REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulators-OH MCD-PY-0039 10/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreement, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.Table of Contents A. 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 …………………………………………………………………………………………………………. 3Transcutaneous Electrical Nerve Stimulators-OH MCD-PY-0039 Effective Date: 10/01/2026 The REIMBURSEMENT Polic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.2 A. Subject Transcutaneous Electrical Nerve Stimulat ors B. Background Transcutaneous electrical nerve stimulation (TENS) devices produce 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 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. Policy I. 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. Supplies A. 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 Coverage These proprietary policies are not a guarantee of payment. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. It is the responsibility of the submitting provider to submit the most accurate and appropriate HCPCS /CPT code(s) for the product or Transcutaneous Electrical Nerve Stimulators-OH MCD-PY-0039 Effective Date: 10/01/2026 The REIMBURSEMENT Policy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.3 service that is being provided. 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 Description E0720 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 History DATE ACTIONDate Issued 08/23/2004Date Revised 02/06/2019 09/16/2020 07/15/2022 12/13/2023 12/18/2024 11/19/2025 06/17 /2026 Updated 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. Review: reviewed references. Approved at Committee. Date Effective 10/01/2026 Date Archived H. References1. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS) : General Provisions , O HIO ADMIN . CODE 5160-10-01 (2024). 2. DMEPOS: Transcutaneous Electrical Nerve Stimulation (TENS) Units, O HIO ADMIN . CODE 5160-10-15 ( 2024). 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-0039 Effective Date: 10/01/2026 The REIMBURSEMENT Polic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.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 systematic 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 6/30/2026
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Telehealth and Place of Service for Community Mental Health Clinics – OH MCD-PY-1813 10/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.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 Telehealth and Place of Service for Community Mental Health Clinics-OH MCD-PY-1813 Effective Dat e: 10/01/2026 2A. SubjectTelehealth and Place of Service for Community Mental Health Clinics B. BackgroundCommunity mental health clinics (CMHCs) have evolved as part of a broader national movement to provide accessible mental health services at a local level, providing greater integration of people with behavioral health diagnoses into communities. CMHCs provide a range of services (eg, counseling, case management, support ) while emphasizing a holistic approach and i ntegrating mental health with primary care, substance use services and social supports. Telehealth services have become more common over the last decade. In Ohio, the billing of telehealth services by CMHCs is subject to specific parameters established by state Medicaid policies, federal guidelines, and sometimes private payer rules. Provider smust be enrolled in Ohio Medicaid and practice under an appropriate scope of practice for the profession. Claims must include appropriate place of service (POS) codes indicating that a service(s) was delivered via telehealth by use of specific modifiers.C. Definitions Distant Site The physical location of the treating practitioner at the time a service is provided via telehealth . Originating Site The physical location of a client at the time the service is furnished via telehealth . Telehealth Health care services provided pursuant to applicable Ohio Dept of Medicaid (ODM) telehealth rules and definitions. D. PolicyI. The provisions of this policy apply to provider types 84 and/or 95. II. Providers must follow OAC 5122-29-31 and the Ohio Dept of Medicaids (ODM)Medicaid Behavioral Health State Plan Services Provider Requirements and Reimbursement Manual for the provision of telehealth services, including eligible providers, provider types and provider responsibilities . Reimbursement will be made for Ohio-approved medically necessary services when delivered via telehealth from the distant site. III. Unless stated otherwise in the billing guidelines, professional claims submitted through the use of telehealth have to includeA. a “GT” modifierB. an allowable POS code for each procedure code as reflected in the appendix to OAC 5160-27-03 (02 is not allowed) C. the location at which the service was provided for POS 99 IV. All CMHC billed claims for telehealth services, regardless of POS, will price at office rates only. Telehealth and Place of Service for Community Mental Health Clinics-OH MCD-PY-1813 Effective Dat e: 10/01/2026 3E. Conditions of CoverageI. The inclusion of a code or modifier in this policy is not a guarantee of coverage, authorization or reimbursement. CareSource may request documentation for substantiation of submitted claims. Failure to provide documentation may result in recoupment. II. Community Behavioral Health Services Fee Schedules use Centers for Medicareand Medicaid Services Place of Service Code Set s located at www.cms.gov .Additional guidance can be found at OAC 5160-27-03. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 07/15/2026 New policy. Approved at Committee.Date Revised Date Effective 10/01/2026 Date Archived H. References1. Medicaid Behavioral Health State Plan Services Provider Requirements and Reimbursement Manual , V 1.28.1. Ohio Dept of Medicaid. Published March 24, 2026. Accessed June 9, 2026. www.ohio.gov 2. Reimbursement for Community Behavioral Health Services, OHIO ADMIN . CODE 5160-27-03 (2024). 3. Telehealth, OHIO ADMIN . CODE 5160-1-18 (2026). 4. Telehealth, OHIO ADMIN . CODE 51 22-29-31 (2022). Appr oved by Ohio Dep artment of Medicaid 07/21/2026.
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 10/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. C oding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage an d payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notif ication, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agre eme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In t he case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the l aw or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medica l and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are n ot subject to limits or requirements that are more restrictive than those that apply to M/S benefits. A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2B. Background ………………………….. ………………………….. ………………………….. …………………… 2C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 Effective Dat e: 10/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectResidential Treatment Services – Substance Use Disorder (SUD) B. BackgroundSubstance Use Disorder (SUD) treatment is tailored to member needs with type, duration and intensity determined by the diagnosis severity, substances used, support systems, prior experiences, and behavioral, physical, gender, cultural, cognitive and social factors , as well as treatment availability and c overage. The American Society of Addiction Medicine (ASAM) levels 3 and 4, or residential and intensive inpatient levels of care (LOC) , serve as transitional stages aiming to return member s to less restrictive community-based care . Level 3 include s clinically managed or medically monitored services, while l evel 4 involves medically managed, intensive inpatient care . Providers follow ASAM criteria to ensure consistent, evidence-based service deliver y acrossthe continuum of care, ensur ing that care is delivered consistently with industry-standard criteria . SUD t reatment is dependent on a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM) . CareSource follows the Ohio Dep t of Medicaids (ODM) policies and procedures and the OhioRevised and Administrative Codes (ORC and OAC, respectively).C. Definitions ASAMs Residential Levels of Care (LOC): o 3.1 Clinically managed, low-intensity residential program o 3.3 Clinically managed, high-intensity, population specific o 3.5 Clinically managed, high-intensity residential program for adults and/or medium intensity for adolescents o 3.7 Medical ly monitored, intensive inpatient for adults and/or high-intensity for adolescents Clinically Managed Services Services directed by nonphysician addiction specialists appropriate for members with emotional, behavioral, cognitive, readiness to change, relapse, or recovery environment concerns. Intoxication, withdrawal, and biomedical concerns, if present, are safely manageable, particularly under Level s 3.1 , 3.3, and 3.5. Inpatient Services Behavioral health (BH) services during an inpatient admission or confinement for acute inpatient services in a hospital or treatment setting on a 24-hour basis under the direct care of a physician, including psychiatric hospitalization, inpatient detoxification, and emergency evaluation and stabilization. Medically Managed Services Services involving 24-hour nursing and daily medical care by an appropriately trained and licensed physician providing diagnostic and treatment services directly, managing the provision of those services, or both, particularly under Level 4 programs. Medically Monitored Services Services provided by an interdisciplinary staff under the direction of a licensed physician through direct patient contact, review of records, team Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 Effective Dat e: 10/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.3 meetings, 24-hour coverage by a physician and nursing staff and a quality assurance program, particularly under Level 3.7 inpatient programs. Medication Assisted Treatment (MAT) The use of Food and Drug Administration (FDA) -approved medications in combination with counseling and behavioral therapies to provide a whole-patient approach to the treatment of SUD. Per Diem A payment made for each day of service based on the sum of the national average routine operating, ancillary , and capital costs for each patient day of care. Residential LOC Services for BH that can include individual, family and group therapy, nursing services, medication assisted treatment, detoxification (ambulatory or subacute) , and pharmacological therapy in a congregate living community with 24-hour support. D. PolicyI. A residential program is staffed 24 hours a day and follows ASAMs LOC criteria and OA C 5122-29-09 . II. A review of medical necessity is require d for the following:A. For the 1st and 2nd admissions per calendar year, a prior authorization (PA) is required after the 30th consecutive day. A member admits for treatment the 1st time in a calendar year for 10 days. No review is required. The same member goes into treatment for a 2nd admission during the same calendar year for 38 days. After day 30, the facility is required to obtain an authorization for days 31 through 38. B. For third and subsequent admission s during the same calendar year, a PA is required from the 1st day of admission. The same member above admits for treatment for a 3rd time during the same calendar year. A PA for this admission is required at day 1. III. Changes in LOC and transfersA. Changes between 2 SUD residential LOC codes within the same provider agency 1. When there is consecutive billing, the step-up or step-down is counted as a single event. 