ligation o myelomeningocele closure (up to 48 hours post-op) Newborn and Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Date: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 o organ transplant Medically necessary inhaled nitric oxide (iNO) Extracorporeal membrane oxygenation (ECMO) High frequency oscillatory or jet ventilation (initial week) Therapeutic cooling Exchange transfusion (day of procedure) Uncontrolled active seizures despite medications Ongoing cardiovascular support (inotropes, chronotropes, antiarrhythmics) Severe hemodynamic instability requiring ongoing IV fluid/medication support o dialysis o IV sedation that includes paralysis o prostaglandin infusion CPR in the last 24 hours (not inclusive of delivery room resuscitation) Transfusion of blood products in setting of severe acute etiology or manifestation (eg, hemolytic anemia, disseminated intravascular coagulation, hemorrhage) E. Conditions of CoverageI. Reimbursement is independent of the location of care and corresponds to the medical treatment provided and level of service the neonate requires. To ensure accurate reimbursement, submitted claims will be reviewed to align with authorized levels of care and/or clinically validate diagnoses, procedures , and other claim information that impact payment. Based on review, the following may occur: Down-code revenue codes to authorized levels of care Issue a base DRG payment Adjust claim diagnoses/procedures that are not substantiated in the medical information provided and apply DRG regrouping, A request for complete medical records and/or itemized statements to support the services on the claim may be made 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.F. Related Policies/Rules NA G. Review/Revision HistoryDATE ACTIONDate Issued 03/13/202 3 New policy . Approved at Committee.Date Revised 03/12/2025 10/22/2025Periodic review. Updated definitions, section D. and references. Approved at Committee. Periodic review. Added Newborn to title and newborn nursery revenue code information. Updated references. Approved at Committee. Newborn and Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Date: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 Date Effective 02/01/2026Date Archived H. References1. About preterm labor and birth. National Institutes of Health. Reviewed May 9, 2023. Accessed October 10, 2025. www.nichd.nih.gov 2. Admission to NICU. Specification Manual for Joint Commission National Quality Measures . The Joint Commission; 2025. Version 2025A1 . Accessed October 10, 2025. www.manual.jointcommission.org 3. Intensity of Care Criteria 1 – Routine Care: LOC-010 (ISC GRG). MCG Health. 29th ed. Accessed October 10, 2025. www.careweb.careguidelines.com 4. Intensity of Care Criteria 2 – Continuing Care: LOC-011 (ISC GRG). MCG Health. 29th ed. Accessed October 10, 2025. www.careweb.careguidelines.com 5. Intensity of Care Criteria 3 – Intermediate Care: LOC-012 (ISC GRG). MCG Health. 29th ed. Accessed October 10, 2025. www.careweb.careguidelines.com 6. Intensity of Care Criteria 4 – Intensive Care: LOC-013 (ISC GRG). MCG Health. 29th ed. Accessed October 10, 2025. www.careweb.careguidelines.com 7. Stark AR, Pursley DM, Papile L, et al. Standards for levels of neonatal care: II, III, and IV. Pediatr . 2023;151(6):e2023061957. doi:10.1542/peds.2023-061957 ODM Approved 11/05/2025

Venipuncture Performed in an Outpatient Setting

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Venipuncture Performed in an Outpatient Setting – OH MCD-PY-1704 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy 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 ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Venipuncture Performed in an Outpatient Setting-OH MCD-PY-1704 Effective Dat e: 01/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectVenipuncture Performed in an Outpatient Setting B. BackgroundN/A C. Definitions Venipuncture A needle used to collect blood from a vein, usually for laboratory testing. D. PolicyI. Professional Services A. Routine venipuncture (36415) is not eligible for reimbursement when reported with office or other outpatient evaluation and management (E/M) codes (99202 – 99205 and 99211-99215) . Routine venipuncture is included in the reimbursement for office E/M services and is not reimbursed separately. II. Outpatient Facility ServicesA. Venipuncture codes (36400, 36405, 36406, 36410, 36415, and 36416) are not eligible for reimbursement when reported by an outpatient facility. These codes are included in the facility payment and are not separate ly reimburs ed . III. CareSource may conduct a post-payment review on claims with venipuncture toensure compliance.E. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and offic e staff are encouraged to use self-service channels to verify a members eligibility. Reimbursement is dependent upon, 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.Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource polic ies apply to both participating and nonparticipating providers and facilities. Venipuncture Performed in an Outpatient Setting-OH MCD-PY-1704 Effective Dat e: 01/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 F. Related Policies/RulesModifier 59 Overpayment Recovery G. Review/Revision HistoryDATE ACTIONDate Issued 10/08/2025 New policy. Approved at Committee.Date Revised Date Effective 01/01/2026 Date Archived H. References1. National Cancer Institute Dictionary of Cancer Terms. Accessed September 8, 2025. www.cancer.gov Approved by ODM on 10/14/2025

