Community Behavioral Health Services Utilization Management

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Community Behavioral Health Services Utilization Management – OH MCD-PY-1748 07/01/2026 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Community Behavioral Health Services Utilization Management-OH MCD-PY-1748 Effective Dat e: 07/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectCommunity Behavioral Health Service s Utilization Management B. BackgroundTo promote the delivery of clinically appropriate and medically necessary Medicaid – funded substance use disorder (SUD) and community behavioral health (BH) services, the Ohio Department of Medicaid (ODM) has determined new service thresholds upon which an authorization requesting to exceed these limits can be required from the provider. This measure is to ensure that Medicaid-funded services are supported by an individualized assessment that accurately summarizes the clinical presentation and presenting tre atment needs. This also ensures the requested services are appropriately captured in the treatment plan to illustrate how the service will support progress toward the individualized treatment goals. C. Definitions Community Behavioral Health Rehabilitative Services Services under this description include o Therapeutic Behavioral Service, Individual (H2019) and Group (H2019 HQ) o Therapeutic Behavioral Service Day Treatment, Per Diem (H2020) o Community Psychiatric Support Treatment, Individual (H0036) and Group (H0036 HQ) o Psychosocial Rehabilitation Service (H2017) Non-Network or Non-Participating Provider Any provider, group of providers or entity eligible as providers according to O hio Administrative Code (OAC) 5160-1-17 but without a CareSource provider contract to provide covered services to members . D. PolicyI. CareSource can opt to apply service thresholds to designated community behavioral health services no more stringently than what is included in the table in D.I II. When CareSource implements service authorizations for a community behavioral health service that does not reflect current authorization requirements found in OAC Chapter 5160-27 or the applicable Provider Agreement, the following applies: A. The service authorization forms for SUD and Community Behavioral Health Centers (CBHC), to be updated for July 1, 2026, available on ODMs website will be accepted as a valid authorization request. B. For CareSource Ohio Medicaid, providers submit authorization requests and track authorization status through the secure CareSource Provider Portal (providerportal.caresource.com). 1. Providers may also reference the CareSource public provider pages for Ohio for current prior authorization requirements, forms, and submission instructions (CareSource.com > Ohio > Medicaid/MyCare, as applicable > Providers > Provider Resources > Prior Au thorization). Community Behavioral Health Services Utilization Management-OH MCD-PY-1748 Effective Dat e: 07/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 2. Determinations (approval, partial approval, or denial) are communicated through plan-issued written determination notices and reflected in theProvider Portal authorization status view. 3. For appeals, providers should follow the CareSource Ohio provider appeals guidance (CareSource.com > Ohio > Medicaid/MyCare, as applicable > Providers > Provider Resources > provider Disputes and Appeals), including required submission methods and timefra mes. C. CareSource ensures accurate system configuration to enforce the limits before implementing authorization for a service. Retroactive recoupments are prohibited if a service was paid in error due to CareSource not having properly configured its system to enforce the limit. II. Recipient Level Utilization VerificationUpon request by a CBHC provider, CareSource will provide a members utilization to date if a service authorization is required. Member utilization will be available within the CareSource Provider Portal by navigating to www.caresource.com Providers/Provider Portal Login. This information is based on claims received to date and may not reflect accurate real-time utilization. A. A designated and reliable point of contact for the provider to access this information will be made available. B. The CBHC providers are responsible for keeping track of service delivery for each member to ensure services rendered do not exceed the authorized threshold. If the member is simultaneously receiving the same service from more than 1 provider, the providers will need to coordinate care to prevent service duplication and reduce risk of prematurely exhausting authorized hours. C. It is recommended that providers routinely check in with members to inquire whether the member is receiving CBHC services elsewhere. III. Providers should refer to CareSources Procedure Code Lookup Tool, any published network notifications at www.CareSource.com and the annual Prior Authorization List in the Provider Portal. These resources will provide the most current information on any service limits required prior to medical necessity review. The following services and associated limits apply per member per calendar year (CY) or per member per day b efore a review of medical necessity is required: Service CodeService Name Service Threshold for Required PA Expected Turnaround Time H0010 Clinically Managed Withdrawal Management ASAM 3.2 WM after 7 th consecutive day 48 hours H0011 Medically Monitored Inpatient Withdrawal Management ASAM 3.7 WM after 7 th consecutive day 48 hours H0012 H0014 Withdrawal Management ASAM 2 WM (Per Diem/Hourly) after 7 th consecutive day 48 hours H0015 SUD Intensive Outpatient Program 30 units per CY 7 days Community Behavioral Health Services Utilization Management-OH MCD-PY-1748 Effective Dat e: 07/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 H0036 Community Psychiatric SupportiveTreatment (CPST) – Ind 200 units (50 hours) per CY 7 days H0036 HQ Community Psychiatric Supportive Treatment (CPST) – Group 120 units (30 hours) per CY 7 days H2017 H2019 Psychosocial Rehabilitation Services (PSR) Therapeutic Behavioral Services (TBS) – Ind 200 units (50 hours) combined TBS and/ or PSR per CY 7 days H2019 HQ Therapeutic Behavioral Service (TBS) – Group 120 units (30 hours) per CY 7 days H2020 Therapeutic Behavioral Service Day Treatment , Per Diem 30 units per CY 7 days E. Conditions of CoverageI. Providers must follow OAC 5160-1-31 regarding submission requirements for authorization forms. II. Providers must adhere to the following authorization request submission timelines to ensure a determination is made prior to the expiration or exhaustion of the current authorization:A. Expedited: Submission must be received at least 2 days prior. B. Standard: Submission must be received at least 7 days prior. III. Services rendered with the KX c risis modifier are excluded from service thresholds.IV. Behavioral health nursing services rendered in accordance with OAC 5160-27-11 are excluded from service thresholds. V. Due to the chronic nature of severe and persistent mental illness and the vulnerability of many requiring reliable access to support, the following applies to BHrehabilitation services : A. The coverage period for approved service is a minimum of 90 days unless a shorter duration is requested by the provider. B. The PA is valid until the approved service limit is exhausted or when the authorization period has expired. C. Children and youth in custody of a public child welfare agency or enrolled in the OhioRISE plan are excluded from PA requirements for BH rehabilitation services. F. Related Policies/RulesBehavioral Health Service Record Documentation Standards Medical Necessity Determinations G. Review/Revision HistoryDATE ACTIONDate Issued 05/20/2026 New policy. Approved at Committee.Community Behavioral Health Services Utilization Management-OH MCD-PY-1748 Effective Dat e: 07/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Date RevisedDate Effective 07/01/2026 Date Archived H. References1. Community Behavioral Health Agency Services, OHIO ADMIN . CODE 5160-27-01 to 14 (2024). 2. Coverage and Authorization of Services, 42 C.F.R. 438.210 (2024). 3. Managed Care: Definitions, OHIO ADMIN . CODE 5160-26-01 (2022). 4. Medicaid and CHIP Payment and Access Commission. Advising Congress on Medicaid and CHIP Policy. MACPAC; 2024. Accessed May 4, 2026 . www.macpac.gov 5. Medicaid Behavioral Health State Plan Services Provider Requirements and Reimbursement Manual . Ohio Dept of Medicaid. Accessed May 12, 2026. www.medicaid.ohio.gov 6. Practice Guidelines, 42 C.F.R. 438.236 (202 4). 7. Prior Authorization, OHIO ADMIN . CODE 5160-1-31 (2024). 8. Requirements and Procedures for Behavioral Health Services, OHIO ADMIN . CODE 5122-29-01 to 31 (2023). 9. Sufficiency of Amount, Scope and Duration, 42 C.F.R. 440.230 (2024) . Ohio Department of Medicaid approved May 2 8, 2026.