2. When billing is not consecutive, the events will be considered separate events . Reviews of medical necessity may be required depending on utilization in that calendar year . See II.A.B. B. SUD residential transfers between 2 facilities (national provider identifiers [NPI] and/or tax identification numbers [TIN]) 1. A medical necessity review is required for a same-LOC admission or transfer when the total stay exceeds 30 calendar days without a break of more than 24 hours between admissions. If a PA was already required for any reason, the receiving facility must obtain a PA effective on the date of admission. 2. Same LOC admissions or transfers without break s in stay greater than 24 hours are not considered and will no t accumulate as separate event s. 3. If there is a break in stay greater than 24 hours between a same LOC admission or transfer, the admission to the receiving facility is considered a separate event and Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 Effective Dat e: 10/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.4 is subject to PA from the date of admission, beginning with the 3rd admission in a calendar year . The admission will accumulate as a separate event. IV. DocumentationA. At least 1 documented face-to-face interaction must be performed by a clinical treatment team provider at the site in order to bill per diem . B. Medical record s must substantiate the medical necessity of services and follow OAC guidelines for documentation in OAC 5160-1-27 and 5160-8-05 . C. Program s must maintain written Affiliation Agreement s, supported by program policies and procedures, to ensure timely member access to outpatient care upon discharge . V. BillingA. Residential LOC admission 1. One admission is considered 1 length of stay. 2. Any stay under 30 consecutive days counts as a full 30-day admission. 3. Service gaps in excess of 24 hours are considered a termination of 1 admission. 4. Leaving the facility due to significant changes in health status (eg, leaving against medical advice, step-ups , acute medical admissions , step-downs in LOC , incarceration ) are considered a termination of admission . 5. Brief absences of 24 hours or less, except in rare cases, must be documented in the members record and supported by the individualized treatment plan. B. The benefit follows the member , not the providers TIN . C. CareSource processes claims from the following: 1. provider type 95 OhioMHAS certified/licensed treatment program 2. provider specialty 954 OhioMHAS certified/licensed SUD residential facility 3. place of service code 55 residential substance abuse treatment facility D. Claims billed out of sequence from date of service may cause inappropriate den ials for no PA or review of medical necessity . E. Claims are paid as received. If services are receive d from more than 1 provider, claims are paid to providers submit ting the first claim , regardless of date of service. F. SUD residential is paid per diem, which excludes room and board. G. The following services are included in the residential treatment service and will not be reimbursed separately: 1. ongoing assessments and diagnostic evaluations 2. crisis intervention 3. individual, group, family psychotherapy and counseling 4. case management 5. substance use disorder peer recovery services 6. point of care urine drug screens 7. medical services H. A member can only receive services through 1 LOC at a time. 1. The following are non-billable when a member is in a residential LOC : a. therapeutic behavioral services b. psychosocial rehabilitation c. community psychiatric supportive treatment Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 Effective Dat e: 10/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.5 d. mental health day treatment e. assertive community treatment f. intensive home-based treatment g. laboratory/definitive urine drug screens at an outside, independent laboratory 2. Members in residential treatment may receive medically necessary services from practitioners not affiliated with the residential program (eg, psychiatry, MAT , other medical treatment ) that are outside the scope of the residential LOC as defined by ASAM when the service is documented in the treatment plan maintained by the residential provider . E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers. Refer to the BH Fee Schedule for codes. Code inclusion in this policy does not imply any right to reimbursement or guarantee claim (s) payment. Additional provisions for services compliant with ASAM s LOC criteria can be found in the OAC , including programs for individuals under age 18, SUD case management, and crisis services. F. Related Policies/RulesMedical Necessity Determinations Behavioral Health Service Record Documentation Standards G. Review/Revision HistoryH. References 1. American Society of Addiction Medicine . The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions , 3rd Ed. Hazelton Betty Ford Foundation; 20 13. DATE ACTIONDate Issued 08/17/2017Date Revised 05/15/2019 09/16/2020 12/28/202011/30/202101/18/ 202 3 01/31/2024 06/04/202506/03 /2026 Updated definition s, medical necessary criteria, and billing .Updated definition s. A dded note under D.I. Added D.I.C.;D.1.IV. A.5 , IV.B. Added related policy. Revised D.IV.H.2 & I.C.D. & E. Provided clarification per ODM D. 1. C, D, and E; and D. IV. A. Removed codes from policy, updated definitions. Annual review. Updated background. Added definitions. Annual review. Updated D.I.A. Deleted Sections D.II and V., 8 on VI.G. Updated Fand H. Approved at Committee. Annual review. Updated reference list. Approved at Committee. Annual review. Updated D.V.G.6. & added D.V.H.1.g. Updated reference list. Approved at Committee. Date Effective 10/01/2026 Date Archived Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 Effective Dat e: 10/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.6 2. Coverag e and Limitations of Behavioral Health Services , OHIO ADMIN . CODE 5160-27-02(202 4). 3. Eligible Provider for Behavioral Health Services , OHIO ADMIN . CODE 5160-27-01 (202 4). 4. Eligible Providers and Supervisors , OHIO ADMIN . CODE 5122-29-30 (202 4). 5. Medicaid Behavioral Health State Plan Services Provider Requirements and Reimbursement Manual . Ohio Dept of Medicaid; 2023. Accessed May 26 , 202 6. www.medicaid.ohio.gov 6. Residential and Withdrawal Management Substance Use Disorder Services, OHIO ADMIN . CODE 5122-29-09 (2023). 7. Statutes, regulations, and guidelines. Substance Abuse and Mental Health Services Administration. Accessed May 26 , 202 6. www.samhsa.gov 8. Substance Use Disorder Qualified Residential Treatment Program (QRTP) for Youth, OHIO ADMIN . CODE 5122-29-09.1 (2022). 9. Substance Use Disorder Treatment Services, OHIO ADMIN . CODE 5160-27-09 (2021). Approved by Ohio Dept of Medicaid 07/14/2026
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Postpayment Review Non-Submission of Medical Records-OH MCD-PY-1815 10/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.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 Postpayment Review Non-Submission of Medical Records-OH MCD-PY-1815 Effective Dat e: 10/01/2026 2A. SubjectPostpayment Review Non-Submission of Medical Records B. BackgroundReimbursement of claims will be established based upon a review of the actual services provided to a member. It is the responsibility of the provider to submit the most accurate and appropriate CPT, HCPCS, revenue codes, modifiers, and/or diagnosis codes f or the product or service that is being provided. Postpayment review of claims assists CareSource with ensuring accuracy in the payment process. Postpayment reviews may be completed as part of claim adjudication, payment integrity, quality improvement and quality of care, credentialing and recredentialing , utilization management, peer review, and other programs required forCareSource operations.In accordance with Ohio Administrative Code 5160-1, p roviders must maintain medicalrecords sufficient to establish medical necessity of services and demonstrate that conditions of payment have been met and records must be furnished upon request toCareSource . C. Definitions Medically Necessary Services Conditions of medical necessity are met if ALL the following apply: o Meets generally accepted standards of medical practice. o Clinically appropriate in type, frequency, extent, duration, and delivery setting. o Appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome. o Is the lowest cost alternative that effectively addresses and treats the medical problem. o Provides unique, essential, and appropriate information if used for diagnostic purposes. o Not provided primarily for the economic benefit of the provider nor for the convenience of the provider or anyone else other than the recipient. D. PolicyI. Providers are required to maintain complete and accurate medical records t hat verify that services are medically necessary , substantiate the accurate coding of the claim , and validate that conditions of payment have been met. II. CareSource will initiate contact with providers to request medical records as part of postpayment review s. Providers are expected to return medical record requests within established timelines. Providers who use third party health information management vendors remain responsible for providing medical records to CareSource. Postpayment Review Non-Submission of Medical Records-OH MCD-PY-1815 Effective Dat e: 10/01/2026 3III. Failure to provide complete medical records as requested will result in a recovery of payment for claims lacking medical records to establish medical necessity of services . E. Conditions of CoverageI. In the event of any conflict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document. II. Prior authorization is not a guarantee of payment or a final determination of medicalnecessity.III. It is the responsibility of the provider to submit the most accurate and appropriate CPT or HCPCS codes along with the appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes.IV. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. Codes and the use of any modifiers must be fully supported in the medical record. CareSource may verify the use of any code through post-payment audit. F. Related Policies/RulesBehavioral Health Service Record Documentation Standards Medical Necessity Determinations Medical Record Documentation Standards for Practitioners Overpayment Recovery G. Review/Revision HistoryDATE ACTIONDate Issued 07/15 /2026 New policy. Approved at Committee.Date Revised Date Effective 10/01/2026 Date Archived H. References1. CareSource Ohio Medicaid Provider Manual . CareSource. Updated October 24, 2025. Accessed May 29, 2026. www.caresource.com 2. General Reimbursement Principles, OHIO ADMIN . CODE 5160-1-02 (2019). 3. Medicaid Medical Necessity: Definitions and Principles, OHIO ADMIN . CODE 5160-1- 01 (202 2). 4. Recovery of Medicaid Overpayments, OHIO REV . CODE 3922.01 (20 15). 5. Review of Provider Records, OHIO ADMIN . CODE 5160-1-27 (2015). Approved by ODM 07/21/2026
