REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Payment to Out of Network Providers-OH MCD-PY-1343 06/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a g eneral 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 additio n 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, a uthorization, 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 llness, or inju ry 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 i n 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 d ocuments, 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 Evidenc e of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the deter mination. 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 Equi ty 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/R ules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Payment to Out of Network Providers-OH MCD-PY-1343Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectPayment to Out of Network Providers B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and w ill be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. This policy is intended to define the reimbursemen t rate for claims received fromproviders who are not contracted (out of network) providers with CareSource.C. Definitions Emergency Services Emergency health care services are used to treat an emergency medical condition. Emergency Medical Condition A medical condition that manifests itself by signs and symptoms of sufficient severity or acuity, including severe pain, such that a prudent layperson would reasonably have cause to believe constitutes a condition that the absence of immediate medical attent ion could reasonably be expected to result in o placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy o serious impairment to bodily functions o serious dysfunction of any bodily organ or part Out of Network Provider A non-participating provider that is not contracted with CareSource. D. PolicyCareSources standard reimbursement approach to out of network providers is as follows: I. Preauthorized, medically necessary services rendered to CareSource members by out-of-network providers will be reimbursed at A. 60% of the Ohio Medicaid Fee schedule charges B. 60% of the Ohio Medicaid Fee schedule for labs C. If a service or procedure is not priced by the Ohio Department of Medicaid fee schedule , then it will be reimbursed to the provider at 20% of billed charges. Payment to Out of Network Providers-OH MCD-PY-1343Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 II. In the event of any conflict between this policy and any written agreement between the provider and CareSource, th e written agreement will be the governing document.III. ExclusionsA. Emergency health care services will be reimbursed based on state regulations.B. Provider types with reimbursement methodology mandated by state/federal regulation/statute or rule or directive. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 07/02/2021 New policyDate Revised 09/29/2021 04/12/2023 01/31/2 024Added III. B. for clarification. Approved at PGC.Removed links from policy. Updated reference. Approved at Committee. Annua l review. Updated reference. Approved at Committee. Date Effective 06/01/2024 Date Archived H. References1. Managed Care : Definitions , OHIO ADMIN . CODE 5160-26-01 (2022). Approved ODM 2/29/2024
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Overpaymen t Recovery-OH MCD-PY-1115 06/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical nece ssity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to , those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysf unction 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 d oes 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 pr ovided 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 limitatio ns that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectOverpayment Recovery B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource . They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and wi ll be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate 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 guarantee claims payment.Retrospective review of claims paid to providers assist Ca reSource with ensuringaccuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified.Fraud, waste , and abuse investigations are an exception to this policy. In theseinvestigations, the lo ok back period may go beyond 2 years.C. Definitions Claims Adjustment A claim that was previously adjudicated and is being updated for one of the following reasons: o denied as a zero payment o a partial payment o a reduced payment o a penalty applied o an additional payment o a supplemental payment Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource , and the other carrier is the primary insurance for the member. Credit Balance/Negative Balance Funds that are owed to CareSource because of a claim adjustment. Explanation of Payment (E OP ) The EOP contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Forwarding Balance (FB) An adjustm ent that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 claim has been adjusted to a different dollar amount and that funds are owed toCareSource. Improper Payment A payment that should not have been made or an overpayment was made. Examples include, but are not limited to the following : o payments made for an ineligible member o ineligible service payments o payments made for a service not received o duplicate payments Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 C.F.R. o A claim adjustme nt is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Provider Level Balancing (PLB ) Adjustments to the total check / remit amount occur in t he PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment (Beginning Segment for Payment O rder/Remittance Advice (BPR ), which means total payment within the EOP ). Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. D. PolicyI. In accordance with 42 C .F.R. 438.608, CareSource requires providers to report any overpayment that has been received by the provider. The overpayment must be returned to CareSource within 60 calendar days after the date on which the overpayment was identified and to notify CareSource in writing of the reason for the overpayment. II. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider:A. The patient’s name, date of birth, and Medicaid identification number . B. The date or dates of ser vices rendered . C. The specific claims that are subject to recovery and the amount subject to recovery, including any interest charges, which may not exceed the amount specified in Ohio law or rule . D. The specific reasons for making the recovery for each of the claims subject to recovery . E. If the recovery is a result of member disenrollment from the CareSource, the effective date of disenrollment . F. An explanation that if a written response to the notice is not received within 30 calendar days from receipt of the notice, the overpayments will be recovered from future claims . Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 G. How the provider may submit a written response disputing the overpayment .H. How the provider may submit a written request for an extended payment arrangement or settlement . III. Overpayment Recov eriesA. Lookback period is 24 months from the claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Coordination of Benefit RecoveriesA. Lookback period is 12 months from claim paid date. B. Advanced notificatio n will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims bei ng submitted within original claim timely filing guidelines. V. Retro Active Eligibility RecoveriesA. Lookback period is 24 months from date CareSource is notified by Medicaid of the updated eligibility status. B. Advanced notification will occur 30 days in advan ce of recovery. VI. Management of Claim Credit BalancesA. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. This information will be displayed on the EOP in the PLB section. B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previously but was up dated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $2 difference. b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D .I D.IV. 2. Overpayment Example Overpayment Recovery-OH MCD-PY-1115Effective Dat e: 06/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D.IV. b. The reduced payment will trigger a 30-day advanced notifi cation with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. D. Providers are notified of negative balances through EOPs and 835s. Providers are expected to use this information to reconcile and maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances. E. Notification of negative bal ances and reconciliation of negative balances may not occur concurrently. Providers are expected to maintain their AR to account for the reconciliation of negative balances when they occur. E. Conditions of CoverageReimbursement is dependent on, but not lim ited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesCareSource Provider Manual National Agreement, Article V. Claims and Payments , 5.11 (d). G. Review/Revision HistoryDATE ACTIONDate Issued 04/29/2020 New policyDate Revised 07/21/2021 03/30/202210/26/202202 /14 /202 4 Revision: Added Management of Claims Balance information. Added compliance with 42 CFR 438.608 for requirement for provider to report identified overpayments . Approved at PGC. No changes. Updated references. Annual review. Removed V.C. Updated references. Approved at Committee. Date Effective 06/01/2024 Date Archived H. References1. Ohio Medicaid Provider Agreement for Managed Care Organization . Ohio Dept of Medicaid. Updated January 1, 2024. Accessed January 2, 2024. www.medicaid.ohio.gov 2. Payments Considered Final Overpayment, OHIO REV . CODE 3901.388 (2002). Approved ODM 2/29/2024
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Coordination of Benefits-OH MCD-PY-1412 06/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regar ding 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, Reim bursement 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, notifica tion 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 llness, or injury and without which t he 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 Poli cy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), cover age 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 ………………………….. ………………………….. ………………………….. ………………… 6 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …………………. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………………. 7 H. References ………………………….. ………………………….. ………………………….. ………………………….. ………. 7 Coordination of Benefits-OH MCD-PY-1412 Effective Dat e: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectCoordination of Benefits B. BackgroundFederal regulations require that all identifiable financial resources be utilized prior to the expenditure of Medicaid funds for most health care services provided to Medicaid beneficiaries. Coordination of benefits (COB) is the method used to designate th e order in which multiple carriers are responsible for benefit payments, which prevents duplication of payments. Providers must utilize other payment sources to the fullest extent prior to filing a claim with CareSource. The terms “third party liability” and “other insurance” are usedinterchangeably to mean any source, other than Medicaid, that has a financial obligation for health care coverage. If other insurance resources are not exhausted and the provider was aware of other insurance coverage, billin g Medicaid may be considered fraud under the False Claim Act. This policy assists in defining the order of coverage. The purpose of this policy is to define the order of coverage and how CareSource willcoordinate benefit payments as the secondary payer.C. Definitions CareSource Provider Agreement The contract between a provider and CareSource for the provision of services by the provider to individuals enrolled with the plan, including but not limited to contracts titled Provider Agreem ent and Group Practice Services Agreement. Coordination of Benefits (COB) The process of dete rmining which health plan or insurance policy will pay first and/or determining the payment obligations of each health plan, medical insurance policy, or third-party resource when two or more health plans, insurance policies , or third-party resources cover the same benefits for CareSource members . Explanation of Payment (EOP) A detailed explanation of payment or denial of a claim by an insurance carrier. Primary Carrier The insurance carrier that has been determined to be responsible for primary paymen t. D. PolicyI. Submitted claims must include the total amount billed, total amount paid by primary carrier, and balance due, along with a valid provider signature. Any balance due after receipt of payment from the primary carrier should be submitted to CareSource for consideration , and the claim must in clude information verifying the payment amount received from the primary plan. CareSource shall coordinate payment for covered services in accordance with the terms of a members benefit plan, applicable state and federal laws, and applicable Centers for M edicare & Medicaid Services (CMS) guidance. If CareSource is not the primary carrier, providers shall bill the primary carrier for all services provide d before submi tting claims to CareSource. Coordination of Benefits-OH MCD-PY-1412 Effective Dat e: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.II. COB GuidelinesA. When CareSource coordinates benefits with the p rimary carrier, reimbursement will be made according to the Medicaid contracted maximum allowable minus any payment made by the primary carrier. Any items or services for which another carriers reimbursement amount is equal to or greater than the Medicaid contracted maximum allowable amount will be paid at zero. Claims that pay at zero are considered to be paid claims, not denied claims. B. When the payment from another insurance carrier is less than the Medicaid contracted amount, CareSource will pay up to t he Medicaid contracted total allowed amount. The sum of the payments will not exceed the Medicaid contracted maximum allowable amount (as indicated in the CareSource Provider Agreement ). Example 1: Charged amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $50.00 $10.00 $0 $0 $40.00 CareSource $35.00 $0.00 Summary : In this example, since the primary carriers paid amount of $40.00 is to theCareSource allowed amount of $35.00, then CareSource pays zero . Example 2: Charged Amount $100.00Carrier Allowed Co-pay Deductible Co-Insurance Paid Primary Insurance $80.00 $50.00 $0 $0 $30.00 CareSource $40 .00 $10.00 Summary : In this example, subtract the primary paid amount of $30.00 from theCareSource allowed amount of $40.00 (less er of the allowed amounts). Therefore, in this example, CareSource will pay $10.00. Example 3: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance Paid Primary Insurance $10 0.00 $0 $10 0.00 $0 $0 CareSource $12 5.00 $10 0.00 Summary: In this example, subtract the primary paid amount of $0 from the primary allowed amount of $100.00 (less er of the allowed amounts). Therefore, in this example, CareSource will pay $100.00. Coordination of Benefits-OH MCD-PY-1412 Effective Dat e: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.Example 4: Charged Amount $200.00Carrier Allowed Co-pay Deductible Co-Insurance PaidPrimary Insurance $150.00 $0 $10 0.00 $40.00 $10.00 CareSource $12 5.00 $115 .00 Summary: In this example, subtract the primary paid amount of $10.00 from theCareSource allowed amount of $125.00 (less er of the allowed amounts). Therefore, in this example, CareSource will pay $115.00 . III. CareSource as Secondary PayerA. Following Medicare reimbur sement , Medicaid pays the remaining portion based on the following criteria: When a member becomes entitled to Medicare before the member’s termination of enrollment, the member may receive covered benefits that are also covered by Medicare. During that time, unless the provider has agreed in writing to an alternative payment metho dology or different secondary claims payment rate, CareSource will reimburse Medicare secondary claims as set forth in O hio Administrative Code Rule 5160-1-05.3 for both network and out-of-network providers , including application of the following exemption s to the Part B Medicaid maximum policy in accordance with the Ohio Administrative Code (OAC ) and other guidance issued by the Ohio Department of Medicaid : 1. hospital services 2. nursing facility services included in the nursing facility per diem 3. covered supple mental medical insurance benefits under the Medicare progra m 4. dual eligible coordinated benefits for members who elect to receive their Medicare Part Bbenefits through the original Medicare program B. Secondary Payer for Obstetrical Services 1. Primary payer EOP is required in order to coordinate coverage. With the primary payer EOP, CareSource will verify if the prenatal visits are a part of the primary carriers global reimbursement. If so , CareSource will not make a payment until a delivery charge is received. If the prenatal visits are excluded from the primary carriers global reimbursement, including when maternity benefits are not covered by the plan, CareSource will process the claim as the primary payer. 