Unlisted and Miscellaneous Codes

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Unlisted and Miscellaneous Codes-OH MCD-PY-1456 08/01/2026 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Unlisted and Miscellaneous Codes-OH MCD-PY-1456Effective Dat e: 08/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectUnlisted and Miscellaneous Codes B. BackgroundCurrent Procedure Terminology (CPT) codes are used to describe medical procedures and physician services. The American Medical Association (AMA) maintains and distributes CPT codes. Health Care Common Procedure Coding System (HCPCS) code set represents items, supplies , and non-physician services not addressed by the CPT codes. The Centers for Medicare and Medicaid Services (CMS) establishes and maintains the HCPCS codes. These code sets w ere established so providers can use the most specific and appropriate code when submitting claims for reimbursement of services rendered to members. Occasionally, a CPT/ HCPCS code may not be available for a procedure or service ifrarely used, unusual , or new. Only then would p roviders use an unlisted, unclassified,not otherwise specified (NOS) , not otherwise classified (NOC) , miscellaneous , or generic code for any such procedure , service , item, suppl y, or non-physician service . C. Definitions Durable Medical Equipment (DME) A collective term for equipment and supplies ordered by a health care provider for everyday or extended use. Miscellaneous (Unlisted, Unclassified, Not Otherwise Specified (NOS ,) or Not Otherwise Classified [NOC ]) Codes Submitted by a supplier for an item or service for which there is no existing code that adequately describes the item or service being billed. Unlisted Code A code representing an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code . D. PolicyI. All unlisted or miscellaneous codes require a medical necessity review prior to the service . II. Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the diagnosis, service, procedure, or item rendered.III. Reimbursement is based on review of the unlisted or miscellaneous code(s) on an individual claim basis.IV. Medical necessity review submitted for unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration : A. a complete description of the item ( eg, the manufacturer, model or style, size , as applicable ), a list of all bundled components, and an itemization of all charges B. statement that no other code exists that would be more appropriate C. any other information requested by CareSource Unlisted and Miscellaneous Codes-OH MCD-PY-1456Effective Dat e: 08/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 V. Unlisted/non-specific codes used for procedures deemed to be experimental and investigational will be reviewed for medical necessity . VI. CareSource may request warranty information regarding the DME item or supply when an unlisted or miscellaneous code is used . If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the request . VII. The following codes are not all inclusive but provide a general reference of unlisted/miscellaneous codes that are commonly used incorrectly.Code DescriptionA4335 Incontinence supply; miscellaneous A4421 Ostomy supply; miscellaneous A9999 Miscellaneous DME supply or accessory, not otherwise specified B9998 Not otherwise classified ( NOC) for enteral supplies E1399 Durable medical equipment, miscellaneous K0108 Wheelchair component or accessory, not otherwise specified Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device E. Conditions of CoverageReimbursement 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. Reimbursement for 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 providers and office staff a re encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guaran teeclaims payment.All unlisted or miscellaneous codes defined within this policy are subject to medicalnecessity review . Approved authorization does not ensure payment.CareSource may verify the use of any code through post-payment audit. If a moreappropriate code is discovered, CareSource may request recoupment.F. Related Policies/RulesNA Unlisted and Miscellaneous Codes-OH MCD-PY-1456Effective Dat e: 08/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 G. Review/Revision History DATE ACTIONDate Issued 10/11/2023 New policy. Approved at Committee.Date Revised 04/09/2025 04/22 /2026 Periodic review. Updated references. Approved at Committee. Annual Review. Removed prior authorization verbiage and updated reference. Approved at Committee. Date Effective 08/01/2026 Date Archived H. References1. CPT overview and code approval. American Medical Association. Accessed April 13 , 2026. www.ama-assn.org 2. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS): General Provisions, OHIO ADMIN . CODE 5160-10-01 ( 2026 ). 3. Healthcare Common Procedure Coding System (HCPCS). American Medical Association. Accessed April 13 , 2026 . www.ama-assn.org 4. Medicaid Medical Necessity: Definitions and Principles, O HIO ADMIN . C ODE 5160-1- 01 (202 3). ODM Approved 04/30 /2026