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Evaluation and Management (E&M) Codes Billed withTreatment/Specialty Room Revenue Codes-OH MCD-PY-182410/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlli ng document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not subject to limits or requirements that are mo re restrictive than those that apply to M/S benefits.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 Evaluation and Management (E&M) Codes Billed withTreatment/Specialty Room Revenue Codes-OH MCD-PY-1824Effective Dat e: 10/01/2026 2A. SubjectEvaluation and Management (E&M) Codes Billed with Treatment /Specialty Room Revenue Codes B. BackgroundThis policy outlines guidelines for evaluation and management (E&M) codes billed with treatment /specialty room revenue codes. Treatment /specialty room revenue codes characterize services that are procedure-based in a facility setting. These charges are typically billed using a UB-04 institutional /facility claim form. E&M codes characterize eva luation and management services performed in an office-based setting and do not represent a specific procedure performed in a treatment/specialty room. These charges are typically billed using a CMS-1500 practitioner claim form. Billing E &Ms ervices using any revenue code outlined within this policy does not align with t he UB-04 manual and Uniform Billing Editor (2020) and , therefore , should be avoided. C. Definitions CMS-1500 A standard claim form that professional providers and medical billing professionals use to bill insurance companies for health care services. Evaluation and Management (E&M) Codes Services reported by physician and non-physician practitioners which the provider is either evaluating or managing a patients health. Revenue Code A 4-digit number used on hospital bills to inform insurance companies either where the patient was when receiv ing treatment or what type of item a patient may have received . Treatment /Specialty Room A room in a facility where a specific procedure or treatment is rendered. UB-04 Claim form used by hospitals and other providers to bill for institutional services. A valid procedure code must accompany a revenue code for it to be accepted by the insurance provider. D. PolicyI. CareSource does not reimburse E&M codes when performed and billed using revenue codes associated with a general room, treatment room or other room . II. Billing treatment /specialty room revenue codes is incorrect coding when reported for office-based evaluation and management services. III. Revenue codes not reimbursable when billed with E &M codes :Revenue Code Description 0760 General Specialty Services 0761 Treatment Room Specialty Services 0769 Other Specialty Services Evaluation and Management (E&M) Codes Billed withTreatment/Specialty Room Revenue Codes-OH MCD-PY-1824Effective Dat e: 10/01/2026 3IV. CPT/HCPCS codes not reimbursable when billed with revenue codes listed above :CPT/HCPCS Code Description 99202-99499 Evaluation and Management Services G0463 Hospital outpatient clinic visit for assessment and management of a patient E. Conditions of CoverageClaims submitted with revenue codes in conjunction with an evaluation and management cod es (CPT/HCPCS) listed within this policy will be denied . Reimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and policyclarification. Reimbursement will be established based on 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. Reimbursement i s dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers, if applicable. Codes referenced in this payment policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 06/17/2026 New policy. Approved at Committee.Date Revised Date Effective 10/01/2026 Date Archived H. References1. CPT. Accessed June 04, 2026. www.ama-assn.org 2. Evaluation and Management (E &M) Coding. Accessed June 04, 2026. www.ama – assn.org 3. Facility fees and how they affect health care prices. Health Care Cost Institute. Accessed June 04, 2026. www.healthcostinstitute.org 4. Healthcare Common Procedure Coding System (HCPCS). Accessed June 04, 2026. www.cms.gov 5. Professional paper claim form (CMS-1500). Centers for Medicare & Medicaid Services. Modified September 10, 2024. Accessed June 04, 2026. www.cms.gov 6. Revenue Codes. Medicare Claims Processing Manual Chapter 25 – Completing and Processing the Form CMS-1450 Data Set. Centers for Medicare & Medicaid Services; 2023. Accessed June 04, 2026. www.cms.gov Evaluation and Management (E&M) Codes Billed withTreatment/Specialty Room Revenue Codes-OH MCD-PY-1824Effective Dat e: 10/01/2026 47. Uniform Billing with Form CMS-1450. Medicare Claims Processing Manual Chapter25 – Completing and Processing the Form CMS-1450 Data Set. Centers for Medicare & Medicaid Services; 2023. Accessed June 04, 2026. www.cms.gov 8. What are E &M Codes? Accessed June 04, 2026 . www.aapc.com 9. What is outpatient facility coding and reimbursement. AAPC. Reviewed April 29, 2026. Accessed June 04, 2026. www.aapc.com Approved by O hio Department of Medicaid 06/2 4/2026
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Point of Care Testing-OH MCD-PY-1617 09/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the control ling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by feder al and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance u se disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not subject to limits or requirements that are more restrictive than those that apply to M/S benefits.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 Point of Care Testing-OH MCD-PY-1617Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectPoint of Care Testing B. BackgroundDrug monitoring protocol helps detect drug use or misuse early, leading to prevention, intervention and treatment. Drug testing can occur via point-of-care testing ( POCT ), performed outside the clinical laboratory setting in a Clinical Laboratory Improvement Amendments (CLIA) -waived lab in close proximity to the qualified provider . POCT has advantages and disadvantages that must be weighed by the provider. H0048 , a Healthcare Common Procedure Coding System (HCPCS) code for alcoholand/or other drug testing: collection and handling only, specimens other than blood , can be used by Ohio providers , as necessary , for POCT . Chain of custody is a critical process in the handling of specimens, particularly urine samples, to ensure the integrity, reliability , and legal admissibility of results. By documenting step s from collection to analysis, authenticity of the sample is preserved . Additionally, by ensuring that all perso nnel involved in the process are trained and follow established protocols, chain of custody contributes to quality assurance in drug testing practices. A robust chain of custody protocol establishes standardized procedures for sample collection, handling, storage and transportation , ensur ing that samples are treatedequally and results are comparable. Many regulatory bodies and industry standards, such as those set by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Department of Transportation (DOT), require str ict adherence to chain of custody protocols. Compliance with standards is essential for maintaining accreditation an d ensuring that testing practices meet legal and ethical guidelines . Laboratory services, eligible providers and collection of specimens for the State of Ohioare governed by the Ohio Administrative and Revised Code s (OAC and ORC,respectively ). CareSource adheres to policies published by the Ohio Dept of Medicaid (ODM) in the handling of drug specimens , and any information published by the State supersedes information in this policy. OAC rule 5160-27-09 establishes the American Society of Addiction Medicine (ASAM) placement criteria as the standard for Ohio Medicaid coverage of substance use disorder (SUD) treatment services. SUD services are covered when provided by eligible providers , as defined in 5160-27-01. This policy pertains to presumptive POCT when immediate test results are needed to guide treatment. C. Definitions Date of Service (DOS) The date the specimen was collected unless an exception noted by 42 C .F.R. 414.510. Place of Service (POS) The location where the laboratory service was collected. o 11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or Point of Care Testing-OH MCD-PY-1617Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.o 57 Non-Residential Substance Abuse Treatment Facility – A location provid ing treatment for substance (alcohol and drug) abuse on an ambulatory basis. Point of Care Testing (POCT) Immediate test results for management of the member available when a qualified provider and member are in the same location for identification of a few specific drugs or classes of drugs and read by the human eye or instrument-assisted direct optical observation. D. PolicyI. POCT must be medically necessary or medically indicated in medical documentation and identify an immediate need . H0048 cannot be billed on the same date of service as H0010, H0011, H0012, H2034, or H2036 ( ie, Substance Use Disorder residential services). A. All providers billing for laboratory services should append identifying modifiers, when appropriate, in accordance with correct coding and instruction from ODM. B. Chain of custody documentation begins at the collection site. II. CareSource reserves the right to request documentation from providers , laboratories or other facilities. Appropriate documentation for POCT includes the following: A. Orders from a physician or other qualified healthcare professional 1. A laboratory service may be rendered on the verbal order of a physician or other qualified healthcare professional. 2. The provider may submit a claim only after a lab oratory provider has obtained a written order given in any industry-recognized format, such as handwriting, typed text or electronic transmission. A written order may consist of an entry in a member’s medical record in an individual practitioner’s office, a group practice or a hospital and includes the following information: a. name of the medicaid-eligible member b. contact information for the practitioner ordering the service c. specification of the service (eg, procedure code, description, number of units) d. at least 1 appropriate diagnosis code e. date of the order f. names of the relevant persons or entities involved in providing the service (eg, referring laboratory, reference laboratory, interpreting practitioner, radiographer) g. any additional information necessary to ensure accurate and timely testing or reporting NOTE : If the ordering provider does not sign the order, the medical record must show intent to order and medical necessity for testing. 