2. If the first claim that CareSource receive s is for a global delivery, the claim will deny for invalid coding. The provider will need to re-bill within 90 days of denial using the delivery-only CPT codes, as CareSource does not recognize global obstetrical codes for claims processing. 3. Once the deli very charge is received, CareSource will combine all prenatal visit charges with the delivery charges. CareSource will subtract the primary carriers payment from the lesser of the primary carrier allowed amount and the CareSource allowed amount (the benef it allowance for all visits and the delivery charge) and will pay any remaining liability. CareSource will not pay Coordination of Benefits-OH MCD-PY-1412 Effective Dat e: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.more than CareSources normal benefit when no other coverage exists or more than the patient responsibility after the primary insurance has p aid. IV. COB Timely Filing GuidelinesA. If a provider is aware that a member has primary coverage, the provider will submit a copy of the primary payer s EOP along with the claim to CareSource within the claims timely filing period. 1. If CareSource receives a claim for a member that is identified as having other coverage and a primary payer EOP was not submitted with the claim(s), CareSource will deny the claim(s) , requesting the required COB information. 2. If a claim is denied for COB in formation needed, the provider must submit the primary payer s EOP. If the initial timely filing period has elapsed, the EOP must be submitted to CareSource within 90 days from the primary payer s EOP date. B. If a provider has information that the primary pa yer s policy has terminated or was not in effect during the date of service for the claim(s), the provider must notify CareSource of the dispute within the original timely filing period or within 90 days of the providers actual receipt of the primary paye rs EOP date, whichever is greater. C. If the dispute is received within the original timely filing period: 1. CareSource will confirm whether or not the primary payer was in effect during the date of service. If the policy was NOT in effect, CareSource will p rocess the claim(s) that are within the original timely filing period or 90 days of the providers actual receipt of the payer s EOP date. 2. If the policy WAS in effect, the claim will remain denied for lack of primary payer s EOP. D. If the provider does no t notify CareSource of the dispute within the original timely filing period or if the provider does not submit the primary payer s EOP within 90 days of the providers actual receipt of the primary payer s EOP date, the claim will re-deny as not being timely filed. V. COB Claim Submission to CareSourceA. CareSource follows The Health Insurance Portability and Accountability Act (HIPAA ) guidelines and accepts industry standard codes. It is imperative that cla ims are filed with the same codes that the primary payer presented on the Explanation of Benefits ( EOB ) to ensure that claims are processed correctly. Claim(s) will be denied if there is a mismatch between the codes on the received claim and the primary pa yer s EOP. B. CareSource applies standard claim adjustment codes . C. Claim Adjustment Group Codes are as follows: 1. CO Contractual Obligation 2. OA Other Adjustment 3. PI Payer Initiated Reductions 4. PR Patient Responsibility D. When filing claims with patients re sponsibility, the following Claim Adjustment Reason Codes should be used: Coordination of Benefits-OH MCD-PY-1412 Effective Dat e: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.1. PR1 Deductible2. PR2 Coinsurance 3. PR3 Copayment E. When filing claims with contractual obligation, please use Adjustment Group Code CO. Contractual obligation can be communicated on the Primary Payers EOB with several different codes. Please use the code reflected on the primary payers EOB. Some examples of these codes are 24, 45, 222, P24, P25, 26. (This is not an all-inclusive list). The same process should be foll owed when using Adjustment Group Code OA – Other Adjustment. VI. Denied COB ClaimsA. Denied COB claims will be automatically adjusted when primary insurance has been updated retroactively to show coverage was terminated at the time of service. This also has a lookback period of 12 months from the paid date or 18 months to the date of service. B. Denied COB claims w ill NOT be automatically adjusted if the updated coverage information was received after 90 days from the denial for COB information. In this case, th e provider must request claim adjustment within the original timely filing period or within 90 days from the date of the EOP denial, whichever is greater. Although CareSource has implemented this COB Adjustment Policy, it is still the providers responsibi lity to review their accounts and submit COB claims in a timely manner for payment. VII. Disputes for Denied COB ClaimsA. Disputes w ill NOT be automatically adjusted if the updated coverage information was received after 90 days from the denial for COB informati on. In this case, the provider must request claim adjustment within the original timely filing period or within 90 days from the date of the EOP denial, whichever is greater. Although CareSource is implementing this COB Adjustment Policy, it is still the p roviders responsibility to review their accounts and submit COB claims in a timely manner for payment. B. CareSource will confirm whether or not the primary coverage was in effect during the date of service. If the policy was NOT in effect, CareSource will p rocess the claim(s) that are within the original timely filing period. If the initial timely filing period has elapsed, then CareSource will process the claims that are within 90 days of the original denial. If the policy WAS in effect, the claim will remain denied for needing primary carriers EOP. If the provider does not notify CareSource of the dispute within the original timely filing period, within 90 days of the CareSource denial, or if the provider does not submit the primary carriers EOP withi n 90 days of the Primary Carriers EOP date, the claim will re-deny as not being filed timely. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicab le. Please refer to the individual fee schedule for appropriate codes. Coordination of Benefits-OH MCD-PY-1412 Effective Dat e: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 12/14/2022 New policyDate Revised 02/14/2024 Annual review. Updated background. Updated references. Approved at Committee. Date Effective 06/01/2024 Date Archived H. References1. Coordination of Benefits, OHIO ADMIN . CODE 5160-1-08 (2019). 2. Managed Care: Primary Care and Utilization Management , OHIO ADMIN CODE 5160 – 26-03.1 (2022). 3. Payment for “Medicare Part B” Cost Sharing , OHIO ADMIN . CODE 5160-1-05.3 (2016) . Approved ODM 03/07/2024
