REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Temporary Codes-OH MCD-PY-1414 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or suppli es that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or si gnificant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also inc lude those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Rei mbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan c ontract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may mod ify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the lim itations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Temporary Codes-OH MCD-PY-1414Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTemporary Codes 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 estab lished 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/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 gua rantee claims payment.Temporary codes exist in both CPT and HCPCS manuals and are updated throughout the year. Tcodes (ie, Category III codes) are temporary CPT codes for emerging technologies, services, and procedures which support data collection to s ubstantiatewidespread use and/or provide documentation for the Food and Drug Administration (FDA) approval process. Many of these codes have not been proven medically necessary and are considered to be experimental or investigational based on a lack of pe er-reviewed scientific literature.A variety of temporary HCPCS codes exist. Temporary HCPCS codes may beestablished by the Centers for Medicare and Medicaid Services (CMS) to report drugs, biologicals, devices, and procedures, identify services and procedures under FDA review, or address miscellaneous services, procedures, and supplies. Durable MedicalEquipment (DME) Medicare Administrative Contractors (MACs) may develop temporary HCPCS codes to report supplies and other products for which a national code has not yet been developed. Temporary HCPCS codes may also be developed by commercial paye rs to report drugs, services, and supplies. Coverage of these services is under the discretion of local carriers. C. DefinitionsNA D. PolicyI. CareSource considers temporary codes medically necessary when ALL the following criteria are met: A. Documentation in the medical record supports the use of the code. B. A more specific code is not available to describe the service/procedure. C. The service provide d is within the scope of the members benefit plan. Temporary Codes-OH MCD-PY-1414Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 II. CareSource will use current industry standard procedure codes (HCPCS CPT I and Category II codes) throughout the processing systems. HIPAA Transaction & Code Set Rule requires providers use the procedure code(s) that are valid at the time the service is provided. III. Providers must use industry standard code sets and specific HCPCS CPT I and Category II codes when available unless otherwise directed through the providers contract.IV. If specific codes are not available, unlisted codes require plan preauthorization.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please re fer to the individual fee schedule for appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/01/2023 New policyDate Revised 01/17/2024 03/26 /2025Annual review: updated references. Approved at Committee.Review: updated references, approved at Committee. Date Effective 07/01/2025 Date Archived H. References1. American Academy of Professional Coders. What is HCPCS? Accessed March 10, 2025 . www.aapc.com 2. CPT Professional 202 5. American Medical Association ; 202 5. 3. HCPCS Codes – Temporary Codes for Use with Outpatient Prospective Payment System. Acce ssed March 10, 2025 . www.hcpcs.codes 4. Understanding the HIPAA standard transactions: the HIPAA transactions and code set rule. American Medical Association. Access ed March 10, 2025 . www.assets.ama-assn.org Approved by ODM on 04/11/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifiers-OH MCD-PY-1345 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. 2 E. Conditions of coverage ………………………….. ………………………….. ………………………….. ….. 3 F. Related policies/rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/revision history ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ………………….. 4 Modifiers-OH MCD-PY-1345Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifiers B. BackgroundReimbursement modifiers are two-digit code s that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifiers can be found in the appendices of both CPT and HCPCS manuals. Use of a modifi er does not change the code or the codes definition. Examples of modifiers use includes: To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same procedure . To indicate that a procedure was performed on the left side, right side, or bilaterally . To report multiple procedures performed during the same session by the same health care provider . To indicate multiple health care professionals participated in the procedure . To indicate a subsequent procedure is due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier throu gh post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyIt is the responsibility of the submitting provider to submit accurate documentation of services performed. Providers are expected to use the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided according to the following industry standard guidelines (may not be all-inclusive) : National Correct Coding Initiative (NCCI) editing guidelines American