3. No separate written order is needed for a medically necessary follow-up procedure if the procedure is performed in accordance with appropriate standard practices and is included in the laboratory provider’s written Point of Care Testing-OH MCD-PY-1617Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 protocols. A written order is needed for any additional procedure that is based solely on a laboratory provider’s internal protocols.B. Laborator ies are to maintain the following as specified in OAC 5160-1-17.2 : 1. a copy of each written order for a procedure or service (clinical diagnostic procedure, pathology procedure, consultation or interpretation) 2. a copy of any clinical diagnostic procedure result for which consultation or interpretation was ordered III. Collection and documentation of specimensA. Collection of specimens Collectors of urine drug tests will ensure a collection protocol that protects the security and integrity of the collection by 1. testing member s as soon as possible after an order is received 2. verifying member identification via photo identification or other confirming identification 3. ensuring removal of garments that might conceal substances or items that could adulterate the sample , including the emptying of pockets 4. securing all water sources and checking the water in the toilet tank and bowl prior to urination 5. inspecting the test site to ensure cleanliness and a lack of unauthorized substances, including the removal of any possible adulterants 6. prohibiting unauthorized personnel from entering the site during collection 7. providing privacy during the collection but supervis ing the process 8. measuring specimen temperature promptly after collection and visually inspecting sample s for color and contaminants 9. sealing and labeling specimen s with seals containing the date and identifying information in the presence of the member B. Documentation of collection Chain of custody documentation must be maintained to ensure the integrity of any specimens collected. Documentation of the following information related to specimen samples is required: 1. The collector will certify with a legible, dated signature that the specimen was collected, labeled and sealed in accordance with standards developed by the State of Ohio. 2. The collector will record the following: a. the temperature of the specimen and whether the specimen was a single collection or a split specimen collection b. if specimen collection was directly observed and why, if applicable c. date of collection and date of seal, if different from the collection date d. time of collection 3. Any specific details regarding release of the specimen to any other facility, laboratory, delivery service or professional, if applicable, including a. person to whom the specimen was released b. documented time of any change in possession of specimen (ie, courier pickup, delivery to lab or facility) Point of Care Testing-OH MCD-PY-1617Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 c. reason for release d. any additional instructions regarding the specimen C. Results of screening or testing will be reviewed by program staff with member s. Documentation of such and a copy of the results will be placed in the members medical record in accordance with OAC 5122-27-04. E. Conditions of CoverageI. Only the eligible provider perform ing specimen collection may receive payment. II. No payment is made for t ravel associated with the collection of specimens.III. Laboratories and p rovider s are to use the code (s) that describes the procedure in the most detail. F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATE ACTIONDate Issued 12/1 7/2025 New policy. Approved at Committee.Date Revised 04/ 22/2026 Added no concurrent with SUD residential (D.I.) & D.III.B.3.b. Updated references. Approved at Committee. Date Effective 09/01/2026 Date Archived H. References1. Behavioral Health Services-Other Licensed Professionals, OHIO ADMIN . CODE 5160 – 8-05 (2021). 2. Collection and Handling of Blood, Urine and Oral Fluid Specimens, OHIO ADMIN . CODE 3701-53-06 (2023). 3. Collection and Handling of Specimens, OHIO ADMIN . CODE 123:1-76-05 (2002). 4. Eligible Providers, OHIO ADMIN . CODE 5160-1-17 (2019). 5. HCPCS code: H0048. HCPCS Codes. Accessed April 13, 2026. www.hcpcs.codes 6. Lab/Services/Orders Fact Sheet. Centers for Medicare and Medicaid Services; 2018. Accessed . www.cms.gov 7. Laboratory Date of Service for Clinical Laboratory and Pathology Specimens, 42 C.F.R. 414.510 (2026). 8. Laboratory Date of Service Policy . Centers for Medicare and Medicaid Services. Accessed April 13, 2026. www.cms.gov. 9. Laboratory Services, OHIO ADMIN . CODE 5160-11-11 (2021). 10. Medicaid Advisory Letter (MAL) No. 650 . Ohio Dept of Medicaid. Revised March 3, 2021. Accessed April 13, 2026. www.ohio.gov Point of Care Testing-OH MCD-PY-1617Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 11. Medicaid Behavioral Health State Plan Services Provider Requirements and Reimbursement Manual . Ohio Dept of Medicaid. Accessed April 13, 2026. www.ohio.gov 12. ODM DXC Working Document: BH Redesign Audits/Edits/Limits. Ohio Dept of Medicaid; no date. Accessed April 13, 2026. www.ohio.gov 13. Place of service code set. Centers for Medicare and Medicaid Services. Updated May 2, 2024. Accessed April 13, 2026. 14. Progress Notes, OHIO ADMIN . CODE 5122-27-04 (2019). 15. Provider Agreement for Providers, OHIO ADMIN . CODE 5160-1-17.2 (2019). 16. Toxicology, OHIO ADMIN . CODE 5122-40-11 (2025). Ohio Department of Medicaid Approved June 8, 2026
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 09/01/2026 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 no t limited to, those health care services or suppli es that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or si gnificant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also inc lude those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Rei mbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan c ontract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may mod ify 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 ………………………….. ………………………….. ………………………….. …… 7 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 9 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 9 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectGeneral Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services B. BackgroundMost dental care can be provided in a traditional dental office setting with local anesthesia and , if medically necessary, a continuum of behavior al guidance strategies ranging from simple communicative techniques to nitrous oxide, or enteral or parenteral sedation. Monitored anesthesia care or sedation ( minimal, moderate, or deep) may be a requirement of some members , including those with challenges related to age, behavior or developmental disabilities, medical status, intellectual limitations, or other special needs. As an increasing number of members of all ages and complexity seek sedation and anesthesia for dental procedures in office-based settings, it is important to keep member safety central to the delivery of sedation and ane sthesia services. Sedation and anesthesia safety in an office-based setting is dependent on patient selection, sedation and anesthesia goals, techniques, vigilant patient monitoring, as well as the skills and competencies of the patient-centered care team. A dental office setting may be a location for sedation and/or anesthesia modalities only when there are trained and licensed personnel to administer and monitor these services and office facilities are properly equipped and safe per federal and state regul atoryrequirements. Additional information on educational and clinical guidelines to deliver safe and effective sedation and anesthesia can be found in the American Dental Associations Guidelines for the Use of Sedation and General Anesthesia by Dentists (see references) . Alternatively , there are certain situations where patient s may require general anesthesiain a healthcare facility , such as an ambulatory surgical center or outpatient hospital facility. Refer to the Dental Services Rendered in a Hospital or Ambulatory Surgery Center reimbursement policy, OH MCD-PY-1244 for more information on t hese services. C. Definitions 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. Office Setting An office or portion thereof utilized to provide medical and/or surgical services to the physician s or dentist s patients. Office setting does not include an office o r portion thereof licensed as an ambulatory surgical facility by the Department of Health pursuant to divi sion (E)(1) of section 3702.30 of the Ohio Revised Code (ORC) , a hospital pursuant to section 3701.07 of the ORC , or an emergency department located within such a hospital . Place of Service (POS) Codes 2-digit codes placed on health care professional claims to indicate the setting in which a service was provided. General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Sedation Continuum When patients undergo procedural sedation/analgesia, a sedation continuum is entered . Several levels have been formally defined along this continuum: minimal sedation/anxiolysis, moderate sedation, deep sedation, and at the deepest level, general anesthesia. 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 adequate. 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 requir e assistance 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, an d positive 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 a 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 initially intended . Practi tioner s 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 of a patien t from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced cardiac life support. D. PolicyI. Safety Attestation Questionnaire General anesthesia and monitored anesthesia care (MAC) for oral maxillofacial surgery (OMS) and dental-type services performed in the dental office setting require the dental office to complete and submit an initial Provider Questionnaire and Patient Safety Attestation for Dental Sedation/General Anesthesia for each practice location to the respective provider contracting team to ensure all Ohio regulations are followed and patient safety is prioritized. After providing to the contracting team , this General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 document should be kept on file. See Appendix A. Provider Questionnaire andPatient Safety Attestation for Dental Sedation/General Anesthesia . II. Office-Based RequirementsA. Patient Selection The treati ng dental provider should select cases based on the medical necessity criteria in section III. As noted by the American Society of Anesthesiologists (ASA): 1. The procedure to be undertaken is within the scope of practice of the health care practitioners and the capabilities of the dental office facility. 2. The procedure should be medically appropriate for a dental office and of a duration and degree of complexity that will permit the member to recover and be discharged from the facility. 3. Member s who by reason of pre-existing medical or other conditions may be at undue risk for complications should be referred to an appropriate facility for performance of the procedure and the administration of anesthesia. B. Office Facility 1. The facility must meet all state requirements. 2. Pursuant to OAC 4715-5-05 , the provider must have a properly equipped facility(s), whether fixed, mobile, or portable, for the administration of general anesthesia or deep sedation in which the permit holder has available and agrees to utilize adequate monitoring, personnel, emerge ncy equipment and drugs as recommended in the “Guidelines for the Use of Sedation and General Anesthesia by Dentists” as adopted by the October 2016 ADA House of Delegates and/or the American Association of Oral and Maxillofacial Surgeon’s Office Anesthesia Evaluation Manual , 9th edition and maintains successful completion of basic life support for healthcare providers (BLS-HCP) and advanced cardiac life support (ACLS) course(s). 3. The practitioner who uses sedation must have immediately available facilities, personnel, and equipment to manage emergency and rescue situations. A protocol for immediate access to back-up emergency services shal l be clearly outlined. For nonhospital facilities, a protocol for the immediate activation of the E mergency Medical Service (EMS) system for life-threatening complications must be established and maintained. The availability of EMS does not replace the practitioners responsibility to provide initi al rescue for life-threatening complications. 4. Pursuant to OAC 4715-5-05 in the case of a mobile or portable facility, 1 inspection of that facility by the Ohio Board shall be conducted in the office of an Ohio-licensed dentist where deep sedation or general anesthesia is administered. A written list of all monitors, emergency equipment, and other materials which the mobile anesthesia provider agrees to make available at all times while administering moderate sedation, deep sedation, and general anesthesia in multiple locations shall be provided to the board. 