Overpayment Recovery

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Overpayment Recovery-OH MCD-PY-1115 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy 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 ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 01/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectOverpayment Recovery B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS 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 guarant eeclaims payment.Retrospective review of claims paid to providers assist CareSource with ensuring accuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified.Fraud, waste , and abuse investigations are an exception to this policy. In these investigations, the look back period may go beyond 2 years. C. Definitions Claims Adjustment A claim that was previously adjudicated and is being updated for one of the following reasons: o denied as a zero payment o a partial payment o a reduced payment o a penalty applied o an additional payment o a supplemental payment Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource , and the other carrier is the primary insurance for the member. Credit Balance/Negative Balance Funds that are owed to CareSource because of a claim adjustment. Explanation of Payment (E OP ) The EOP contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Forwarding Balance (FB) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 01/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 claim has been adjusted to a different dollar amount and that funds are owed to CareSource. Improper Payment A payment that should not have been made or an overpayment was made. Examples include, but are not limited to the following : o payments made for an ineligible member o ineligible service payments o payments made for a service not received o duplicate payments Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 C.F.R. o A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Provider Level Balancing (PLB ) Adjustments to the total check / remit amount occur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) e quals the total payment (Beginning Segment for Payment Order/Remittance Advice (BPR ), which means total payment within the EOP ). Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. D. PolicyI. In accordance with 42 C .F.R. 438.608, CareSource requires providers to report any overpayment that has been received by the provider. The overpayment must be returned to CareSource within 60 calendar days after the date on which the overpayment was identified and to notify CareSource in writing of the reason for the overpayment. II. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider:A. The patient’s name, date of birth, and Medicaid identification number . B. The date or dates of services rendered . C. The specific claims that are subject to recovery and the amount subject to recovery, including any interest charges, which may not exceed the amount specified in Ohio law or rule . D. The specific reasons for making the recovery for each of the claims subject to recovery . E. If the recovery is a result of member disenrollment from the CareSource, the effective date of disenrollment . F. An explanation that if a written response to the notice is not received within 30 calendar days from receipt of the notice, the overpayments will be recovered from future claims . Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 01/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 G. How the provider may submit a written response disputing the overpayment .H. How the provider may submit a written request for an extended payment arrangement or settlement . III. Overpayment RecoveriesA. Lookback period is 24 months from the claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely fil ing guidelines. IV. Coordination of Benefit RecoveriesA. Lookback period is 12 months from claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. V. Retro Active Eligibility RecoveriesA. Lookback period is 24 months from date CareSource is notified by Medicaid of the updated eligibility status. B. Advanced notification will occur 30 days in advance of recovery. VI. Management of Claim Credit BalancesA. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. This information will be displayed on the EOP in the PLB section. B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $2 difference. b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D.IV. 2. Overpayment Example Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 01/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D.IV. b. The reduced payment will trigger a 30-day advanced notification with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. D. Providers are notified of negative balances through EOPs and 835s. Providers are expected to use this information to reconcile and maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances. E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. Providers are expected to maintain their AR to account for the reconciliation of negative balances when they occur. 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. F. Related Policies/RulesCareSource Provider Manual National Agreement, Article V. Claims and Payments , 5.11 (d). G. Review/Revision HistoryDATE ACTIONDate Issued 04/29/2020 New policyDate Revised 07/21/2021 03/30/202210/26/202202 /14 /202 4 09/10 /2025Revision: Added Management of Claims Balance information. Added compliance with 42 CFR 438.608 for requirement for provider to report identified overpayments. Approved at PGC. No changes. Updated references. Annual review. Removed V.C. Updated references. Approved at Committee. Periodic review. Updated references. Approved at Committee. Date Effective 01/01/2026 Date Archived H. References1. Ohio Medicaid Provider Agreement for Managed Care Organization . Ohio Dept of Medicaid. Updated July 1, 202 5. Accessed August 25, 2025 . www.medicaid.ohio.gov 2. Payments Considered Final Overpayment, OHIO REV . CODE 3901.388 (2002). ODM approved 09/18/2025

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