Modifiers

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifiers-OH MCD-PY-1345 08/01/2026 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 ………………………….. ………………………….. ………………………….. ………………………….. 2 E. Conditions of coverage ………………………….. ………………………….. ………………………….. ….. 3 F. Related policies/rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/revision history ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ………………….. 4 Modifiers-OH MCD-PY-1345Effective Dat e: 08/01/20262A. SubjectModifiers B. BackgroundReimbursement modifiers are 2-character codes used by providers to indicate that a service or procedure has been altered due to a specific circumstance. Modifiers can be found in the appendices of both Current Procedural Terminology CP Tand Healthcare Common Procedure Coding System ( HCPCS ) manuals. Use of a modifier does not change the code or the codes definition. Examples of modifier use include To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same procedure . To indicate that a procedure was performed on the left side, right side, or bilaterally . To report multiple procedures performed during the same session by the same health care provider . To indicate multiple health care professionals participated in the procedure . To indicate a subsequent procedure is due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment or post-payment edit or audit . Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSource s request. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure that correct coding standards and guidelines are met. II. Provider claims billed with a modifier may be flagged for either a prepayment or post-payment coding review.III. It is the responsibility of the submitting provider to submit accurate documentation Tosubstantiate the coding of the claim. Failure to submit accurate and completeModifiers-OH MCD-PY-1345Effective Dat e: 08/01/20263documentation may result in a denial. If the documentation does not support the claim submission, this will also result in a claim denial.IV. Providers are expected to use the most accurate and appropriate CPT or HCPCScode(s) for the product or service that is being provided according to the following industry standard guidelines (may not be all-inclusive) : A. National Correct Coding Initiative (NCCI) editing guidelines B. American Medical Association (AMA) guidelines C. American Hospital Association (AHA) billing rules D. Current Procedural Terminology (CPT) E. Healthcare Common Procedure Coding System (HCPCS) F. The International Classification of Diseases and Related Health Problems , Tenth Edition (ICD-10-CM and ICD-10-PCS) G. National Drug Codes (NDC) H. Diagnosis Related Group (DRG) guidelines I. CCI table edits V. The inclusion of a code in a policy does not imply any right to reimbursement or guarantee payment of claims.VI . Other CareSource policies may overlap with this topic. Consult the current catalogue of policies for this market.E. Conditions of coverageI. Reimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and offic e staff are encouraged to use self-service channels to verify a members eligibility. II. Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes.III. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource polic ies apply to both participating and nonparticipating providers and facilities.IV. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.Modifiers-OH MCD-PY-1345Effective Dat e: 08/01/20264F. Related policies/rulesNA G. Review/revision historyDATE ACTIONDate Issued 09/01/2019 New policyDate Revised 04/15/2020 10/13/2021 10/12/202209/27/202304/ 09/2025 04/22/2026Added Place of Service 19 to Modifier SARemoved modifiers, changed background and policy sections to simplify language No changes. Updated references. Updated references. Approved at Committee. Periodic review. Updated references. Approved at Committee. Annual review. Moved D.I and D.II from Section Bto Section D, updated D.III for clarity, added D.VI, updated references. Approved at Committee. Date Effective 08/01/2026 Date Archived H. References1. 2026 AMA CPT Professional . American Medical Association; 2025. 2. 2026 HCPCS Level II Expert . AAPC; 2025. 3. 2026 ICD-10-CM Official Coding Guidelines for Coding and Reporting. AAPC; 2025. 4. General Correct Coding Policies. National Correct Coding Initiative Policy Manual for Medicare Services . Centers for Medicare and Medicaid Services; 2026. Accessed March 3 1, 2026. www.cms.gov 5. Medicaid National Correct Coding Initiative Technical Guidance Manual . Centers for Medicare and Medicaid Services; 2026. Accessed March 31, 2026. www.cms.gov Approved by ODM 05/01/2026

Durable Medical Equipment (DME) Modifiers

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 08/01/2026 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 08/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDurable Medical Equipment (DME) Modifiers B. BackgroundModifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additional information, to the code description, of the product or service. Using a modifi er inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. The purpose of this policy is to simplify and standardize the use of modifiers, when billing for rented, purchased, or rent to purchase DME equipment. There are many modifiers that can be used when billing DME. This policy addresses the rental modifier RR and the new equipment purchase modifier NU. CareSource expects providers touse the modifiers stated in this policy to increase efficiency and timely reimbursement. Any other appropriate modifier per national or state billing standards can be appended to a DME item along with the modifiers addressed in this policy ( eg, LT, RT, etc.). Some DME equipment may have individual policies which can be referenced for detailed information. The modifiers addressed in this policy is not an all-inclusive list andproviders should adhere to national and state billing guidelines for modifier usage fo r all other modifiers not addressed within this policy. C. Definitions Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated , and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. This policy outlines the use of Durable Medical Equipment (DME) modifiers for the rental and/or purchase of DME. II. DME items can be:A. purchasedB. rented or C. rented on a short-term basis and then purchased at the end of the rental period III. DME items must be billed with appropriate HCPCS codes along with appropriate modifiers when applicable:Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 08/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 A. Purchase Modifier – NU:1. CareSource requires that Modifier NU is appended to all claims for the purchase of DME equipment. B. Rental Modifier – RR: 1. CareSource requires that Modifier RR is appended to all claims for the rental period of DME equipment. 2. All rental authorizations are based on: a. A calendar month authorization period, through the month in which the member becomes ineligible; b. The item is no longer medically necessary; or c. The maximum amount allowable is reached. 3. Unless otherwise outlined in the O hio Administrative Code (OAC) 5160 – 10-01, the initial rental period must not exceed 6 months. a. After the initial 6 month rental period , additional rental months may be authorized if medically necessary. 4. The combined total reimbursement for rental and subsequent purchase of a DME item, cannot exceed the Medicaid maximum fee. 5. At the end of the rent to purchase period, the DME becomes the property of the member. IV. Disposable supplies do not require a modifier.A. DME items that are submitted for reimbursement without a modifier are considered a purchase. If the DME item was intended to be a rental and the modifier RR was left off the claim in error, CareSource will review the claim during a post-payment audit and p roper reimbursement adjustment will occur. V. Modifiers that are not to be used for claims submission for DME equipment include :A. LL Lease/rental B. NR New when rented C. RB Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement parts are considered new equipment) VI. CareSource considers a replacement part as a new equipment purchase and modifier NU should be used instead of modifier RB.NOTE : CareSour ce may verify the use of any modifier through post-payment audit. All information regarding the use of these modifiers must made available upon CareSources request. E. Conditions of CoverageReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 08/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligib ility.It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant eeclaims payment.F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 05/13/2020 New policyDate Revised 09/14/2022 10/1 1/2023 04/09/2025 04/22 /202 6 No changes. Updated references. Annual review. Updated references. Approved at Committee. Periodic review. Updated references. Approved at Committee. Periodic review. Updated references. Approved at Committee. Date Effective 08/01/2026 Date Archived H. References1. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS): General Provisions, OHIO ADMIN CODE 5160-10-01 (2024). 2. Medical Equipment. Accessed March 31, 2025. www.medicaid.ohio.gov 3. Healthcare Common Procedure Coding System (HCPCS). Accessed March 31, 2025. www.cms.gov 4. What are medical coding modifiers? 2022. American Academy of Professional Coders. Accessed March 31, 2025. www.aapc.com ODM Approved 04/30 /2026