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Chiropractic Care-OH MCD-PY-1328 06/01/2024 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, i ndustry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edic al 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 lim ited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illn ess, 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 pro vider. 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 P olicy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to serv ices 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 li mitations 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/R ules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Chiropractic Care-OH MCD-PY-1328Effective Dat e: 06/1/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectChiropractic Care B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and o ffice staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is beingprovi ded. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Chiropractic is a licensed healthcare profession where treatment typically involvesmanual therapy, often including spinal manipulation.C. Definitions Acute Subluxation Member is being treated for a new injury defined by x-ray or physician exam which result s in an expected improvement in, or arre st of, progression in the members condition. Billing Provider A chiropractor, mechanotherapist, profession al medical group, hospital , or fee-for-service clinic as noted by the Ohio Administrative Code. Maintenance Therapy A therapy that is performed to treat a chronic, stable condition or to prevent deterioration . Rendering Providers A chiropractor or a mechanot herapist who is eligible to provide spinal manipulation . D. PolicyI. CareSource follows the Ohio Administrative Code for payment of spinal manipulation . II. Payment may be made for manual correction to correct a spin al subluxation determined by x-ray or physician exam for a condition that is acute and episodic in nature. When the maximum therapeutic benefit has been met, ongoing therapy is considered maintenance therapy and is not medically necessary. III. Payment may be made for the following services:A. Spinal ma nipulation 1. chiropractic manipulative treatment (CMT); spinal, one to two regions 2. chiropractic manipulative treatment (CMT); spinal, three to four regions Chiropractic Care-OH MCD-PY-1328Effective Dat e: 06/1/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 3. chiropractic manipulative treatm ent (CMT); spinal, five regionsB. Diagnostic imaging to determine the existence of a subluxation 1. spine, entire; survey study, anteroposterior and lateral 2. spine, cervical; anteroposterior and lateral 3. spine, cervical; anteroposterior and lateral; minimum of four views 4. spine, cervical; anteroposterior and lateral; complete, including oblique and flexion and/or extension studies 5. spine, thoracic; anteroposterior and lateral views 6. spine, thoracic; complete, with oblique views; minimum of four views 7. spine, thoracolumbar; anteroposterior and lateral views 8. spine, lumbosacral; anteroposterior and lateral views 9. spine, lumbosacral; complete, with oblique views 10. spine, lumbosacral; complete, including bending views IV. All services performed must be medically ne cessary and related to the treatment of a specifi c medical complaint. A. To determine medical necessity, CareSource requires all of the following: 1. a primary diagnosis of subluxation (ie, lumbar and/or sacral) 2. a secondary diagnosis that supports the treatment provided ( eg , osteoarthritis, congenial musculoskeletal deformities of the spine) B. Manual manipulation must have a direct therapeutic relationship to the members condition as documented in the medical record . The lack of documentation specifying the relationship between the members condition and treatment shall result in the service being ineligible for reimbursement. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting appro ved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesMedical Necessity Determination Policy G. Review/Revision HistoryDATE ACTIONDate Issued 05/26/2021Date Revised 04/12/2023 01/31/2024Annual review: Title modified. Updated references.Approved at Committee. Annual review. Updated references . Approved at Committee. Date Effective 06/01/2024 Date Archived H. References1. Chiropractic Services, OHIO ADMIN . CODE 5160-8-11 (2022). Chiropractic Care-OH MCD-PY-1328Effective Dat e: 06/1/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Approved ODM 2/29/2024
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-OH MCD-PY-0007 05/01/2024 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, i ndustry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are 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 t he Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addi ction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Preventive Evaluation and Management Services and AcuteCare Visit on Same Date of Service-OH MCD-PY-0007Effective Dat e: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectPreventive Evaluation and Management Services and Acute Care Visit on Same Date of Service B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claim s 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 staf f 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 code(s) for the product or service that is being provided. Theinclusion of a code does not imply any right to reimbursement or guarantee claims payment.CareSource will reimburse participating providers for medically necessary andpreventive screening tests as required by federal statute through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF). C. Definitions Preventive Services Exams and screenings t hat check for health problems with the intention to prevent any problem discovered from worsening and may include, but are not limited to, physical checkups, hearing, vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccination s/immunizations. Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age but are especially important for children under the age of 18 years . D. PolicyI. When any of the following pediatric and adolescent preventive exam codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse both codes at 100%. A. Preventive Health Service Codes 1. 99381-99384 2. 99391-99394 B. Acute Care Visit Codes 1. 9920 2-99205 2. 99212-99215 II. When any of the following adult preventive health service codes are billed on th e same date of service as an acute care visit with the appropriate ICD-10 codes, Preventive Evaluation and Management Services and AcuteCare Visit on Same Date of Service-OH MCD-PY-0007Effective Dat e: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 CareSource will reimburse only the preventive service code at 100%. The acute care visit service codes will not be reimbursed unless billed with the appropriate modifier to identify significant, separately identifiable services that were rendered by the same physician on the same date of service. A. Preventive Health Service Codes 1. 99385-99387 2. 99 395-99397 B. Acute Care Visit Codes 1. 9920 2-99205 2. 99212-99215 III. CareSource reserves the right to request documentation to support billing both services for all claims received. If documentation is requested, it must clearly delineate the problem-oriented histor y, exam, and decision making from those of the preventive service. Documentation must include the following: A. Key elements support ing the additional preventive health services that were rendered . B. A separate history paragraph describing the chronic/acute co ndition that clearly supports additional work needed on the same date of service. C. A clear list in the assessment portion of the documentation of the acute/chronic conditions being managed at the time of the encounter. If there is a portion of the physical exam that is not routinely performed at the time of a preventive service, the provider should clearly identify those exam pieces (eg, A thorough MS and neuro exam of the left hip performed as it relates to the HPI). E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule for appropriate codes. F. Related Policies/RulesModifier 25 Reimbursem ent policy G. Review/Revision HistoryDATE ACTIONDate Issued 11/17/2014Date Revised 11/17/2015 08/06/2019 09/14/202201/17/2024Revision includes payment policy legal language Updated reimbursement rate from 50% to 100% for services that are rendered on the same date of service Annual review: removed reference to archived policies, updated codes, added reference to Modifier 25 policy Annual Review; Approved at Committee. Date Effective 05/01/2024 Date Archived Preventive Evaluation and Management Services and AcuteCare Visit on Same Date of Service-OH MCD-PY-0007Effective Dat e: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 H. References1. Draak K. Successfully bill a preventive service with a sick visit . American Academy Professional Coders. March 1, 2022. Accessed December 20 , 2023. www.aapc.com 2. Healthcheck , OHIO ADMIN . CODE 5160-1-14 (2017). 3. Preventive Services, OHIO ADMIN . CODE 5160-1-16 (2017). Approved by ODM on 01/25/2024