Medical Association (AMA) guidelines American Hospital Association (AHA) billing rules Modifiers-OH MCD-PY-1345Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Current Procedural Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS) ICD-10 CM and PCS National Drug Codes (NDC) Diagnosis Related Group (DRG) guidelines CCI table edits . The inclusion of a code in a policy does not imply any right to reimbursement or guarantee claims payment. E. Conditions of coverageReimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify a members eligibility. Reimbursement is dependent up on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers, if applicable. In the absence of State specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource policies applyto both participating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related policies/rules NA G. Review/revision historyDATE ACTIONDate Issued 09/01/2019 New policyDate Revised 04/15/2020 10/13/2021 10/12/202209/27/202304/ 09/2025 Added Place of Service 19 to Modifier SA Removed modifiers, changed background and policy sections to simplify language No changes. Updated references. Updated references. Approved at Committee. Periodic review. Updated references. Approved at Committee. Modifiers-OH MCD-PY-1345Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Date Effective 07/01/2025Date Archived H. References1. Billing 340B Modifiers Under the Hospital Outpatient Prospective Payment System (OPPS) . US Centers for Medicare and Medicaid Services. March 3, 2023. Accessed March 26, 2025 . www.cms.gov 2. CPT overview and code approval. American Medical Association. Accessed March 26, 2025 . www.ama-assn.org 3. Medicare Claims Processing Manual, XII: Physicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services. Issued December 19, 2024 . Accessed March 26, 2025 . www.cms.gov 4. Medicare Claims Processing Manual, XIV: Ambulatory Surgical Centers . US Centers for Medicare and Medicaid Services. March 24, 2023. Accessed March 26, 2025 . www.cms.gov Approved ODM 04/14/202 5
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDurable Medical Equipment (DME) Modifiers B. BackgroundReimbursement 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 wi ll be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant eeclaims payment.Modifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additional information, to the code description, of the product or service. Using a modifi erinappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service.The purpose of this policy is to simplify and standardize the use of modifiers, when billing for rented, purchased, or rent to purchase DME equipment. There are many modifiers that can be used when billing DME. This policy addresses the rental modifier RR and the new equipment purchase modifier NU. CareSource expects providers touse the modifiers stated in this policy to increase efficiency and timely reimbursement. Any other appropriate modifier per national or state billing standards can be appended to a DME item along with the modifiers addressed in this policy ( eg, LT, RT, etc.). Some DME equipment may have individual policies which can be referenced for detailed information. The modifiers addressed in this policy is not an all-inclusive list andproviders should adhere to national and state billing guidelines for modifier usage fo r all other modifiers not addressed within this policy. C. Definitions Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated , and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. This policy outlines the use of Durable Medical Equipment (DME) modifiers for the rental and/or purchase of DME. II. DME items can be:A. purchasedB. rented or C. rented on a short-term basis and then purchased at the end of the rental period III. DME items must be billed with appropriate HCPCS codes along with appropriate modifiers when applicable:A. Purchase Modifier – NU: 1. CareSource requires that Modifier NU is appended to all claims for the purchase of DME equipment. B. Rental Modifier – RR: 1. CareSource requires that Modifier RR is appended to all claims for the rental period of DME equipment. 2. All rental authorizations are based on: a. A calendar month authorization period, through the month in which the member becomes ineligible; b. The item is no longer medically necessary; or c. The maximum amount allowable is reached. 3. Unless otherwise outlined in the O hio Administrative Code (OAC) 5160 – 10-01, the initial rental period must not exceed 6 months. a. After the initial 6 month rental period , additional rental months may be authorized if medically necessary. 4. The combined total reimbursement for rental and subsequent purchase of a DME item, cannot exceed the Medicaid maximum fee. 5. At the end of the rent to purchase period, the DME becomes the property of the member. IV. Disposable supplies do not require a modifier.A. DME items that are submitted for reimbursement without a modifier are considered a purchase. If the DME item was intended to be a rental and the modifier RR was left off the claim in error, CareSource will review the claim during a post-payment audit and p roper reimbursement adjustment will occur. V. Modifiers that are not to be used for claims submission for DME equipment include :A. LL Lease/rental B. NR New when rented Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 C. RB Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement parts are considered new equipment) VI. CareSource considers a replacement part as a new equipment purchase and modifier NU should be used instead of modifier RB.NOTE: CareSour ce may verify the use of any modifier through post-payment audit. All information regarding the use of these modifiers must made available upon CareSources request. E. Conditions of CoverageF. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 05/13/2020 New policyDate Revised 09/14/2022 10/1 1/2023 04/09/2025 No changes. Updated references. Annual review. Updated references. Approved at Committee. Periodic review. Updated references. Approved at Committee. Date Effective 07/01/2025 Date Archived H. References1. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS): General Provisions, OHIO ADMIN CODE 5160-10-01 (2024). 2. Medical Equipment. Accessed March 31, 2025. www.medicaid.ohio.gov 3. Healthcare Common Procedure Coding System (HCPCS). Accessed March 31, 2025. www.cms.gov 4. What are medical coding modifiers? 2022. American Academy of Professional Coders. Accessed March 31, 2025. www.aapc.com Approved ODM 04 /14/202 5
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Doula Services-OH MCD-PY-1591 07/01/2025 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, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and util ization 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 the patient ca n 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 co st alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements , Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy t o services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Doula Services-OH MCD-PY-1591Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDoula Services B. BackgroundDoula services have been shown to improve maternal and birth outcomes and maternal experiences and reduce health care disparities, Doulas provide advocacy, physical, educational, and emotional support during pregnancy and reimbursement of doula services wi ll be conducted according to the Ohio Administrative Code (OAC) 5160-8-43 and Ohio Medicaid fee schedule. C. Definitions Doula A trained, nonmedical professional who advocates for, and provides continuous physical, emotional, and informational support to, a pregnant woman through the delivery of a child and immediately after the delivery, including during any of the following periods: o The antepartum period o The intrapartum period o The postpartum period D. PolicyI. CareSource follows the O AC for Doula services reimbursement . II. CareSource may reimburse for the allowed hours set forth by the OAC.III. If additional hours are needed that exceed the allowed hours set forth by the OAC,CareSource will perform a review of medical necessity. Documentation must be submitted upon CareSources request . IV. Doula services are not intended for routine childcare, meal prep, cleaning and other domestic servic es not typically covered by the Ohio Department of Medicaid (ODM) .CareSource may request post payment documentation to confirm services were medically necessary. Post payment recoupment may occur if services are found to not be in alignment with our membe rship and the OAC rule. E. Conditions of CoverageA. Claims submission must include a ppropriate HCPCS codes and any applicable modifiers. B. Documentation must be submitted upon CareSources request . C. Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Doula Services-OH MCD-PY-1591Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Providers must follow pr oper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy applies to both participati ng and nonparticipating providers and facilities. D. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/12/2025 New policy. Approved at Committee.Date Revised Date Effective 07/01/2025 Date Archived H. References1. Doula Services, OHIO ADMIN . CODE 5160-8-43 (2024). Appr oved by ODM 04/ 01/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Diagnostic Colonoscopy and/or Sigmoidoscopy-OH MCD-PY-1592 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Interest Payments-OH MCD-PY-1324 05/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 2 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments-OH MCD-PY-1324 Effective Date: 05/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Interest Pay ments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. 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 /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. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim is a claim that can be processed without obtaining additional information from the provider of a service or from a third party and do not include payments made to a provider of service or a third party where the timing of the payment is not directly related to submission of a completed claim by the provider of service or third party. A clean claim also does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical neces sity. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by Ohios Medicaid Prompt Payment rules and contract. D. Policy I. CareSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations. II. In alignment with the Ohio Administrative Code and the Medicaid Provider Agreement, CareSource does not pay interest on Ohio Medicaid claims. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. Interest Payments-OH MCD-PY-1324 Effective Date: 05/01/2025 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.3F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 03/31/2021 New PolicyDate Revised 01/05/2022 04/27/2022 04/ 12/2023 01/31/2024 01/15/2025 Updated language and references per Legal. No change; did for review cycle consistency No change; updated references. Approved at Committee. No change; updated references. Approved at Committee. Updated references. Approved at Committee Date Effective 05/01/2025 Date Archived H. References1. Definitions, O HIO REV . CODE 5164.01(C) (2023 ). 2. Ohio Medicaid Contract, Appendix J, 4. Accessed December 3, 2024. www.managedcare.medicaid.ohio.gov 3. Timely Claims Payment, 42 C.F.R. 447.45(b) (2022). Approved by ODM 01/23/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Acupuncture Services-OH MCD-PY-0152 05/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Acupuncture Services B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. 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 /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. Acupuncture is an ancient Chinese method of treatment based on the theory that stimulation of specific key points on or near the skin by the insertion of needles or by other methods improves vital energy flow . The term acupuncture describes a variety of methods and styles to stimulate specific anatomic points in the body. Acupuncture is used to relieve pain, induce surgical anesthesia, or for therapeutic purposes. It is considered an alternative treatment and an adjunct to standard treatment . C. Definitions Acupuncturist A n individual who holds , at a minimum, a valid certificate to practice as an acupuncturist or as an oriental medicine practitioner. Chiropractor An individual who holds a certificate to practice acupuncture issued by a state chiropractic board. Other Individual Medicaid Provider A physician assistant or an advanced registered nurse practitioner who has a valid certificate as an acupuncturist . Physician An individual who has completed medical training in acupuncture with a current and active designation or an equivalent designation from the National Certification Commission for A cupuncture and Oriental Medicine. D. Policy I. CareSource reimburses for acupuncture services according to the criteria found in Ohio Administrative Code (OAC) 5160-8 -51 for the following conditions: A. m igraines B. low back pain C. cervical (neck) pain D. osteoarthritis hip E. osteoarthritis of knee F. acute post-operative pain Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2025 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.3G. a cute nausea and vomiting (pregnancy and chemotherapy-related, not inpatient ) II. CareSource does not require prior authorization for acupuncture services for the first 30 visits per calendar year for participating providers. Although CareSource does not require a prior authorization for the first 30 visits for acupuncture services, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. III. Participating providers must be one of the following: A. A physician who has completed medical training in acupuncture with a current and active designation, or an equivalent designation from the National Certification Commission for Acupuncture and Oriental Medicine. B. A chiropractor with a valid certificate to practice acupuncture. C. Other individual Medicaid provider, including an advanced practice registered nurse or a physician assistant , with a valid certificate as an acupuncturist. IV. Limitations: A. No separate reimbursement will be made for both an evaluation and management service and an acupuncture service performed by the same provider to the same individual on the same day. B. No separate reimbursement will be made for services that are an incidental part of a visit , such as but not limited to, providing instruction on breathing techniques, diet , or exercise. C. No reimbursement will be made for an additional treatment after an initial treatment period if any of the following occur : 1. Symptoms show no evidence of clinical improvement after an initial treatment period. 2. Symptoms worsen over a course of treatment . E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes . The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one on one contact with the patient 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one on one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2025 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.497813 Acupuncture, 1 or more needles with electrical stimulation, initial 15 minutes of personal one on one contact with patient 97814 Acupuncture, 1 or more needles with electrical stimulation, each addition 15 minutes of personal one on one contact with the patient, with re-insertion of needle(s) (List separately in addition for primary procedure) F. Related Policies/Rules N/AG. Review/Revision History DATE ACTIONDate Issued 10/31/2013 New Policy Date Revised 10/31/2013 06/06/2016 04/30/2020 05/25/2022 05/24/2023 01/17/2024 01/15/2025 New Allowed Services Removed III. D. Shoulder Pain Updated references. No changes. Approved at committee. Updated references. No changes. Approved at Committee Updated references. No changes. Approved at CommitteeDate Effective 05/01/2025Date Archived H. References1. Acupuncture Services , O HIO ADMIN . CODE 5160-8- 51 (2021 ). 2. License to Practice, O HIO REV . CODE 4762.02 (2023) . 3. Non-Institutional Fee Schedule, Appendix DD, O HIO ADMIN . CODE 5160-1- 60 (2024 ). Approved by ODM on 01/23/2025
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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