5. External rescue and emergency services should be available and accessible in a timely manner should they be needed. General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 C. Genera l Monitoring and Patient SafetyEquipment used to monitor the member during sedation and anesthesia should be consistent with A merican Association of Nurse Anesthesiology (AANA) Standards for Office Based Anesthesia Practice and other nationally recognized standards and guidelines. The American Academy of Pediatric Dentistry (AAPD ) Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures should be followed as a guide for patient safety and any applicable state requirements. 1. An emergency cart or kit must be immediately accessible and must contain the necessary age and size-appropriate equipment (eg, oral and nasal airways, bag-valve-mask device, LMAs or other supraglottic devices, laryngoscope blades, tracheal tubes, face masks, blood pressure cuffs, intravenous catheters) to resuscit ate a child. 2. Monitoring devices, such as electrocardiography (ECG) machines, pulse oximeters with size-appropriate probes, end-tidal carbon dioxide monitors, and defibrillators with size-appropriate patches/paddles, must have a safety and function check on a regular ba sis as required by local or state regulation . 3. Documentation prior to and during sedation shall include, but not be limited to, the following: a. health evaluation b. informed consent c. anesthesia documentation time d. treatment documentation D. Anesthesia Provider and Team 1. The practitioner providing sedation and/or anesthesia care in the dental office-based setting must have a permit in good standing issued by the state of Ohio respective licensing board. 2. There must be enough appropriately trained staff to both carry out the procedure and monitor the patient, before, during , and a fter, with a staffed recovery area in accordance with OAC 4715-5-05. 3. Pharmaceuticals must be properly stored and maintained, and th e anesthesia provider must maintain appropriate records of all controlled substances received, administered, dispensed, or used in accordance with ORC 3719.07. If the provider is function ing as a manufacturer or wholesale distributor of such su bstances, an appropriate licen se , in accordance with ORC 4729.52 , must be maintained . 4. Pre-anesthesia evaluation a. A pre-anesthesia evaluation must be completed and documented within 48 hours of an inpatient or outpatient surgery or any procedure requiring anesthesia services. This does not negate the evaluation required immediately prior to induction of anesthesia set forth by The Joint Commission. The delivery of the first dose of medication for the purpose of inducing anesthesia marks the end of the 48-hour time frame. b. In accordance with current standards of anesthesia care, some elements of the pre-anesthesia evaluation may be performed prior to the 48 hours; General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 however, these elements cannot be performed more than 30 days prior to surgery or a procedure requiring anesthesia services. Review of these elements must be conducted, and any appropriate updates documented, within the 48-hour time frame.5. Post-anesthesia evaluation a. The post-anesthesia evaluation must be performed immediately following the conclusion of services for which anesthesia was provided with documentation completed no later than 48 hours after the patient is moved into the designated recovery area. b. The accepted standards of anesthesia care indicate that the evaluation should not begin until the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation at an age-appropriate level . c. For patients unable to participate in the post-anesthesia evaluation ( eg , post-operative sedation, mechanical ventilation, age), a notation that the patient was unable to participate and why, as well as expectations for recovery time (if applicable) , should be noted. d. Patients who received long-acting regional anesthesia with acute effects last ing beyond the initial post-anesthesia evaluation time frame should have a notation that the patient is otherwise able to participate in the evaluation but full recovery from regional anesthesia has not occurred and is not expected within the stipulated time frame for the completion of the evaluation. e. Patient should not be discharged until criteria met and patient has returned to pre-anesthesia state of consciousness. A responsible adult should be present at discharge. E. Medical Necessity Criteria 1. General anesthesia and MAC for OMS and dental-type services , whether covered under the medical plan benefits or dental plan benefits , is considered medically necessary when at least 1 of the following clinical criteria are met: a. Extensive or complex oral surgical procedures , such as: 01. 4 or more simple and/or surgical extractions in more than 1 quadrant in 1 appointment 02. impacted wisdom teeth 03. surgical root recovery from maxillary antrum 04. surgical exposure of impacted or unerupted cuspids 05. radical excision of lesions more than 1.25 cm b. Any of the following medical conditions apply : 01. mental incapacitation (such that the members ability to cooperate with procedures is impaired), including intellectual disability, cerebral palsy, epilepsy, organic brain disease and behavioral problems associated with uncooperative but otherwise healthy children that would render the member noncompliant 02. severe physical disorders affecting the tongue or jaw movements 03. seizure disorders General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 04. significant psychiatric disorders resulting in impairment of the members ability to cooperate with procedures05. previously demonstrated idiosyncratic or severe reactions to IV sedation medication 06. medical condition(s) which require monitoring ( eg, cardiac problems, severe hypertension), a medical consultation with the members physician is recommended. 07. documented failed sedation or a condition where severe periapical infection would render local anesthesia ineffective c. Documentation that member is less than 3 years old with extensive treatment , which is provided in the members medical record . 2. Other Sedation Continuum a. Moderate/IV conscious sedation administered intravenously may be indicated for the following situations: 01. anxiety and fear when other techniques have proven inadeq uate 02. pain control when other techniques have proven inadequate 03. management of gag reflex if nitrous oxide is ineffective or not suitable 04. member medically compromised or with special needs 05. lengthy restoration procedures for pediatric members 06. allergy or sensitivity to local anesthesia b. Non-intravenous sedation may be indicated for the following situations: 01. anxiety 02. member uncooperative or unmanageable with complex dental needs c. Nitrous oxide ( anxiolysis) may be indicated for the following: 01. ineffective local anesthesia 02. anticipatory or situational anxiety 03. apprehensive/frightened child 04. member s with special needs 05. extensive and/or complex services 06. members with behavioral or uncooperative challenge s 07. management of a severe gag reflex d. Nitrous oxide and other sedation will not be considered strictly for member or provider convenience. e. Only 1 type of sedation/anesthesia is reimbursable per date of service . E. Conditions of CoverageThe following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all-inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service for all benefit categories. The member-specific benefit plan document and applicable laws that may require coverage for a specific service determine benefit coverage for health services. The inclusion of a code does not imply any rig ht to reimbursement o r guarantee claim payment. See corresponding benefit grid for limitation, exclusions, and benefit categories Dental Office Place of Service (POS) (11) General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 o Use CPT code 00170 for general anesthesia or G9654 for monitored anesthesia when performing intraoral treatments. o 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 units (ie, 75 minutes ; 75 = 5 units [of 15 min increments ]. CMS base units = 5 ). Maximum state allowances may be applicable. o Payment for an anesthesia service is the lesser of the provider’s submitted charge or the Medicaid maximum, which is determined by a formula. Codes Description00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified G9654 Monitored anesthesia care (MAC) 99151 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the mo nitoring of the patients level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age 99152 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the mo nitoring of the patients level of consciousness an d physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 99153 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the mo nitoring of the patients level of consciousness and physiological status; each additional 15 minutes intraservice time D9222 Adminis tration of d eep sedation/general anesthesia first 15 minutes , or any portion thereof , with or without co-administration of nitrous oxide D9223 Administration of deep sedation/general anesthesia each subsequent 15 – minute increment or any portion thereof D9224 Administration of general anesthesia with advanced airway-first 15 minutes or any portion thereof, with or without the coadministration of nitrous oxid e D9225 Administration of general anesthesia with advanced airway-each additional 15 minutes or any portion thereof D9230 Administration of nitrous oxide D9239 Administrat ion of mod erate sedation intravenous first 15 minutes or any portion thereof , with or without co-administration of nitrous oxide General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.9 D9243 Admi nistration of moderate sedation intravenous each subsequent 15-minute increment or any portion thereof D9244 In-office administration of minimal sedation-single drug-enteral, D9245 Administration of moderate sedation-enteral D9246 Administration of moderate sedation-non-intravenous-first 15 minutes or any portion thereof, with or without the coadministration of nitrous oxide D9247 Administration of moderate sedation-non-intravenous-each additional 15 minutes or any portion thereof F. Related Policies/RulesDental Services Rendered in Hospital or Ambulatory Surgical Center G. Review/Revision HistoryDATE ACTIONDate Issued 04/09/2025 New policy. Approved at Committee.Date Revised 05/20 /2026 Review: updated coding, references, approved at Committee. Date Effective 09/01/2026 Date Archived H. References1. Accreditation of Office Settings, OHIO ADMIN . CODE 4731-25-07 (2018). 2. American Academy of Pediatric Dentistry . Pain management in infants, adolescents and individuals with special health care needs. Reference Manual of Pediatric Dentistry. 2025-2026:456-464 . Accessed April 27, 2026 . www.aapd.org 3. American Academy of Pediatric Dentistry . Policy for selecting anesthesia providers for the delivery of office-based deep sedation/general anesthesia. Reference Manual of Pediatric Dentistry. 2025-2026:177-179 . Accessed April 27, 2026 . www.aapd.org 4. American Academy of Pediatric Dentistry . Policy on care for vulnerable populations in a dental setting. Reference Manual of Pediatric Dentistry. 2025-2026:52-60 . Accessed April 27, 2026 . www.aapd.org 5. American Academy of Pediatric Dentistry . Policy on patient safety. Reference Manual of Pediatric Dentistry. 2025-2026:30-35 . Accessed April 27, 2026 . www.aapd.org 6. American Academy of Pediatric Dentistry . Policy on the ethical responsibilities in the oral health care management of infants, children, adolescents, and individuals with special health care needs. Reference Manual of Pediatric Dentistry . 