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 26 and TC: Professional and Technical Component – OH MCD-PY-1474 03/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guideline s. 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 benef its 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. Medi cally 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 llness, 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 provide d 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 Handbook s, 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 co nflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavio ral 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 ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Da te: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 26 and TC: Professional and Technical Component B. BackgroundReimbursement policies are designed to a ssist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guaran teeclaims payment.According to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), a modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specificcircumstance but not changed in its definition or code. It may also provide more information about a service such as it was performed more than once, unusual events occurred, or it was performed by more than one physician and/or in more than one location. The Current Procedural Terminology (CPT) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency. CPT codes are also used fo r administrative management purposes such as claimsprocessing and developing guidelines for medical care review. Some p rocedure coding,described by a single CPT code, is comprised of two distinct portions: a professional component (26) and a technical co mponent (TC) . When the professional component of one such procedure is performed separately, the specific service performed by the physician may be identified by adding CPT modifier 26 . In this scenario, the facility provides the technical component of a s ervice/procedure , bill ing the same procedure code with modifier TC. In this way the components of the service can be separately billed by the provider and facility. C. Definitions Global Procedure /Service – Represents both the professional and technical component as a complete procedure or service. Identified by reporting the procedure without modifier 26 or TC. Modifier 26 ( Professional Component) – Used to indicate when a physician or other qualified healt h care professional renders the supervision and interpretation portion of a service or procedure and the preparation of a written report. Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Da te: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Modifier TC (Technical Component) Used to indicate the technical personnel,equipment, supplies and institutional ch arges of a service or procedure . D. PolicyI. CareSource expects providers and facilities to adhere to national coding guidelines and standards when utilizing modifiers . II. Modifier 26A. The professional component is outlined as a physicians service, which may include technician supervision, interpretation of re sults, and a written and signed report. B. To claim only the professional portion of a service, CPT instructs professionals (or providers) to append modifier 26 to the appropriate CPT code. C. Modifier 26 is also be used t o bill for the professional component p ortion of a test when the provider utilizes equipment owned by a hospital/facility . III. Modifier TCA. The technical component includes the provision of all equipment, supplies, personnel, and costs related to the performance of the procedure.B. The payment for the technical component portion also includes the practice expense and the malpractice expense. C. To claim only the technical portion of a service, append modifier TC to the appropriate CPT code. D. Fees for the technical component are generally r eimbursed to the facility or practice that provides or pays for the supplies, equipment, and/or clinical staff (technicians). E. Hospitals are typically exempt from appending modifier TC , because it is assumed that the hospital is billing for the technical co mponent portion of any onsite service. IV. Global Procedure /ServiceA. The global procedure is when the same physician or other qualified health care professional performed both the professional component and technical component of that service. This may be the case if an X-ray of a broken bone is taken in the orthopedic surgeons office. B. A global service is identified by reporting the eligible code without modifier 26 or TC. In such cases, the provider is reimbursed for the equipment, supplies, and technical su pport, as well as the interpretation of the results and the report. C. When reporting a global service, no modifiers are necessary to receive payment for both components of the service. V. ExclusionsA. Do not append modifier 26 if there is a dedicated code to describe only the professional/physician component of a given service (eg, 93010 Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Da te: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 electrocardiogram, routine ECG with at least 12 leads; interpretation and report only).B. Do not append modifier TC if there is a dedicated code to describe the technical component, for example, 93005 electrocardiogram: tracing only, without interpretation and report. C. CareSource does not allow reimbursement for use of modifier 26 or modifier TC when 1. It is reported with an Evaluation and Management (E&M) code. 2. There is a separate standalone code that describes the professional component only, technical component only , or global test only of a selected diagnostic test. VI. Duplicate billingA. W hen o ne provider reports a global procedure and a different provider reports the same procedure with a professional (26) or technical (TC) component modifier for the same patient on the same date of service, the first charge approved by CareSource will be eligi ble for reimbursement and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. B. W hen one provider reports a procedure with a professional (26) and a different provider reports a global p rocedure for the same patient on the same date of service, the first charge approved by CareSource will be eligible for reimbursement and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement . C. When one provider reports a procedure with a technical (TC) component modifier and a different provider reports a global procedure for the same patient on the same date of service, the first charge approved by CareSource will be eligible for reimburse ment and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. VII. CareSource may request documentation for post-payment review of claims submitted with modifier 26 or modifier TC. If documenta tion is not provided, CareSource may recoup previously paid claim. E. Conditions of CoverageNA F. Related Policies/RulesElectrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation G. Review/Revision HistoryDATE ACTIONDate Issued 11/29/2023 New policy. Approved at Committee.Date Revised Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Da te: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Date Effective 03/01/2024Date Archived H. References1. CPT overview and code approval. American Medical Association. Accessed November 6, 2023. www.ama-assn.org 2. Medical and Surgical Services, OHIO ADMIN . CODE 5160-4-01 to 33 (2022). 3. Medicare Claims Processing Manual Chapter 23 – Fee Schedule Administration an d Coding Requirements . Centers for Medicare and Medicaid Services. Revised June 2, 2023. Accessed November 6, 2023. www.cms.gov 4. Modifiers Recognized by Ohio Medicaid . Ohio Dept of Medicaid; 2022. Accessed November 6, 2023. www.medicaid.ohio.gov ODM Approved 01/11/2024