Diagnostic Colonoscopy and/or Sigmoidoscopy

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Diagnostic Colonoscopy and/or Sigmoidoscopy-OH MCD-PY-1592 08/01/2026 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 ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Diagnostic Colonoscopy and/or Sigmoidoscopy-OH MCD-PY-1592 Effective Dat e: 08/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDiagnostic Colonoscopy and/or Sigmoidos copy B. BackgroundColo no scopies and sigmoidoscopies pertain to procedures that involve direct visual examination of the lower gastrointestinal tract using a flexible tube fitted with a camera. The procedures identify polyps, tumors, and other intestinal irregularities or health issues and are performed by medical professionals, typically gastroenterologists or colorectal surgeons. Both procedures are valuable tools in diagnosing and monitoring gastrointestinal conditions. Specific cli nical indications and area of examination determine w hich procedure will be utilized. There are different billing procedures for screening versus diagnostic colonoscopies andsigmoidoscopies. Screening procedures are typically performed as part of preventive services for cancer or other health issues. Diagnostic procedures can include patient signs or symptoms in the lower gastrointestinal tract (eg, constipation, rectal bleeding, blood in stool, diarrhea), polyps within the past 10 years or other positive-stool-based tests or computed tomography (C T) colonographies that require follow-up. Similarly, some screening procedures can become diagnostic procedures if practitioners fin d health issues to address (eg, mass needing biopsy, polyps) while performing initial screening procedures . Both screening and diagnostic procedures are performed similarly using the same equipment, so it is imperative to maintain thorough documentation in the members medical record to substantiate the medical necessity of these tests. This policy exclusively pertains to diagnostic colonoscopies and does not apply to preventive screenings that follow US Preventive Services Task Force (USPSTF) or otherpreventive guidelines. Refer to the appropriate Healthcare Common Procedure CodingSystem (HCPCS) and Current Procedural Terminology (CPT) codes for screenings (ie, G0104, G0105, G0121). Providers are encouraged to use modifiers when procedures meet modifier criteria . CareSource follows Ohio Department of Medicaid (ODM) guidance and policies and the Ohio Administrative (OAC) and Revised Codes (ORC) . Any information found in those sources supersede this policy. C. Definitions Colonoscopy A procedure in which a physician inserts a flexible tube fitted with a camera through the anus into the rectum to examine the entire length of the colon from the rectum to the cecum and may include the terminal ileum , allowing for screening and diagnosis of health issues. Sigmoidoscopy A procedure similar to a colonoscopy that examines the lower third of the large intestine , the rectum, sigmoid colon and possibly a portion of the descending colon for screening and diagnosing health conditions. Diagnostic Colonoscopy and/or Sigmoidoscopy-OH MCD-PY-1592 Effective Dat e: 08/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. PolicyI. CareSource requires appropriate documentation of medical necessity and valid diagnosis codes for reimbursement of diagnostic colonoscopies and sigmoidoscopies. Claims submitted without supporting medical necessity or correct coding will be denied. ODM publishes documentation requirements for medical necessity and billing in appropriate State resources. II. CareSource follow s ODM guidelines regarding the billing of diagnostic colonoscopies and sigmoidoscopies . A. Reimbursement requests must include a procedure code with a diagnosis code that best describes the condition for which the service was performed. B. If the service begins as a screening procedure but results in a diagnostic or therapeutic procedure at the same operative session, health care providers should report an appropriate screening I nternational Classification of Diseases (ICD) diagnosis code as the primary diagnosis and the diagnostic or abnormal finding ICD diagnosis code as the secondary or subsequent diagnosis. C. If the member is symptomatic or the claim for these services indicates a primary diagnosis of something other than preventive or wellness, colonoscopy examinations will be covered as a diagnostic service , not a preventive health care service. E. Conditions of CoverageI. Claims should be submitted pursuant to the National Correct Coding Initiative and according to the coding standards set forth in the HCPCS, CPT codebook or ICD handbooks. II. CareSource reserves the right to request medical record documentation from providers.F. Related Policies/RulesMedical Necessity Determinations Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 03/26/2025 New policy. Approved at Committee.Date Revised 04/22 /2026 Annual review. Updated references. Approved at Committee. Date Effective 08/01/2026 Date Archived H. References1. Colonoscopy ACG: A-0129. MCG. 2 9th ed. Updated June 15, 2025 . Accessed April 10, 2026 . www .careguidelines.com 2. Colonoscopy. American Cancer Society. Accessed April 10, 2026 . www.cancer.org Diagnostic Colonoscopy and/or Sigmoidoscopy-OH MCD-PY-1592 Effective Dat e: 08/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 3. Flexible sigmoidoscopy. Mayo Clinic. Accessed April 10, 2026 . www.mayoclinic.org4. Sigmoidoscopy ACG: A-0128. MCG. 2 9th ed. Updated June 15, 2025 . Accessed April 10, 2026 . www.careguidelines.com 5. Submission of Medicaid Claims. OHIO ADMIN . CODE 5160-1-19 (2023). Approved by Ohio Dept of Medicaid 04/ 29 /202 6