2025-2026:26 – 27 . Accessed April 27, 2026 . www.aapd.org 7. American Academy of Pediatric Dentistry . Use of anesthesia providers in the administration of office-based deep sedation/general anesthesia to the pediatric dental patient. Reference Manual of Pediatric Dentistry. 2025-2026:451-455 . Accessed April 27, 2026 . www.aapd.org 8. American Academy of Pediatric Dentistry . Use of local anesthesia for pediatric dental patients. Reference Manual of Pediatric Dentistry. 2025-2026:407-414 . Accessed April 27, 2026 . www.aapd.org General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.10 9. American Academy of Pediatric Dentistry . Use of nitrous oxide for pediatric dental patients. Reference Manual of Pediatric Dentistry. 2025-2026:415-422 . Accessed April 27, 2026 . www.aapd.org 10. American Association of Oral and Maxillofacial Surgeons. Ambulatory Surgical Center Coding and Billing. Accessed April 21 , 202 6. www.aaoms.org 11. American Dental Association. ADA Guidelines for the Use of Sedation and General Anesthesia by Dentist s. October 20 25 . Accessed April 21 , 202 6. www.ada.org 12. American Dental Association. CDT Coding Guide: Nitrous Oxide, Sedation and General Anesthesia. January 2026. Accessed April 28, 2026. www.ada.org 13. American Society of Anesthesiologists. Statement on Office-Based Anesthesia. Accessed April 27, 2026 . www.asahq.org 14. Anesthesia Services, OHIO ADMIN . CODE 5160-4-21 (2024). 15. ASA Committee on Economics. Distinguishing between a pre-anesthesia evaluation and a separately reportable evaluation and management service. American Society of Anesthesiologists . Updated March 2023. Accessed April 21 , 202 6. www.asahq.org 16. Conditions and Limitations, OHIO ADMIN . CODE 5160-2-03 (2022). 17. Cot, CJ, Wilson S, American Academy of Pediatric Dentistry, American Academy of Pediatrics. Guidelines for monitoring an d management of pediatric patients before, during, and after sedation f or diagnostic and therapeutic procedures. Ped Dentistry. 2019;41(4):E26-E52. Accessed April 27, 2026 . www.aapd.org 18. Definition of Terms, OHIO ADMIN . CODE 4731-25-01 (2011). 19. Dental Services, OHIO ADMIN . CODE 5160-5-01 (202 4). 20. FDA drug safety communication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. US Food and Drug Administration. Updated March 8, 2018. Accessed April 27, 2026 . www.fda.gov 21. General Provisions, OHIO ADMIN . CODE 4731-25-02 (2024). 22. Licenses for Wholesale Distributors and Manufacturers of Dangerous Drugs, Outsourcing Facilities, Third-Party Logistics Providers, and Repackagers; Application; Issuance; Renewal; Fees, OHIO REV . CODE 4729.52 (2020). 23. Medicaid Medical Necessity: Definitions and Principles, OHIO ADMIN . CODE 5160-1- 01 (2022). 24. Pediatric Anesthesia. US Food and Drug Administration. Updated April 24, 2017. Accessed April 27, 2026 . www.fda.gov 25. Record of All Controlled Substances Received, Administered, Dispensed, or Used, OHIO REV . CODE 3719.07 (2019). 26. Standards for Surgery Using Anesthesia Services, OHIO ADMIN . CODE 4731-25-04 (2018). 27. Standards for Surgery Using Moderate Sedation/Analgesia, OHIO ADMIN . CODE 4731 – 25-03 (2018). 28. Standards FAQs: medication security anesthesia cart. Office Based Surgery: Medication Management MM. The Joint Commission; 2016. Updated January 9, 2026. Accessed April 28, 2026 . www.jointcommission.org General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.11 29. Standard FAQs: sedation and anesthesia rescue requirements . Office BasedSurgery: Provision of Care Treatment and Services PC . The Joint Commission; 2016. Updated January 9, 2026 . Accessed April 28, 2026 . www.jointcommission.org 30. Standards FAQs: sedation and anesthesia understanding the assessment requirements. Office Based Surgery: Provision of Care Treatment and Services PC . The Joint Commission; 2016. Updated January 19, 2023 . Accessed April 28, 2026 . www.jointcommission.org Approved by ODM 05/27/202 6General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.12 Appendix AProvider Questionnaire and Safety Attestation for Dental Sedation/General Anesthesia CareSource Provider Questionnaire and Attestation for Dental Sedation/General Anesthesia Please answer the following questions and attach a full written explanation pertaining to each YES response. 1. Has any disciplinary action been taken against you by any state board or any regulatory board? ( ) YES ( ) NO 2. Have you had any patient require hospitalization or medical attention, or have you had any patient deaths in the facility or office? ( ) YES ( ) NO 3. Are there any other facts not disclosed by your answers which may have a bearing on your fitness or eligibility to practice dentistry in Ohio, in particular conscious sedation and/or general anesthesia? ( ) YES ( ) NO I, , hereby certify and attest that: (1) I have, or will contract with s omeone who does, all necessary licenses, certifications, and/or permits to the extent required by the applicable laws and regulations of the state of Ohio including, but not limited, to Ohio Admin. Code 4715-5-05, Ohio Admin. Code 4715-3-01, Ohio Admin. Co de 4715-5-06, Ohio Admin. Code 4715-5-07, Ohio Admin. Code 4715-9-01.2, Ohio Admin. Code 4715-11-02.1 Ohio Rev. Code 4715.70, Ohio Rev. Code 4715.71, Ohio Rev. Code 4715.72, and Ohio Rev. Code 4715.73 (collectively, Ohio Law) for the administrati on of conscious sedation and/or general anesthesia/deep sedation in a facility or private dental office setting, as appropriate; (2) I have properly equipped facility(s) or private dental office(s) for the administration of conscious sedation and/or genera l anesthesia/deep sedation in accordance with Ohio Law and generally accepted dentistry practice standards; (3) my facility(s) or private dental office(s) is staffed with qualified dental providers and a supervised team of certified auxiliary personnel in accordance with Ohio Law and generally accepted dentistry practice standards; and (4) the administration of conscious sedation and/or general anesthesia/deep sedation in a facility or private dental office setting, as appropriate, will only be administered by qualified providers in accordance with Ohio Law. I certify and attest that all of the following equipment, drugs, and supplies are in good workingorder at each facility or private dental office for which conscious sedation or general anesthesia/deep sedation services will be performed:1. equipment capable of delivering positive pressure oxygen ventilation including ancillary airway devices 2. pulse oximeter 3. suction equipment that allows aspiration of the oral and pharyngeal cavities 4. operating table or chair that allows for patient positioning to maintain airway 5. firm platform for cardiopulmonary resuscitation (CPR) 6. fail-safe inhalation system if nitrous oxide/oxygen is used 7. equipment necessary to establish intravascular access 8. equipment to continuously monitor blood pressure, heart rate, and rhythm 9. EKG monitor (required for general anesthesia/deep sedation only) General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.13 10. manual or automatic external defibrillator11. appropriate emergency drugs per advanced cardiovascular life support (ACLS), including reversal agents for narcotics and/or benzodiazepines depending on which is actually utilized, or pediatric advanced life support (PALS) protocol 12. recovery area with available oxygen and suction 13. continual monitoring of end tidal CO2 (expired carbon dioxide), unless invalidated by the nature of the patient, procedure or equipment (required for general anesthesia/deep sedation only) I certify and attest all of the aforementioned equipment, drugs, and supplies will at all times remain in good working order and shall be subject to random on-site inspection by CareSource or its delegated benefits administrator . I further certify and attest that all rendering providers of conscious sedation or general anesthesia/deep sedation services and all support personnel are certified in CPR at the basic life support healthcare provider level from a n Ohio Board of Dentistry approved sponsor andhave the appropriate education and training required under Ohio Law. In addition, I certify and attest all rendering providers of conscious sedation or general anesthesia/deep sedation services have: (1) (A) a current certification in advanced cardiovascular life support (ACLS) for adult patients, or (B) a pediatric advanced life support (PALS) for pediatric patients, or (2) an appropriate dental sedation/anesthesia emergency management course approved by Ohio Board of Dentistry. I certify and attest all of the aforementioned certifications will be maintained in accordance with Ohio Law and copies of such certification shall be provided to CareSource upon request.Please initial each paragraph Initial1. I understand I am responsible for maintaining full compliance at all times with Ohio Law when conscious sedation and/or general anesthesia/deep sedation services will be performed at the facility(s) or private dental office(s) listed on this questionnaire and attestation. 2. I understand and agree that CareSource has the full authority to conduct on-site visits at each facility or private dental office listed on this questionnaire and attestation to ensure I am following Ohio Law and generally accepted dentistry practice stand ards when administering conscious sedation or general anesthesia/deep sedation. 3. I understand and agree that I must notify CareSource immediately of any change that may affect the ability of the facility(s) or private dental office(s) listed on this questionnaire and attestation to safely and effectively administer conscious sedation o r general anesthesia/deep sedation services. 4. I understand and agree that I must notify CareSource and fill out additional questionnaire(s) and attestation(s) if I wish to add any additional facilities or private dental offices that are not currently listed on this questionnaire and attestation that will administer conscious sedation or general anesthesia/deep sedation services. General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.14 5. I understand and agree that if I choose to utilize the services of an anesthesiologist who is duly licensed to practice medicine in Ohio pursuant to Chapter 4731 of the Revised Code and who is a member of the anesthesiology staff of an institution classified as a hospital and issued a permit under Ohio Admin. Code 5160-2-01 and for administering conscious sedation or general anesthesia in a dental office setting, that such anesthesiologist must remain on the premises of the facility or private dental office until any patient given conscious sedation or general anesthesia/deep sedation by the anesthesiologist is stabilized and has regained consciousness. 6. I understand and agree that in order to administer conscious sedation or general anesthesia/deep sedation services on CareSource members, all services may be subject to post payment review and all records must be timely available upon request. 7. I understand and agree that maintaining full compliance with Ohio Law for the administration of conscious sedation or general anesthesia/ deep sedation services is material to CareSources review and decision process when considering prior authorization requests. 8. I acknowledge, understand and agree to defend, indemnify and hold harmless CareSource and its directors, officers, employees, agents and affiliates against any and all allegations, actions, suits, demands, liabilities, obligations, losses, settlements, exp enses, damages, costs,judgements, claims or other liabilities, including reasonable attorney fees resulting from any and all acts or omissions arising out of or in connection with administration of conscious sedition or general anesthesia. I, the undersigned, do hereby affirm that all statements made and information contained in this questionnaire and attestation are true, accurate, and correct to the best of my knowledge and belief.Provider Signature: Date:Ohio Medicaid ID#:Facility/Office Name(s):Facility/Office Address(es):