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name Policy Number Effective Date Single Dose Vial Claims Modif ier s PY-PHARM-0100 07-01-2023 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing lo gic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify thi s 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 limitatio ns that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 3 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Sin g le Do se Vial Claims Mo d ifiersOh io Med icaidPY-PHARM-0100 Effective Date: 07-01-2023 2 A. SubjectThis policy provides guid ance for claims billing documentation and reimbursement of single dose injectable vials. B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and polic y clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encouraged to use self-service channels to verif y members eligibility. It is the responsibility of the submitting provider to submit the most a ccurate andappropriate CPT/HCPCS /ICD-10 code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. This policy describes documentation require ments and reimbursement guidelines f orbilling of the administered and discarded portion (s) of drugs and biologicals . Providers shall bill and receive reimbursement f or both the dose administered and the unused portion of weight-based or variable dosing injectable drugs that are manuf actured and supplied only in single dose or single use f ormat. The JW modif ier is required to be reported on a claim to report the amount of drug that is discarded and e ligible f or payment and should be used only f or claims that bill single-dose container drugs. The discarded portion of single use or single dose vials must be identif ied with the JW Modif ier as a separate line item f rom the dose or administered portion. Pr oviders may be reimbursed f or the discarded portions of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropriately reported based on the policy reimbursement guidelines. As of July 1, 2023, providers and suppliers a re required to report the JZ modif ier on allclaims that bill f or drugs f rom single-dose containers when there are no discarded amounts. The JZ modif ier is reported on a claim to attest that no amount of drug was discarded and should only be used f or claim s that bill f or single-dose container drugs. Claims containing drug administered f rom multi-dose vials are not subject to this requirement. Under this policy, a ll claims for separately payable single dose format injectabledrugs must include either a JW modifier or a JZ modifier after 7-1-2023 in order to be reimbursed Sin g le Do se Vial Claims Mo d ifiersOh io Med icaidPY-PHARM-0100 Effective Date: 07-01-2023 3 MODIFIER SHORT DESCRIPTOR LONG DESCRIPTORJW Discard ed p o rtio n o f d rug no t ad ministered Drug amo unt d iscard ed /no t ad ministered to any p atient JZ All d rug ad ministered no ne d iscard ed Zero d rug amount d iscarded/not administered to any p atient C. Def initionsModif ie r JW ref ers to the drug amount discarded (wasted)/not administered to any patient . Modif er JZ ref ers to zero drug amount discarded/not administered to any patient. Discarded Wastage or Unused Portion is def ined as the amount of a single use/dose vial or other single use/dose package that remains af ter administering a dose/quantity of a drug or biological. Single Dose Vial is def ined as a vial of medication intended f or administration by injection or inf usion that is meant f or use in a single patient f or a sing le procedure. These vials are labeled as single-dose or single-vial by the manuf acturer and typically do not contain a preservative. Multi-Dose Vial is def ined as a vial of medication intended f or administration by injection or inf usion that contains more than one dose of medication. These vials are labeled as multi-dose by the manuf acturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. D. PolicyModif ier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modif ier JW. Both details are reimbursable. CareSource will consider reimbursement f or: I. A single-dose or single-use vial drug that is wasted, when Modif ier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not administered to another patient. CareSource will NOT consider reimburse ment f or:I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. NOTE: The JZ modif ier is required when there are no discarded amounts of a single – dose container drug f or which the JW modif ier would be required if there were discarded Sin g le Do se Vial Claims Mo d ifiersOh io Med icaidPY-PHARM-0100 Effective Date: 07-01-2023 4 amounts. The JZ modif ier is required to attest that there were no discarded amounts,and no JW modif ier amount is reported. E. Conditions of Coverage Providers must not use the JW modif ier f or medications manuf actured in a multi – dose vial f ormat. Providers must choose the most appropriate vial size(s) required to prepar e a dose to minimize waste of the discarded portion of the injectable vials. Claims considered f or reimbursement must not exceed the package size of the vial used f or preparation of the dose. Providers must not bill f or vial contents overf ill. Providers must not use the JW modif ier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modif er is only applied to the amount of drug or biological that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modif ier. 1. Claim Line #1 HCPCS code f or drug administered and the amount admistered to the patien t. 2. Claim Line #2 HCPCS code f or drug discarded (wasted) with JW modif ier appended to indicate waste and the amount discarded (wasted). The JZ Modif ier is applied when zero amounts of a single-dose container drug is discarded. F. Related Policies/Rules Chapt er 17, Section 40.1 of CMS Medicare Claims Processing Manual G. Review/Revision History DATE ACTIONDate Issued 01-22-2023 Original ef f ective dateDate Revised 08-25-2023 Updated policy to include JZ modif ier. Updated policy name and ref erences. Date Effective 07-01-2023 Date Archived H. Ref erences 1. Billin g an d Co d ing : JW an d JZ Mo d ifier Billin g Guid elines Article – Billin g an d Co d in g : JW an d JZ Mo d ifier Billin g Guid elin es (A55932) (cms.g o v) 2. New JZ Claims Mo d ifer fo r Certain Med icare Part BDru gs h ttp s://www.cms.g o v/files/d ocumen t/mm13056-n ew-jz-claims-modifier-certain-med icare-part-b- d rug s.p d f 3. Discard ed Drug s an d Bio lo g icals JW Mo d ifier an d JZ Mo d ifier Po licy FAQs. jw-mo d ifier – faq s.p d f (cms.g o v) The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in theReimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date 340B Drug Pricing PY-PHARM-008 7 10-1-2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing logic, benefit s design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify thi s 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 limitatio ns that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Cov erage ………………………….. ………………………….. ………………………….. ……. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 340B Drug PricingOHIO MEDICAIDPY-PHARM-008 7 Effective Date: 10-01-2022 2 A. Subject340B Drug Pricing B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate 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. The 340B Drug Pricing Pro gram is a fed eral program, which limits the cost of coveredoutpatient drugs to eligible health care organizations and covered entities. The purpose of the program was to enable covered entities to stretch scarce federal resources as far as possible, reac h more eligible patients and provid e more comprehensive services. This policy describes the claim submission requirements for outpatient pharmacy and provider administered drugs. C. Definitions 340 BCovered Entity (CE) A facility t hat is eligible to purch ase drugs through the 340B Program and appears on the HRSA Office of Pharmacy Affairs Information System (OPAIS). 340B Drug Discount Program (340B) Section 340B of the Public Health Service (PHS) Act (1992) that requires drug manufactures participating i n the Medicaid Drug Rebate Program to sign a pharmaceutical pricing agreement (PPA) with the Secretary of Health and Human Services. Actual Acquisition Cost The actual prices paid to acquire drug products sold by a specific manufacturer. Care Management Organization (CMO) Organizations, such as CareSource, contracted by the Ohio Department of Medicaid to coordinate services for Medicaid members. Contract Pharmacy A pharmacy contract ed with a Covered Entity to dispense 340B medications purchased by the Covered Entity . Current Procedural Terminology (CPT) A medical code set maintained by the American Medical Association to describe and bill for medical, surgical, and diagnostic services. Fee-for-Service (F FS) Claims billed directly to Ohio Medicaid for prescriptions and physician administered drugs provided to FFS members. 340B Drug PricingOHIO MEDICAIDPY-PHARM-008 7 Effective Date: 10-01-2022 3 Healthcare Common Procedure Coding System ( HCPCS ) A set of health care procedure codes based on CPT. Health Resources and Services A dministration (HRSA) The primary federal agency responsible for administering the 340B program. National Council for Prescription Drug Programs (NCPDP) the standards organization that creates the standard format through which pharmacy claims are submit ted to a Pharmacy Benefit Manager (PBM). National Drug Code (NDC) A drug product that is identified and reported using a unique, three-segment number, which serves as a universal product identifier for the specific drug. Pharmacy Benefit Manager (PBM) The entity that processes retail pharmacy or PBM benefit claims for CareSource. Provider Administered Drugs Drugs administered directly by a health care provider to a patient. D. Policy I. Pharmacies Allowed to Bill 340B Claims A. Only Covered Entities that elected to dispense 340B medications to Medicaid members on the HRSA Medicaid Exclusion File may bill 340B claims. B. Contract pharmacies are not allowed to bill for 340B purchased drugs. II. Retail Pharmacy (Point-of-Sale) 340B Claim s A. In addition to the NDC and other fields consistently submitted to the PBM for payment, a ll 340B Covered Entities must identify 340B claims using either of the two below NCPDP Telecommunication Standard D.0 fields: Submission Clarification Code (SCC – Field 420-DK) of 20 and/or: Basis of Cost Determination – (Field 423-DN) of 08 plus their 340B acquisition cost in the Ingredient Cost Submitted (Field 49-D9) B. When submitting 340B claims, providers are permitted, but no t required to, submit Basis of Cost Determination Code 08. Providers electing to identify 340B claims using this field must also submit their 340B acquisition code in the Submitted Ingredient Cost field 409-D9. C. For drugs not purchased at 340B rates, do n ot include either of the 340B identifiers listed above. III. Provider Administered 340B Drug Claims A. In addition to the HCPCS/CPT code, NDC, and other fields consistently submitted for claims payment, 340B Covered Entit ies should submit the claim on a CMS 1500 or UB-04 claim form with the either of the following modifiers: SE Drug or biological acquired through the 340B drug pricing program discount 340B Drug PricingOHIO MEDICAIDPY-PHARM-008 7 Effective Date: 10-01-2022 4 IV. Auditing a nd MonitoringA. To ensure compliance with 340B billing requirements, CareSource will monitor both 340B and non-340B claim submissions to identify potential 340B claims. Should we identify a claim we believe is 340B, we will inform the provider of the potent ial billing error and ask for validation, as well as correction. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting the appropriate and applicable drug-related codes (HCPCS, CPT, NDC) along with appropriate 340B claim fiel ds , if applicable . F. Related Policies/Rules ORC 5167.123 requires the following regarding managed care organization contracts with 340B providers: A) No contract between a medicaid managed care organization, including a third – party administrator, and a 340B covered entity shall contain any of the following provisions: (1) A payment rate for a prescribed drug that is less than the national average drug acqu isition cost rate for that drug as determined by the United States centers for medicare and medicaid services, measured at the time the drug is administered or dispensed, or, if no such rate is available at that time, a reimbursement rate that is less than the wholesale acquisition cost of the drug, as defined in 42 U.S.C. 1395w – 3a(c)(6)(B); (2) A fee that is not imposed on a health care provider that is not a 340B covered entity; (3) A fee amount that exceeds the amount for a health care provider that is n ot a 340B covered entity. (B) The organization, or its contracted third-party administrators, shall not discriminate against a 340B covered entity in a manner that prevents or interferes with a medicaid recipient’s choice to receive a prescription drug fro m a 340B covered entity or its contracted pharmacies. (C) Any provision of a contract entered into between the organization and a 340B covered entity that is contrary to division (A) of this section is unenforceable and shall be replaced with the dispensin g fee or payment rate that applies for health care providers that are not 340B covered entities. G. Review/Revision HistoryDATE ACTIONDate Issued 08/26/2021Date Revised 08/25/2022 Date Effective 10/01/2022 Date Archived 340B Drug PricingOHIO MEDICAIDPY-PHARM-008 7 Effective Date: 10-01-2022 5 H. References1. Frequently Asked Questions: 340B Drug Pricing Program. Available from: https://pharmacy.medicaid.ohio.gov/sites/default/files/2018-6- 4%20340B%20FAQ.pdf . Revis ed June 2018 2. Section 5167.123 Medicaid MCO contracts with 340B program participants. Ohio Revised Code, Tital 51 Public Welfare, Chapter 5157 Medicaid Managed Care. Available from: https://codes.ohio.gov/ohio-revised-code/section-5167.123 . Effective April 12, 2021 3. Modifiers Recognized by Ohio Medicaid . Revised January 2 8, 2022. https://medicaid.ohio.gov/static/Providers/Billing/BillingInstructions/ModifiersODM.pdf The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Standard Medical Billing Guidance PY-PHARM-0125 – OH-MCD 02-01-202 3 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standa rd 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 re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CareSource and it s 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 f or the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………….. . 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. … 2 B. Background ………………………….. ………………………….. ………………………….. ………………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ….. 3 E. Conditions of Coverage. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …….. 5 H. References ………………………….. ………………………….. ………………………….. ………………………. 