Obstetrical Care–Unbundled Cost

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Obstetrical Care Unbundled Cost-OH MCD-PY-0004 07/01/2026 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 ………………………….. ………………………….. ………………………….. ….. 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 8 H. References ………………………….. ………………………….. ………………………….. …………………… 8 Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 07/01/20262A. SubjectObstetrical Care-Unbundled Cost B. BackgroundObstetrical care refers to health care treatment given in relation to pregnancy and delivery of a newborn child. This include s care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members receive in a hospital or birthing center , as well as all associated outpatient services . The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the qualified provider . Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. This policy is for practitioners meet ing either of the following: Obstetrical practitioners who are not part of a free standing birthing center . Obstetrical practitioners part of a free standing birthing center when any of the following occur: o Unbundled obstetrical care is the preferred method of billing . o The member has a change of insurer during pregnancy . o The member received part of the antenatal care elsewhere (eg , from another group practice ). o The member leaves the practitioners group practice before the global obstetrical care is complete . o The member must be referred to a provider from another group practice or a different licensure (eg , midwife to medical doctor) for a cesarean delivery . o The member has an unattended precipitous delivery . o Termination of pregnancy without delivery occurred (eg , miscarriage, ectopic pregnancy) . C. Definitions Initial and Prenatal Visit A practitioner visit to determine whether a member is pregnant. Freestanding Birthing Center (FBC) Freestanding facilities that are not considered hospitals , provid ing peripartum care for low-risk women with uncomplicated , singleton term vertex pregnancies expected to have an uncomplicated birth . High Risk Delivery Labor management and delivery for an unstable or critically ill pregnant patient. Pregnancy For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days. Premature Birth Delivery before 37 weeks of pregnancy is completed. Prenatal Profile Initial laboratory services. Unbundled Obstetrical Care The practitioner bil ls delivery, antepartum care, and postpartum care independently. o Antepartum Care Basic care (eg, obtaining and updating subsequent medical history, physical examination, recording of vital signs, and routine chemical Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 07/01/20263urinalysis provided monthly up to 28 weeks gestation, biweekly there after up to36 weeks gestation, and weekly thereafter until delivery. o Delivery Admission to a facility, medical history during admission, physical examinations, and management of labor (either by vaginal delivery or by cesarean section). o Postpartum Care The time period that begins on the last day of pregnancy and extends through the end of the month in which the 60 day period following termination of pregnancy ends. The American College of Obstetricians and Gynecologists (ACOG) recommends contact within the first 3 weeks post partum. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile – Evaluation and management (E/M) codes are utilized for t he initial visit , prenatal profile , and antepartum care. B. Risk Appraisal – Case Management Referral 1. Providers may complete the Pregnancy Risk Assessment Form (PRAF) and will be paid for the completion of the form. Providers are encouraged to submit a PRAF any time there is a change in condition during the pregnancy. Please use code H1000 and append modifier 33 or TH as appropriate on the associated claim to indicate that an assessment form was submitted. 2. Any eligible woman who meets any of the risk factors listed on the Pregnancy Risk Assessment Form (PRAF) is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those case management services. NOTE : CareSource follows the Ohio Department of Medicaid (ODM) guidanceregarding PRAF and can be submitted during any pregnancy stage according to ODM . Beginning 4/1/2025 ODM will allow PRAF submissions for postpartum care . C. Unbundled Obstetric Care – The practitioner w ill bill antepartum care, delivery,and postpartum care independently of one another. 1. Antepartum care only do es not include delivery or postpartum care . a. Use the appropriate E/M code and trimester code(s) . b. Use the appropriate modifier , if applicable . 2. Delivery only – Use if only a delivery was performed . a. Deliveries must be greater or equal to 20 weeks gestation to be billed as a delivery. b. Use the appropriate CPT and delivery outcome code(s): CPT Code Description59409 Vaginal delivery only (with or without episiotomy and/or forceps)59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 07/01/20264c. Services (This list may not be all inclusive):Services included that may NO Tbe billed separately Services excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or forceps Vaginal delivery after prior cesarean sectionPrevious cesarean delivery who present with expectation of vaginal deliverySuccessful vaginal delivery after previous cesarean deliveryCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean deliveryCesarean deliveryClassic cesarean section Low cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesia Artificial rupturing of membranes prior to delivery Insertion of a cervical dilatorDelivery of placenta Minor laceration repairs Inpatient management after delivery/discharge services E/M services provided within 24 hours of delivery3. Delivery and postpartum care only – If only delivery and postpartum care were provided a. Use the appropriate CPT and trimester code: 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery CPT Code Description59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care59515 Cesarean delivery only; including postpartum care Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 07/01/20265b. Services included in the delivery only and postpartum care codes ; and therefore are NOT allowed to be billed separately ( this list may not be all inclusive): 01. admission history 02. admission to hospital 03. artificial rupture of membranes 04. care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 05. hospital/office visits following cesarean section or vaginal delivery 06. management of uncomplicated labor 07. physical exam 08. vaginal delivery with or without episiotomy or forceps 09. caesarean delivery 10. classic cesarean section 11. low cesarean section 12. successful vaginal delivery after previous cesarean delivery 13. previous cesarean delivery member who present s with the expectation of a vaginal delivery 14. caesarean delivery following unsuccessful vaginal delivery attempt after previous cesarean delivery 4. Postpartum care only If postpartum care only was provided a. Use code 59430 postpartum care only. b. Only one code 59430 can be billed per pregnancy as this includes all E/M pregnancy related visits provided for postpartum care. c. There is no specified number of visits included in the postpartum code. This includes h ospital and office visits following vaginal or cesarean section delivery. ACOG recommends contact within the first 3 weeks postpartum. d. Postpartum care may include and therefore is not allowed to be billed separately for the following (not an all inclusive list ): 01. office and outpatient visits following cesarean section or vaginal delivery 02. qualified health care professional providing all or a portion of antepartum/postpartum care, but no delivery due to referral to another physician for delivery or termination of pregnancy by abortion e. The following are billable separately during the postpartum period (list may not be all inclusive): 01. conditions unrelated to pregnancy (eg , respiratory tract infection ) 02. treatment and management of complications during the postpartum period that require additional services 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 07/01/20266II. Member EligibilityA. If a member was not eligible for Medicaid for the 9 months before delivery, the practitioner must use the appropriate delivery only or delivery and postpartum code to be reimbursed. Charges for hospital admission, history and physical , or normal hospital evaluation and management services are not reimbursable. B. If a member becomes eligible for Medicaid due to a live birth, no prenatal services , including laboratory services , are reimbursable. III. Multiple GestationsA. Include diagnosis code for multiple gestations. B. Modifier 51 should be added to the second and any subsequent vaginal births identifying multiple procedures were performed. C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 may be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. IV. High Risk Pregnancy and DeliveryA. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 supervision of high-risk pregnancy. B. Modifier 22 may be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. E. Conditions of CoverageIn the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. The inclusion of a cod e in this policy does not imply any right to reimbursement or guarantee of claimspayment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify a members eligibility. Submission of claims for reimbursement will serve as the providers certification of medical necessity for these services. Proper billing and submission guidelines must be followed, including the use of industry standard, compliant codes on all claims subm issions. Services should be billed using Current Procedure Terminology (CPT)codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes areObstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 07/01/20267required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilitiesReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individualfee schedule for appropriate codes .The following list of codes is provided as a reference. This list may not be all inclusive and is subject to updates.CPT Code DescriptionUse E/M codes For antepartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59430 Postpartum care only 59514 Cesarean delivery only 59515 Cesarean delivery only; including postpartum care 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care F. Related Policies/RulesObstetrical Care-Hospital Admissions Obstetrical Care-Total Cost for Freestanding Birthing Centers Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 07/01/20268G. Review/Revision History DATE ACTIONDate Issued 06/10/2015Date Revised 10/18/2017 07/22/2020 09/15/202110/10/202210/11 /202311/20/202401/15/202512/17 /202502/11/2026Updated codes, templateNew title was Preferred Obstetrical Services; policy broken into two policies. Updated definitions, reorganize topics, removed total care information, updated most content and codes. Clarified who can bill unbundled charges. Revised antepartum language for clarity. Remov ed modifiers. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Updated D.I.B.1. Approved at Committee. Updated D.I.C.2, conditions of coverage, and references. Approved at Committee. Added modifier TH to D.I.B.1. Approved at Committee. Date Effective 07/01/2026 Date Archived H. References1. ACOG Committee Opinion no. 579: definition of term pregnancy. Obstet Gynecol . 2013; 122(5):e1139-e1140. Reaffirmed 2025. doi:10.1097/01.AOG.0000437385.88715.4a 2. ACOG Committee Opinion no. 736: optimizing postpartum care. Obstet Gynecol .. 2018;131(5):e140-e150. Reaffirmed 2025. doi:10.1097/AOG.0000000000002633 3. ACOG Committee Opinion no. 761: cesarean delivery on maternal request. Obstet Gynecol . 2019;133(1)e73-e77. Reaffirmed 2024. doi:10.1097/AOG.0000000000003006 4. American Academy of Professional Coders. Code obstetrical care with confidence. December 1, 2011. Accessed November 12, 2025 . www.aapc.com 5. American College of Obstetricians and Gynecologists. Billing for care after the initial outpatient postpartum visit: the fourth trimester. Accessed November 12, 2025 . www.acog.org 6. American College of Obstetricians and Gynecologists. Preterm labor and birth. Updated April 2023. Accessed November 12, 2025 . www.acog.org 7. Freestanding Birth Center Services, OHIO ADMIN . CODE 5160-18-01 (2023). 8. Limitations on Elective Obstetric Deliveries, OHIO ADMIN . CODE 5160-1-10 (2015). 9. Managed Care: Definitions, OHIO ADMIN . CODE 5160-26-01 (2022). 10. Medically Indicated Late-Preterm and Early-Term Deliveries . American College of Obstetricians and Gynecologists; 2024 . Committee Opinion No. 831. Accessed November 12, 2025 . www.acog.org 11. Modifiers Recognized by Ohio Medicaid . Ohio Dept of Medicaid; 2011. Revised November 3, 2025 . Accessed November 12, 2025 . www.medicaid.ohio.gov Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 07/01/2026912. Pregnant Women Eligible for Extended Coverage, 42 C .F.R. 436.122 ( 2024 ).13. Reproductive Health Services: Pregnancy-Related Services, OHIO ADMIN . CODE 5160-21-04 ( 2025 ). 14. Reardon CC, Chen F. Critical illness during pregnancy and the peripartum period. UpToDate. Updated December 5, 2024. Accessed November 17, 2025. www.uptodate.com 15. Scope of Specialized Nursing Services, OHIO REV . CODE 4723.43 (2020). Approved by ODM on 04/22/2026

