E/M – Preventive and Acute Care Visit on Same Date of Service

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective E/M – Preventive and Acute Care Visit on Same Date of Service-OH MCD – PY-0007 07/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 E/M – Preventive and Acute Care Visit on Same Date ofService-OH MCD-PY-0007Effective Dat e: 07/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectE/M – Preventive and Acute Care Visit on Same Date of Service B. BackgroundCareSource will reimburse participating providers for medically necessary and preventive screening tests as required by federal statute through criteria based on recommendations from the US Preventive Services Task Force (USPSTF). C. Definitions Preventive Services Exams and screenings t hat check for health problems with the intention to prevent any problem discovered from worsening and may include, but are not limited to, physical checkups, hearing, vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider f or preventive services are encouraged at every age but are especially important for children under the age of 1 8 years . D. PolicyI. When any of the following preventive exam codes are billed on the same date of service as an acute care visit or other E/M codes with the appropriate ICD-10 codes, CareSource will reimburse only the pre ventive service code at 100%. The acute care visit or Other E/M services 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. 99381-9938 7 2. 99391-9939 7 B. Acute Care Visit Codes 1. 9920 2-99205 2. 99212-99215 C. Other E/M 1. 99211 2. 99242-99245 3. 99252-99255 II. CareSource reserves the right to request documentation to support billing both services for all claims received. The physician or other qualified health care pro vider may need to indicate that in the process of performing a preventive/wellness health service, an abnormality was encountered or a new or existing problem was addressed, and the problem or abnormal finding was significant enough to require additional work t o perform the key components of a problem-focused (acute care) evaluation and management (E/M) service. Documentation must support the following: E/M – Preventive and Acute Care Visit on Same Date ofService-OH MCD-PY-0007Effective Dat e: 07/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 A. A separately identifiable service significant enough to require additional work to perform the key components of a problem-focused (acute care) E/M service.B. Acute care service may be billed based on time or medical decision making (MDM). 1. If billed based on time, documentation must reflect start/stop or total time spent. If time is used for selection, then the time spent on the preventive service cannot be counted toward the time of the work of the problem assessment, because time spent can not be counted twice. Please see the American Medical Association (AMA) Guidelines for Selecting Level of Service Based on Time. 2. If billed based on MDM, documentation must support the level of service based on AMA Medical Decision-Making Guidelines . 3. A medically appropriate history and physical exam, when performed. E. Conditions of CoverageFor the purposes of this policy, physician and provider are defined as a physician or other health care provider of the same group reporting the same federal tax identification number. Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule for appropriate codes. Reimbursement will be established basedupon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify member eligibility.F. Related Policies/RulesModifier 25 Reimbursement policy G. Review/Revision HistoryDATE ACTIONDate Issued 11/17/2014Date Revised 11/17/2015 08/06/2019 09/14/202201/17/202 411/05/2025 03/11/2026Revision includes payment policy legal languageUpdated reimbursement rate from 50% to 100% for services that are rendered on the same date of service Annual review: removed reference to archived policies, updated codes, added reference to Modifier 25 policy Annual Review; Approved at Committee. Annual review : D.III. documentation requirements revised , Approved at Committee. D. I and II combined. Approved at Committee. Date Effective 07/01/2026 Date Archived E/M – Preventive and Acute Care Visit on Same Date ofService-OH MCD-PY-0007Effective Dat e: 07/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 H. References 1. Healthcheck , OHIO ADMIN . CODE 5160-1-14 (20 25). 2. Preventive Services, OHIO ADMIN . CODE 5160-1-16 (2017). Approved by ODM 03/20/2026

Dental Services Rendered in a Hospital or Ambulatory Surgery Center

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Dental Services Rendered in a Hospital or Ambulatory Surgery Center – OH MCD-PY-1244 06/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource, and its affiliates are intended to provide a general reference regarding billi ng, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. These policies are designed to assist providers and f acilities submitting claims to CareSource. The policies are routinely updated to promote accurate coding and clarificati on. These proprietary policies are not a guarantee of payment. This Policy does not ensure an authorization or reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service( s) referenced herein . If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and any applicable referral, authorizatio n, notification, and utilization management guidelines. Medically necessary services include, but are not limited to, those heal th care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and wit hou t which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a b ody organ or part, or significant pain and discomfort. These services must meet the standards of good clinical practice in the l ocal area, are the lowest cost alternative, and are not provided for the convenience of the member or provider. Medically necessar y services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medic al Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Prior authorization is required for certain services. If authorization is not obtained prior to performing the service, CareSource may not reimburse for the pro cedure. Health care providers and their office staff are encouraged to use the self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology/He althcare Common Procedure Coding System (CPT/HCPCS) code(s) for the medical product or service being provided and the appropriate Current Dental Terminology (CDT) code(s) for the dental product or service. The inclusion of a code in this policy does not im ply any right to reimbursement or guarantee for a submitted claim payment. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 4 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDental Services Rendered in a Hospital or Ambulatory Surgery Center B. BackgroundThe decision to perform dental care in a particular place of service is based on a wide variety of factors, including the age and special health care needs (physical, intellectual, and developmental disabilities or long-term medical conditions) of the individual, in addition to the type, number , and complexity of procedures planned. These factors also determine the type of anesthesia used during the procedure. Most dental care can be provided in a dental office setting with local anesthesia or local anesthesia supplemented with non-pharmacological behavior guidance (basic toadvanced techniques) and/or pharmacological options. Basic non-pharmacological behavior guidance includes communication guidance, positive pre-visit imagery, direct observation, tell-show-do, ask-tell-ask, voice control, non-verbal communication, positive reinforcement and descriptive praise, distraction, and desensitization. Pharmacological options may include nitrous oxide, oral conscious sedation and intravenous (IV) sedation (mild, moderate, or deep) , or monitored general anesthesia by trained , certified individuals in each level of sedation dentistry. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require the use of general anesthesia as medically necessary in a healthcare facility, such as an ambulatory surgic al center , hospital operating room , or short procedure unit (SPU). C. Definitions Ambulatory Surgical Center (ASC) Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization that meets all criteria of Ohio Administrative Code (OAC) 5160-22-01. Enhanced Ambulatory Patient Groups (EAPGs ) A patient classification system designed to explain the amount and type of resources used during an ambulatory visit. Each EAPG has similar clinical characteristics, resource use , and cost. Inpatient Hospital A nonpsychiatric facility which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. Medical Necessity Procedures, items, or services which prevent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease, or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without its use the person can be expected to suffer prolonged, increased, or new morbidity; impairment of function; dysfunction of a body organ or part; or significant pain and discomfort as defined by OAC 5160-1-01. Monitored Anesthesia Care (MAC) A specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Outpatient Hospital A facility which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require admission or an overnight stay . Place of Service (POS) Codes 2-digit codes placed on health care professional claims to indicate the setting in which a service was provided. Sedation Continuum When patients undergo procedural sedation/analgesia, they enter a sedation continuum. Several levels have been formally defined along this continuum: minimal sedation/anxiolysis, moderate sedation, deep sedation, and at the deepest level, general anesthesi a. o Minimal Sedation (Anxiolysis ) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. o Moderate Sedation/Analgesia (Conscious Sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is ad equate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. o Deep Sedation/Analgesia A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require a ssistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. o General Anesthesia A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and p ositive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. NOTE : Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initia lly intended. Individuals administering moderate sedation should be able to rescue patients who enter a state of deep sedation, while those administering deep sedation should be able to rescue patients who enter a state of general anesthesia. Rescue o f a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced cardiac life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intende d level of sedation (such as hypoventilation, hypoxia, and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 level of sedation. Short Procedure Unit (SPU ) A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic, or medical services. D. PolicyThis policy is intended to provide guidance on the process for obtaining authorization and reimbursement for dental services performed in a place of service (ASC or hospital OR/SPU) and reimbursement for related facility charges (eg, operating room, anesthesia, medical consults). CareSource Dental Benefits for Ohio Medicaid are administered through our partnered ,delegated vendor , Delta Dental . Coverage for professional services performed by the dentist/oral surgeon in the POS (ASC or OR/SPU) and reimbursement for these services may be provided through the dental benefit once approved via the Delta Dental process of dental utilization review for medical necessity of services and requested place of service. Medical necessity criteria and clinical policies are in the respective Dental Office Reference Manual. OAC 5160-2-03(A)(2)(h) states that dental services are only covered in a hospital setting when the nature of the surgery or the condition of the patient precludes performing the procedure in the dentists office or other non-hospital