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Evaluation and Management (E/M) and Psychotherapy Add-On – OH MCD-PY-1769 09/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the control ling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by feder al and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance u se disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not subject to limits or requirements that are more restrictive than those that apply to M/S benefits.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 Evaluation and Management (E/M) and Psychotherapy Add-On-OH MCD-PY-1769 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectEvaluation and Management (E/M) and Psychotherapy Add-On B. BackgroundAn Evaluation and Management (E/M) service is a particular medical service provided by qualified healthcare professionals to evaluate a patient’s health status, assess condition, establish diagnoses, and manage care, which includes guiding treatment plans. The difference between a regular and a high-level E/M code primarily relates to the complexity of care, the extent of the evaluation and the intensity of medical decision – making performed during the encounter. These differences are reflected in the docume ntation requirements and the corresponding CPT codes used for billing. When a provider, based on tax identification number (TIN), performs both E/M andpsychotherapy on the same date of service (DOS) for a member , the 2 services must be coded correctly . Psychotherapy sessions often include some evaluation components . To address the potential overlap, add-on psychotherapy codes are used in addition to E/M services for these visits. Ad d-on psychotherapy services must be documented, requiring start/stop times specific to the service and any therapeutic communication that ameliora tes mental and behavioral symptoms, modif ies behavior and support , and encourage s personal growth as treatment for behavior al disturbance s or mental illness. C. DefinitionsNA D. PolicyI. When psychotherapy add-on codes 90833, 90836 or 90838 are billed concurrently with high-level E/M codes 99204, 99205, 99214 or 99215 on the same date of service for the same member by the same provider based on the provider TIN , the add-on psychotherapy codes will be denied. The E/M portion of the claim will be reimbursed. Due to the complexity and cognitive demands of moderate to high complexity Medical Decision Making (MDM), it is unlikely that clinical effort required to complete both E /M and psychotherapy services would not overlap. A. Providers are responsible for appropriate use of add-on codes, billing with modifiers, including use of modifier 25, and interactive complexity. CareSource may request documentation that supports submitted claims. B. Service documentation must ensure that psychotherapy and E/M services are clearly documented, substantial and significant, and independently identifiable. Overlapping time spent in an encounter cannot be counted toward both services. II. The type and level of E/M service is based on MDM. Please see the AmericanMedical Association (AMA) CPT Evaluation and Management (E/M) Services Guidelines for additional instructions.Evaluation and Management (E/M) and Psychotherapy Add-On-OH MCD-PY-1769 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 A. Time spent on activit y of the E/M service is not included in the time used for reporting the psychotherapy service. E/M documentation must support the level of service based on AMA Medical Decision-Making Guidelines . B. Time may not be used as the basis of E/M code selection , and prolonged services may not be reported when psychotherapy with E/M (90833, 90836, 90838) are reported. E. Conditions of CoverageThe following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT CodeDescription90833 Psychotherapy, 30 minutes with patient when performed with an E/M service . 90836 Psychotherapy, 45 minutes with patient when performed with an E/M service . 90838 Psychotherapy, 60 minutes with patient when performed with an E/M service . 99204 Office or other outpatient visit for the E/M of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making . When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. 99205 Office or other outpatient visit for the E/M of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. 99214 Office or other outpatient visit for the E/M of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 99215 Office or other outpatient visit for the E/M of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. F. Related Policies/RulesModifier 25 G. Review/Revision HistoryDATE ACTIONDate Issued 03/11/2026 New policy. Approved at Committee.Date Revised Date Effective 09/01/2026 Date Archived Evaluation and Management (E/M) and Psychotherapy Add-On-OH MCD-PY-1769 Effective Dat e: 09/01/2026 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) Services Guidelines. American Medical Association. Accessed February 23, 2026. www.ama-assn.org Ohio Dep artment of Med icaid approved 06/05/2026
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Electrocardiogram (EKG/ECG) Interpretations-OH MCD-PY-1810 09/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the control ling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by feder al and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance u se disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not subject to limits or requirements that are more restrictive than those that apply to M/S benefits.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 Electrocardiogram (EKG/ECG) Interpretations-OH MCD-PY-1810 Effective Dat e: 09/01/2026 2A. SubjectElectrocardiogram (EKG/ECG) Interpretations B. BackgroundAn electrocardiogram (EKG/ECG) is a non-invasive test that records the electrical activity of the heart and is often used when a possible cardiac issue occurs. The recording is reviewed by a provider who renders an interpretation and written report. An EKG /ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspects together as one service. For the purpose of this policy, EKG will be used to represent both EKG and ECG. A second EKG interpretation may be warranted only under unusual circumstances asmedically necessary .C. DefinitionsNA D. PolicyI. CareSource will reimburse the first EKG interpretation claim that is received for the member on the date of service. A. If another claim for the same EKG interpretation is received for reimbursement , CareSource will only reimburse the first claim received for the same member on the same date of service . B. CareSource will not reimburse for duplicate claims for the same service on the same member on the same date of service without the appropriate modifier. II. If a second EKG interpretation is medically necessary on the same date of service before the member is discharged, modifier 76 or modifier 77 must be appended to the second EKG interpretation for reimbursement.III. CareSource expects providers to work with other departments within the provider organization to determine which department will submit the claim to prevent duplicate claim submissions.E. Conditions of Coverage I. CareSource expects providers to use appropriate standard billing guidelines. Modifiers are listed below as a reference only . Modifier Description 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional II. Reimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Electrocardiogram (EKG/ECG) Interpretations-OH MCD-PY-1810 Effective Dat e: 09/01/2026 3Reimbursement of claims may be subject to limitations and/or qualifications. Reimbursement will be established based on a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care provi ders and office staff are encouraged to use self-service channels to verify a members eligibility. III. Reimbursement is dependent on, but not limited to, submitting approved CPT or HCPCS codes along with appropriate modifiers if applicable. Please refer to individual fee schedule for appropriate codes.IV. 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 poli cies apply to both participating and nonparticipating providers and facilities.V. In the event of any conflict between this policy and the providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/Rules Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 05/20/2026 New policy created. Previous Administrative policy AD-1084 converted to Reimbursement policy PY-18 10 . Removed imaging language to improve clarity. Approved at Committee. Date Revised Date Effective 09/01/2026 Date Archived H. References1. Prutkin JM. ECG tutorial: Basic principles of electrocardiography analysis. UpToDate. Updated March 9, 2026. Accessed April 23, 2026. www.uptodate.com 3. Sattar Y, Chhabra L. Electrocardiogram. In: StatPearls . Updated June 5, 2023. Accessed April 23, 2026. www.ncbi.nlm.nih.gov Approved by ODM 06/08/2026
REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-PY-1638 09/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the control ling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by feder al and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance u se disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not subject to limits or requirements that are more restrictive than those that apply to M/S benefits. Table of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-PY-1638 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectApplied Behavior Analysis for Autism Spectrum Disorder B. BackgroundProvider reimbursement issues for Applied Behavior Analysis (ABA) services for Autism Spectrum Disorder (ASD) can arise from various factors, impacting families, providers and the overall accessibility of care. Key issues relating to payment problems can include coverage issues, billing and coding challenges, access to services and legislative and policy issues. Billing and coding issues are common due to a variety of factors, some of which include the complexity of coding, incorrect coding, insufficient do cumentation, authorization issues and billing for supervision and telehealth services. CareSource strives to provide clear practices regarding reimbursement for services and follows Ohio Department of Medicaid (ODM) guidance regarding payment of claims .Medical criteria for the provision of ABA services is located in CareSources Applied Behavior Analysis for Autism Spectrum Disorders medical policy at www.caresource.com in the Provider tab.C. Definitions Medically Unlikely Edit (MUE) Maximum units of service for 1 Current Procedural Terminology (CPT) code a provider can report for 1 member on 1 date of service. D. PolicyI. General Guidelines A. Pr oviders must meet the participation and provider requirements outlined by the State and CareSource . B. Ohio Medicaid provides fee schedules on the Ohio Medicaid website. Fee schedules and procedure codes do not guarantee payment, coverage or the reimbursement amount , and f ee schedule and procedure code information may be changed or updated at any time. C. The members treatment record (eg, plans of care, treatment plans, behavior support plans, functional assessments) must be completed by the provider or practitioner and submitted to CareSource prior to claim submission. Claims will not be accepted without accompanying treatment documentation. II. Reimbursement RulesA. A review of medical necessity is required prior to any ABA service provision. B. Covered services use fee schedule reimbursement methodology in which reimbursement is made at the lower of the billed charge for the service or the maximum allowable reimbursement for the service under Ohio Medicaid. The maximum allowable reimbursement for a service is the same for all ABA providers. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-PY-1638 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. ODMs Medicaid Behavioral Health (BH) State Plan Services ProviderRequirements and Reimbursement Manual (hereafter shortened to BH Manual ) provides information on billing time-based CPT codes. D. Unless specifically stated in State rules, laws or other sources, concurrent billing (eg , occupational therapy, physical therapy, speech therapy) , time spent preparing a member for services, cleaning or prep ari ng an area before or after services, rest, toileting or other break times betw een service activities is not billable. E. Time spent on documentation alone is not billable as a service unless specifically permitted by the State or code description (eg, treatment planning). III. Documentation RequirementsODM establishes guidelines related to record documentation requirements located in the OAC . Appropriate records must be maintained for payment of claims. CareSource may request records for any member at any time and audit records for accuracy and compliance. A. Professional standard s support compliance for the protection of members, including ethics code written by the Behavior Analyst Certification Board (BACB). All ABA providers must comply with written ethical standards, including published codes for the supervision of member services. Documentation should follow guidance in OAC 4783-7-01, at a minimum . Other documentation standards are located in OAC 5160-8-05. B. Supervision requirements regarding documentation standards are published by the State of Ohio and the BACB. Supervision plan requirements are located in OAC 4783-3-01 . Supervision d ocumentation must be maintained for a minimum of 5 years following the termination of supervision . Additional supervision information, including documentation requirements, are located in OAC 4783-6. IV. Covered ServicesCovered services are only reimbursable when delivered in accordance with the members Individual Treatment Plan (ITP). Assessment and service descriptions, along with allowed provider types, are located on ODMs website and incudes instruction for billing the following services (not an all-inclusive list) : A. Behavior Identification Assessment Services These services must be performed by a BCBA and are, generally, not to exceed 6-10 hours every 6 months unless additional justification is provided . The unit of service calculation should only include 1. face-to-face time spent by the BCBA with the member and/or parent/guardian conducting a comprehensive evaluation 2. any non-face-to-face time spent by the BCBA preparing the accompanying comprehensive evaluation report and developing the members initial ITP B. ABA Therapy Treatment Services These services are reimbursed on a per unit basis and must be performed one – on-one by a BCBA, BCaBA supervised by a BCBA, or an RBT supervised by a BCBA. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-PY-1638 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 C. Adaptive Behavior Treatment with Protocol Modification ServicesThe unit of service calculation should only include face-to-face time spent supervising, observing and interacting in-person with the member and BCaBA or RBT under the BCBAs supervision during a session. Each BCaBA or RBT performing ABA therapy treatment services must be supervised by a BCBA who is responsible for the quality of the services rendered . Appropriate uses of the service include 1. adjustments to specific components of a protocol face-to-face with a member (eg, treatment targets, treatment goals, observation and measurement, reinforcer delivery, prompts, instructions, materials, discriminative stimuli, contextual variables) 2. 1:1 direct treatment by a qualified provider to observe a member for determining if protocol components are effective for the member or require adjustments 3. active direction of a technician while delivering a face-to-face service with a member to train the implementation of a new or modified prot ocol 4. qualified provider i mplementation of a protocol with a member to determine if changes are needed to improve progress or test a modified protoco l service D. Family Adaptive Behavior Treatment Service Services must include participation of the parent/guardian or other appropriate caregiver and performed by a BCBA. Reimbursement only includes time spent collaborating face-to-face with the parent/guardian. E. Telemedicine Services Telemedicine services are reimbursed in the same manner and subject to the same limits as in-person, face-to-face service delivery. V. Special Provisions Related to RBTsA. Current Standards for RBTs 1. RBT services must be supervised by a qualified RBT supervisor. RBTs must obtain ongoing supervision for a minimum of 5% of the hours spent providing ABA services per month. Additionally, the BACB publishes information regarding the structure of supervision and parameters for group and individual supervision in the RBT Handbook. 2. A BACB-certified RBT may provide ABA under the supervision of an independent practitioner when the independent practitioner is enrolled and active in the Medicaid program and affiliated with the organization under which the provider is employed or contracted. If the independent practitioner leaves the affiliated organization and no longer provides supervision, the RBT may not continue to provide service s under that independent practitioner. Additionally, if the RBT leaves the affiliated organization and no longer receives mandated supervision, the RBT may not provide services to the member(s). 3. RBTs must use appropriate modifiers that indicate qualifications of staff delivering services , if appropriate. B. RBT Changes from the Behavior Analyst Certification Board Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-PY-1638 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 1. RBT supervisors must hold BCBA or BCaBA certification. Noncertified supervisors are not allowed to provide BACB-required supervision to RBTs. Continuity of care for members is required . 2. RBTs must comply with new rules adopted by the BACB, effective January 1, 2026, regarding eligibility for and maintenance of certification . VI. ExclusionsReimbursement for the following services or activities is not permitted: A. any services not documented in the treatment plan B. behavioral methods or modes considered experimental C. education-related services or activities described under IDEA D. vocational services funded under the Rehabilitation Act of 1973 E. components of adult day care programs F. treatment solely for the benefit of the family, caregiver, or therapist G. treatment focused on recreational activities H. treatment worsening symptoms, prompting member regression or part of core symptoms of ASD I. personal training or life coaching J. services more costly than an alternative service(s) that are likely to produce equivalent diagnostic or therapeutic results for the member K. programs or services performed in nonconventional settings, even if performed by a licensed provider (eg, spas/resorts, wilderness camp, ranch programs ) E. Conditions of CoverageI. Providers are required to bill at the appropriate practitioner level (ie, modifiers) and service code for service rendered , as appropriate and outlined by ODM . Providers must use applicable procedure codes with MUE limits, modifiers , and place of service codes as applicable. A. Providers agree to bill Medicaid for only those services rendered by a qualified provider or by a provider u nder the providers direct supervision. Under no circumstances may a provider bill for services rendered by another practitioner enrolled or eligible to enroll as a provider. B. Providers must utilize the procedure code(s) best describ ing the service rendered and not bill under separate procedure code (s) for services included under a single procedure code. Coding of both diagnoses and procedures is required for all claims and must be to the highest level. C. CareSource will ensure a continued and uninterrupted path for providers to bill ABA services as previously billed with H0036, facilitating a smooth transition while maintaining access to necessary services for members. Providers will be supported in billin g practices to ensure compliance with current regulations and upholding quality of care for members. However, it is important to note that CareSource will not reimburse H0036 if the provider is able to use designated ABA codes. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-PY-1638 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 D. Providers cannot submit multiple dates of service on a single claim line. Each claim line must be specific to a single date of service and the units provided on that single date of service.E. CareSource complies with the Centers for Medicare and Medicaid Services (CMS) medically unlikely edit (MUE) table. If CMS updates the MUE list, the update will take precedence over this policy. F. Treatment codes are based on daily total units of service in 15-minute increments. A unit of time is attained when the mid-point is passed. ODM provides examples of correct unit usage for number of minutes per treatment session. II. Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified and provider prepayment review. Program Integrity will be engaged for an annual review of data.III. When a member has other insurance, Medicaid is always the payer of last resort. CareSource will not pay more than the Medicaid rate totals for service. Primary payer must provide evidence of determinations for consideration of Medicaid coverage for service s.F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/11/2026 New policy. Split payment information from MM 0028 &revised . Approved at Committee. Date Revised Date Effective 09/01/2026 Date Archived H. References1. NCCI MUE Edits-Practitioner Services. Centers for Medicare and Medicaid Services. Accessed February 10, 2026 . www.cms.gov 2. BACB Newsletter. Behavior Analyst Certification Board . Accessed February 10, 2026 . www.bacb.com 3. BACB Newsletter: Introducing the 2026 RBT Examination and Certification Requirements. Behavior Analyst Certification Board. Accessed February 10, 2026 . www.bacb.com 4. Board Certified Behavior Analyst Handbook. Behavior Analyst Certification Board. Accessed February 10, 2026 . www.bacb.com 5. Board Certified Assistant Behavior Analyst Handbook. Behavior Analyst Certification Board. Accessed February 10, 2026 . www.bacb.com Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-PY-1638 Effective Dat e: 09/01/2026 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. 7 6. Ethics Code for Behavior Analysts. Behavior Analyst Certification Board . AccessedFebruary 10, 2026 . www.bacb.com7. Registered Behavior Technician Handbook. Behavior Analyst Certification Board.Accessed February 10, 2026 . www.bacb.com8. State Board of Psychology Certified Ohio Behavior Analysts, OHIO A DMIN . CODE4783 (2025).Ap proved by Ohio Dep artment of Medicaid 06/05/2026
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