Digital EEG Spike Analysis

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Digital EEG Spike Analysis-OH MCD-PY-1789 07/01/2026 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 ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Digital EEG Spike Analysis-OH MCD-PY-1789Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDigital EEG Spike Analysis B. BackgroundEpilepsy is a chronic brain disorder that affects approximately 1.2% of the US population or 3,700,000 people. Epileptic seizures are associated with a loss of awareness, fatigue, drowsiness, physical weakness, and confusion. Epilepsy seizures can be trigg ered by stress, dehydration, alcohol, toxic exposure, hormonal changes, sleep deprivation, and visual stimulation. Epilepsy and seizures are diagnosed with a detailed medical history, blood tests, developmental, neurological, and behavioral tests, and scan s and imaging techniques (eg, electroencephalography, computerized tomography, magnetic resonance imaging). Electroencephalography (EEG) is a diagnostic test that measures electrical activity in the brain. EEG is a non-invasive procedure where small electrodes are attached to thepatients scalp and the patient remains still or is instructed to perform specific tasks while brain wave patterns are recorded. Specific wave patterns are then used to help diagnose medical conditions such as epilepsy . Advances in digital technology have led to software and hardware applications that expand the capability to record brai n wave forms, graph brain wave patterns, and automatically detect brain wave spikes indicative of abnormal brain activity. Abnormal EEG findings are often associated with epileptiform activity, such as epileptiform discharge. An epileptiform discharge represents disrupt ion in brain functionand is typically associated with spikes and sharp waves. Analy zing spikes and sharps with the accompanying slow waves helps localize seizure onset. When combined with clinical observation, prolonged monitoring via ambulatory EEG, and the recorded clinical behavior provided by video EEG, spike analysis helps to diagnose e pilepsy and other hea lth conditions. Digital EEG spike analysis requires substantial additional work by the technician to process data from the digital EEG as well as the physicians time to review the technicians work, review the data produced, and form a careful analysis of clinical obser vation with any changes in the EEG occurring before, during, and after the seizure. C. Definitions Ambulatory EEG (aEEG) Monitoring Portable recording of EEG outside of the hospital or clinic setting. Can be done with simultaneous video recording. Often uses computer software to detect seizures and interictal epileptiform discharges (IED) to aid in interpretation. Digital EEG Systems that allow for the recording, analysis, and storage of EEG data. These systems often include software tools that can detect spikes and other abnormal brain patterns and can help visualize, quantify, and interpret the data. Dipole Analysis Localization and quantification of the sources of electrical activity in the brain, which helps understand the origins of conditions such as epilepsy. Digital EEG Spike Analysis-OH MCD-PY-1789Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Epileptiform Activity Indicates cortical hyperexcitability, which is associated with an increased risk of seizures and the presence of an epileptic network in the brain. Sharp Waves Single epileptiform discharge defined by its duration and disruption of the EEG background. Spikes Sharp, transient waveforms that are clearly distinguished from background activity and indicate abnormal electrical activity in the brain. Spikes are often associated with seizures. Video-EEG Monitoring Synchronous recording and display of EEG patterns and video-recorded behavior. Procedure can be done in the outpatient EEG laboratory, in the home, or in a hospital inpatient setting. D. PolicyI. CareSource considers digital EEG spike analysis (CPT code 95957) medically necessary and , therefore , reimbursable when performed in conjunction with EEG for topographic voltage and/or dipole analysis. This applies specifically for pre-surgical evaluation with video-EEG long-term monitoring in members with intractable epilepsy, intracranial injuries, and concussions. II. CareSource does not consider Digital EEG spike analysis to be medically necessary for other indications. III. The submitting provider is responsible for submitting accurate documentation to substantiate the coding of claims. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claim submission, thi s will also result in a claim denial.E. Conditions of Coverage Reimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement 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. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 04/08 /2026 New policy. Approved at Committee.Date Revised Date Effective 07/01/2026 Date Archived Digital EEG Spike Analysis-OH MCD-PY-1789Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 H. References1. Baumgartner C, Pirker S. Video-EEG. Han d Clin Neurol . 2019;160:171-183. doi:10.1016/B978-0-444-64032-1.00011-4 2. EEG, noninvasive. MCG Health, 29th edition . Updated June 13, 2025 . Accessed February 24, 2026 . www.careweb.careguidelines.com 3. EEG, video monitoring. MCG Health, 29 th edition. Updated June 13, 2025 . Accessed February 24, 2026 . www.careweb.careguidelines.com 4. Eom TH. Electroencephalography source localization. Clin Exp Pediatr . 2022;66(5):201-209. doi:10.3345/cep.2022.00962 5. Epilepsy and seizures. National Institute of Neurological Disorders and Stroke. Updated April 7, 2025. Accessed February 24, 2026 . www.ninds.nih.gov 6. Feyissa AM, Tatum WO. Adult EEG. Handb Clin Neurol . 2019;160:103-124. doi:10.1016/B978-0-444-64032-1.00007-2 7. Guideline Twelve: guidelines for long-term monitoring for epilepsy. JClin Neurophysiol . 2008; 25(3): 170-80. doi: 10.1097/WNP.0b013e318175d472 8. Haider HA, Hirsch LJ, Sutherland HW. Electroencephalography (EEG) in the diagnosis of seizures and epilepsy. UpToDate. Updated April 29, 2025. Accessed February 24, 2026 . www.uptodate.com 9. Halford JJ, Sabau D, Drislane FW, et al. American Clinical Neurophysiology Society Guideline 4: Clinical EEG on digital media. JClin Neurophysiol . 2016; 33(4):317-9. doi: 10.1097/WNP.0000000000000318 10. Hirsch LJ, Fong MWWK, Leitinger M, et al. American Clinical Neurophysiology Societys standardized critical care EEG terminology: 2021 version. JClin Neurophysiol . 2021; 38:1-29. doi: 10.1097/WNP.0000000000000806 11. Kobau R, Luncheon C, Greenlund K. Active epilepsy prevalence among U.S. adults is 1.1% and differs by educational level National Health Interview Survey, United States, 2021. Epilepsy Behav . 2023;142:109180. doi:10.1016/j.yebeh.2023.109180 12. Moeller J, Haider HA, Hirsch LJ. Video and ambulatory EEG monitoring in the diagnosis of seizures and epilepsy. UpToDate. Updated May 6, 2025. Accessed February 24, 2026 . www.uptodate.com 13. Tatum WO, Halford JJ, Olejniczak P, et al. Minimum technical requirements for performing ambulatory EEG. JClin Neurophysiol . 2022;39(6):435-440. doi:10.1097/WNP.0000000000000950 Approved by ODM 04/21/2026