5 Standard Billing Reimbursement StatementOHIO MEDICAIDPY-PHARM-0125-OH-MCD Effective Date: 02-01-2023 2 A. SubjectStandard Medical Billing Guid ance B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office sta ff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. This reimbursement policy applies to all health care services reported using theCMS 1500 Health Insurance Professional Claim Form (a/k/a HCFA ), th e CMS 1450Health Insurance Institutional Claim Form (a/k/a UB04) or its electronic equivalent or any successor form. This policy applies to all products, all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Additionally, this policy applies to drugs and biologicals being used for FDA-approved indications or label s. Drugs and biologi cals used for indications other than those in the approved labeling may be covered if it is determined that the use is medically accepted, taking into consideration the major drug compendia, authoritative medical literatures and/or accepted standards of me dical practice. C. Definitions Indication is defined as a diagnosis, illness, injury, syndrome, condition, or other clinical parameter for which a drug may be given. is defined as birth before 37 weeks of gestation. FDA approved Indication /Label is the offic ial description of a drug product which includes indication (what the drug is used for); who should take it; adverse events (side effects); instructions for uses in pregnancy, children, and other populations; and safety information for the patient. Labels are often found inside drug product packaging. Off-label/Unlabeled use of a drug is defined as a use for a non-FDA approved indication, that is, one that is not listed on the drugs official label/prescribing information. Off-label use is further defined as giving the drug in a way that deviates significantly from the labeled prescribing information for a particular indication. This includes but is not necessarily limited to, dosage, route of administration, duration and frequency of ad ministration, and population to whom the drug would be administered. Standard Billing Reimbursement StatementOHIO MEDICAIDPY-PHARM-0125-OH-MCD Effective Date: 02-01-2023 3 Unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label . Drug compendia , defined as summaries of drug information that are compiled by experts who have reviewed clinical data on drugs. CMS (Center for Medicare and Medicaid Services) recognizes the following compendia: American Medical Association Drug Evaluations (AMA-DE), United States Pharmacopoeia-Drug Information (USP-DI) or its successor publication and American Hospital Formulary Service-Drug Information (AHFS-DI) as authoritative sources for use in the determination of a “medical ly-accepted indication” of drugs and biologicals used off – label in an anticancer chemotherapeutic regimen. The USP DI is a database of drug information developed by the U.S. Pharmacopoeia but maintained by Micromedex, which contains medically accepted uses for generic and brand name drug products D. PolicyCare Source requires that the u se of a drug or biological must be safe and effective and otherwise reasonable and necessary. Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for indications specified on the labeling. Therefore, reimbursement may be provided for the use of an FDA approved drug or biological, if: It was administered on or after t he date of the FDAs approval; It is reasonable and necessary for the individual patient; and All other applicable coverage requirements are met. An unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label may be covered if it is determined that the use is medically necessary , taking into consideration the major drug compendia, authoritative medical literatur e and/or accepted standards of medical practice. The following guidelines identify three categories in which medications would not be reasonable and necessary according to accepted standards of medical practice. Not for Particular Illness Medications gi ven for a purpose other than the treatment of a particular condition, illness, or injury are not covered (except for certain immunizations .) Route of Administration Not Indicated Medication given by injection (parenterally) is not covered if standard me dical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. Excessive Medications Medications administered for treatment of a disease which exceed the freque ncy or duration of dosing indicated by accepted standards of medical practice are not covered. Effective January 1, 1994, off-label, medically accepted indications of Food and Drug Administration -(FDA) approved drugs and biologicals used in an anti-neoplas tic chemotherapeutic regimen are identified under the indications described below. A Standard Billing Reimbursement StatementOHIO MEDICAIDPY-PHARM-0125-OH-MCD Effective Date: 02-01-2023 4 regimen is a combination of anti-neoplastic agents clinically recognized for the treatment of a specific type of cancer. Off-label, medically accepted indications are supp orted in either one or more of the compendia or in peer-reviewed medical literature. E. Conditions of Coverage A medically accepted indication is one of the following: An FDA approved, labeled indication or a use supported in the American Hospital Formulary Service Drug Information (AHFS-DI), NCCN Drugs and Biologics Compendium, Truven Health Analytics Micromedex Drug Dex , Elsevier/Gold Standard Clinical Pharmacology and Wolters Kluwer Lexi – Drugs as the acceptable compendia based on CMS’ Change Request 619 1 (Compendia as Authoritative Sources for Use in the Determination of a “Medically Accepted Indication” of Drugs and Biologicals Used Off-Label in an Anti-Cancer Chemotherapeutic Regimen); or Articles o f Local Coverage Determinations (LCDs) published by C MS. In general, a use is identified by a compendium as medically accepted if the: Indication is a Category 1 or 2A in NCCN, or Class I, Class IIa, or Class IIb in DrugDex; or, Narrative text in AHFS-DI or Clinical Pharmacology is supportive, or Indication is listed in Lexi-Drugs as Use: Off-Label and rated as Evidence Level A A use is not medically accepted by a compendium if the: Indication is a Category 3 in NCCN or a Class III in DrugDex; or, Narrative text in AHFS or Clinical Pharmacol ogy is not supportive, or Indication is listed in Lexi-Drugs as Use: Unsupported If a use is identified as not indicated by CMS or the FDA, or if a use is specifically identified as not indicated in one or more of the compendia listed, or if it is dete rmined, based on peer-reviewed medical literature, that a particular use of a drug is not safe and effective, the off-label use is not supported and the drug will not be covered. Reimbursement is dependent on, but not limited to claims submissions reporte d usingCMS 1500/HCFA, CMS 1450/UB 04 or electronic equivalent, and must include the following: 11-digit NDC (National Drug Code) HCPCS/CPT Code Correct HCPCS units ( not NDC units) Correct NDC unit of measure PLEASE NOTE THE FOLLOWING: Providers are responsible for sourcing and submitting accurate codes. Multi-source brands are not accepted without an additional medical necessity review for Dispense as Written (DAW). Medical Necessity for DAW policies can be found at CareSource.com under the applicable markets administrative policies tab. Standard Billing Reimbursement StatementOHIO MEDICAIDPY-PHARM-0125-OH-MCD Effective Date: 02-01-2023 5 If applicable, individual drug reimbursement information may be found in a drugs Pharmacy Policy .F. Related Policies/Rules G. Review/Revision History DATE ACTIONDate Issued 07/22/2022 Original effective dateDate Revised 12/06/2022 Additions to clarify claims submission requirements, responsibility for sourcing of codes, and MSBs not accepted without additional DAW review. Individual drug reimbursement information may be found in a drugs Pharmacy Policy Date Effective 02/01/2023 Date Archived H. References1. Drugs@FDA Glossary of Terms https://www.fda.gov/drugs/drug-approvals-and-databases/drugsfda – glossary-terms 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publi cations and services https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals 3. United States Federal Food, Drug and Cosmetic Act https://www.fda.gov/regulatory-information/laws-enforced-fda/federal-food-drug-and-cosmetic-act-fdc-act The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
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