Temporary Codes

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Temporary Codes-OH MCD-PY-1414 07/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Temporary Codes-OH MCD-PY-1414Effective Date: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTemporary Codes B. Background Temporary codes exist in both CPT and HCPCS manuals and are updated throughout the year. Tcodes (ie, Category III codes) are temporary CPT codes for emerging technologies, services, and procedures which support data collection to substantiate widespread use and/or provide documentation for the Food and Drug Administration (FDA) approval process. Many of these codes have not been proven medically necessary and are considered to be experimental or investigational based on a lack of peer-reviewed scientific literature. A variety of temporary HCPCS codes exist. Temporary HCPCS codes may be established by the Centers for Medicare and Medicaid Services (CMS) to report drugs, biologicals, devices, and procedures, identify services and procedures under FDA review, or address miscellaneous services, procedures, and supplies. Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) may develop temporary HCPCS codes to report supplies and other products for which a national code has not yet been developed. Temporary HCPCS codes may also be developed by commercial payers to report drugs, services, and supplies. Coverage of these services is under the discretion of local carriers.C. Definitions Temporary codes CPT category III alphanumeric codes for new and developing technology, procedures and services. The use of these codes allows physicians and other qualified health care professionals to identify emerging technology, services, procedures, and service paradigms for clinical efficacy, utilization and outcomes. D. PolicyI. CareSource considers temporary codes medically necessary when ALL the following criteria are met: A. Documentation in the medical record supports use of the code. B. A more specific code is not available to describe the service/procedure. C. The service provided is within the scope of the members benefit plan. II. CareSource will use current industry standard procedure codes (HCPCS CPT I andCategory II codes) throughout the processing systems. HIPAA Transaction & Code Set Rule requires providers use the procedure code(s) that are valid at the time the service is provided. III. Providers must use industry standard code sets and specific HCPCS CPT I and Category II codes when available unless otherwise directed through the providers contract. Temporary Codes-OH MCD-PY-1414Effective Date: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 IV. If specific codes are not available, all unlisted or miscellaneous codes require medical necessity review. E. Conditions of CoverageReimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules Unlisted and Miscellaneous Codes G. Review/Revision History DATE ACTIONDate Issued 02/01/2023 New policyDate Revised 01/17/2024 03/26/202503/25/2026Annual review: updated references. Approved at Committee. Review: updated references, approved at Committee. Periodic Review. Updated references and DIV. Approved at Committee. Date Effective Date Archived H. References1. American Academy of Professional Coders. What is HCPCS? Accessed 12, 2026. www.aapc.com 2. American Medical Association. CPT Category III Codes. Accessed March 12, 2026. www.ama-assn.org 3. CPT Professional 2026. American Medical Association; 2026. 4. HCPCS Codes Temporary Codes for Use with Outpatient Prospective Payment System. Accessed March 12, 2026. www.hcpcs.codes 5. Understanding the HIPAA standard transactions: The HIPAA Transactions and Code Set rule. American Medical Association. Accessed March 12, 2026. www.assets.ama-assn.org Temporary Codes-OH MCD-PY-1414Effective Date: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 6. CareSource Ohio Medicaid Provider Manual (2025). Accessed March 12, 2026. www.caresource.com ODM Approved 04/06/2026

Modifier 59, XE, XP, XS, XU

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 07/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 59 , XE, XP, XS, XU B. BackgroundReimbursement modifiers are 2-character code s used by physicians and other qualified health care professionals to indicate that a service or procedure has been altered due to a specific circumstance. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier inappropr iately can result in the denial of a claim or an inc orrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when 2 Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situa tions or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management ( E/M ) services, that are not usually reported together but are appropriate under the patients specific circumstance. National Correct Co ding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because 2 different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the 2 procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established 4 HCPCS modifiersto define specific subsets of modifier 59 XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. CPT instructions state that m odifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59. Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) and provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a pre-payment or post-payment coding review. A. For pre-payment review, once the claim line has been validated , it is either processed for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim line is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of the claim . Failure to submit accurate and completedocumentation may result in a denia l. If the documentation does not support the claim submission, this will also result in a denial. IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59.VI. Modifier X {EPSU} or 59 , when applicable , may only be used to indicate that a distinct procedural service was performed independently from other non-E/M services performed on the same day when no other more appropriate modifier is available . Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group , and/or provider specialty. A. Modifier XS (or 59, when applicable) is for sur gical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed at different anatomic sites 2. are not ordinarily performed or encountered on the same day Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 3. cannot be described by 1 of the more specific anatomic NCCI Procedure toProcedure (PTP) -associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1 – T9, LC, LD, RC, LM, RI) B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed during different patient encounters 2. cannot be described by 1 of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91) C. Modifier XE (or 59, when applicable) may also be used when 2 timed procedures are performed during the same encounter but occur 1 after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are either 1. performed at separate anatomic sites 2. performed at separate patient encounters on the same date of service E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when all the following apply: 1. diagnostic procedure is the basis for performing the therapeutic procedure 2. occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires 3. provides clearly the information needed to decide whether to proceed with the therapeutic procedure 4. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately.) F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when all the following apply: 1. diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure 2. occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires 3. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the post-procedure diagnostic procedure is an inherent component or otherwise included (eg, not separately payable) post – procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately.) E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, when applicable. In the absence of state specific instructions, the CMS guidelines on Modifier 59, XE, XP, XS, XU will apply. Please refer to the individual fee schedule for appropriate codes. Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to both participating and nonparticipating providers and facilities. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/Rules Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised 08/02/2023 07/17/2024 07/16/2025 03/11 /2026 Annual review: updated references. Approved at Committee. Review: updated references, approved at Committee. Review: updated references, approved at Committee. Annual review . Updated DI. Updated references. Approved at Committee. Date Effective 07/01/2026 Date Archived H. References1. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services . US Centers for Medicare and Medicaid Services; 2025. Accessed March 10 , 2026. www.cms.gov 2. Mechanized Claims Processing and Information Retrieval Systems; Operational, etc., Requirements, 42. U.S.C. 1396b(r) (2026). 3. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners. US Centers for Medicare & Medicaid Services; 202 5. Accessed March 10 , 2026. www.cms.gov 4. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicare and Medicaid Services. Updated January 1, 2026. Accessed March 10 , 2026 . www.cms.gov 5. MLN1783722 – Proper Use of Modifiers 59 & -X{EPSU}. US Centers for Medicare and Medicaid Services; 2025. Accessed March 10 , 2026. www.cms.gov 6. Transmittal R1422OTN – Publication 100-20 – MM8863 – Specific Modifiers for Distinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Accessed March 10 , 2026. www.cms.gov ODM Approved 03/20/ 2026

Modifier 25

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 25-OH MCD-PY-1360 07/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 25-OH MCD-PY-1360Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 25 B. BackgroundReimbursement modifiers are a 2-digit code that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifier 25 is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association (AMA) Current Procedural Terminology (CP T) book defines modifier 25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of modifier 25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a medically necessary,significant and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see E/M Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. This modifier is not used to report an E/M service that resulted in a decision to perform surgery ; s ee modifier 57 for services that resulted in a surgical decision . For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Using a modifierinappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSource s request. CareSource uses published guidelines from CPTand the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly. Modifier 25-OH MCD-PY-1360Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. Definitions American Medical Association (AMA) A professional association of physicians and medical students that maintains the Current Procedural Terminology coding system. Current Procedural Terminology (CPT ) Codes that are issue d, updated, and maintained by the AMA , provid ing a standard language for coding and billing medical services and procedures. Evaluation and Management (E/M) A medical coding process established by Congress that supports medical billing and determines the type and severity of patient conditions. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by CMS, provid ing a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 25 may be flagged for either a prepayment or post-payment coding review . A. For prepayment review, once the claim has been validated , it is either processed for payment or the claim line is denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim line is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of claim s. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial. IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifier 25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier 25, the code may be denied. VI. Other CareSource policies may overlap with this topic. Refer to the PreventiveEvaluation and Management Services and Acute Care Visit on Same Dat e of ServiceModifier 25-OH MCD-PY-1360Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 policy for specific information on reimbursement practices for E/M and acute care regarding modifier 25. VII. Appending modifier 25 to an E/M service is considered inappropriate in the followingcircumstances:A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. B. The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure. C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. H. The preventative E/M service is performed at the same time as a preventative care visit (eg, a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preve ntative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation. J. CareSource will not reimburse CPT 99211 when billed with Modifier 25. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document.F. Related Policies/RulesModifiers Modifier 25-OH MCD-PY-1360Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022 New PolicyDate Revised 08/02/2023 07/17/2024 06/04/2025 03/ 25 /2026Annual Review: updated references. Approved at CommitteeReview: updated references, approved at Committee Review: added 99211 statement, updated references, approved at Committee. Review: clarified review process in D.II, added related policies section D.VI , removed first paragraph in Background . Approved at Committee. Date Effective 07/01/2026 Date Archived H. References1. American Medical Association. Reporting CPT modifier 5. CPT Assistant (Online). 2023;33(11):1-12. Accessed February 26, 2026 . www.ama.assn.org 2. Appropriate use of Modifier 25. American College of Cardiology. Accessed February 26, 2026 . www.acc.org 3. Chaplain S. Are you using Modifier 25 correctly. American Academy of Professional Coders. Published March 25, 2022. Accessed February 26, 2026 . www.aapc.com 4. Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services . Centers for Medicare and Medicaid Services; 202 6. Accessed February 26, 2026 . www.cms.gov 5. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag . 2004;11(9):21-22. Accessed February 26, 2026 . www.aafp.org 6. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services; 2025. Accessed February 26, 2026 . www.cms.gov Approved ODM 0 4/06/2026

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