outpatient setting and the inpatient or outpatient service is a Medicaid covered service. As such, it would e xclude any diagnostic or preventative dental services that could be performed effectively and safely in an ambulatory state, unless patient characteristics and cooperation do not allow it. CareSource Medical Benefits for Ohio Medicaid are administered directly throughCareSource. Coverage and reimbursement for f acility charges (eg, operating room,anesthesia) related to dental services performed in POS (ASC or OR/SPU), are eligible for coverage and reimbursement under the member’s medical benefit when the dental services have been approved via the Delta Dental Utilization Management process. The two-step process for dental services and facility services should be followed toobtain authorization prior to submitting claims for reimbursement:A. Step 1 – Dental authorization for services to be performed in a (OR/SPU or ASC) 1. Requests for dental services in POS (19, 21, 22, 24) are submitted by the treating dental provider to the CareSource Ohio Medicaid dental vendor, Delta Dental . The p rovider must include POS on dental claim and add in authorization notes request is for hospital or ASC setting. 2. The dental vendor reviews for appropriate medical necessity requirements listed in the vendors Office Reference Manual. 3. If the dental authorization is approved, the dental vendor will send an automated fax approval letter to the requesting dentist which can additionally be viewed in the Delta Dental provider portal. 4. If the dental authorization request is not approved, a Notice of Adverse Benefit Determination (Denial Notice) will be issued by the dental vendor to the submitting provider. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 B. Step 2 – Facility precertification processOnce dental procedure approval has been obtained, providers are required to administer services at CareSource participating hospitals and must obtain facility precertification. 1. For facility precertification , the facility provider (hospital or ASC) may submit the request on the CareSource Provider Portal at CareSource.com . 2. The Provider may also request a facility precertification by calling CareSource directly at 800.488.0134 and select ing the option to request an authorization. 3. The facility approval request should include the facility services (ie, operating room charges, anesthesia) requested, the Delta Dental Authorization Approval Letter, and authorization number. 4. The CareSource Medical Utilization Management (UM-MM) team will complete ALL the following: a. Verify that the facility is in-network. b. Review the Delta Dental pre-determination letter (PDL) or approved dental authorization and complete administrative approval for facility fee and anesthesia. c. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted. d. Fax a Facility Approval to the hospital/ASC which can also be viewed in the CareSource Provider Portal. E. Conditions of CoverageFacility reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate code modifiers, if applicable to CareSource. Please refer to the individual fee schedule for appropriate codes. Reimbursement for items assigned to a dental service EAPG type will be paid as follows: Outpatient Hospital Facility (SPU) POS (19, 22) o Use HCPCS code G0330 as the facility fee code. Discounting factors – payments shall be multiplied by any applicable discounting factor, rounded to the nearest whole cent. o Use CPT code 00170 for anesthesia when performing intraoral treatments, including biopsy. Time units for physician and CRNA services – both personally performed and medically directed, are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. Total minutes are listed as the units (ie, 75 minutes) 75 = 5 units (of 15 min increments). CMS Base units = 5. Maximum state allowances ma y be applicable. Payment for an anesthesia service is the lesser of the provider’s submitted charge or the Medicaid maximum, which is determined by a formula. Inpatient Hospital Facility POS (21) o All services as well as any additional room and board fees need to be pre – certified and receive medical necessity review. Services are subject to benefit provisions. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 Ambulatory Surgical Center POS (24)o Use code G0330 for facility fee. Payments for dental services will be made in accordance with the discounting factors as determined by the EAPG grouper. o Use code 00170 for Anesthesia professional services. CPT 00170 is calculated in CMS base units. The base unit = 5 units. See Hospital section above. Dental/Oral Surgery Professional ServicesThe scope of this policy is limited to medical plan coverage reimbursement codes for facility and/or general anesthesia services provided in conjunction with dental treatment, and not the actual dental or oral surgery services provided. For information on dental benefits and coding, please consult the partnered dental vendor Delta Dental Office Reference Manual for clinical guidelines, policies, and procedures. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 09/16/2020 New PolicyDate Revised 01/26/2022 02/14/202406/04/202511/19/2025 03/11 /2026 Annual review. Removed dental codes , removed tables, simplified coding information Annual review: adjusted title, updated definitions, policy language, and references, corrected base unit typo. Approved at Committee. Review: updated references, approved at Committee. Review: updated vendor information, approved at Committee. Review: updated coding information, approved at Committee. Date Effective 06/01/2026 Date Archived H. References1. Ambulatory Surgery Center (ASC) Services: Provider Eligibility, Coverage, and Reimbursement OHIO ADMIN . CODE 5160-22-01 (202 4). 2. American Academy of Pediatric Dentistry . Management of dental patients with special health care needs. Reference Manual of Pediatr ic Dent istry . 2025-2026 :364 – 371 . Accessed February 5, 2026. www.aapd.org 3. American Academy of Pediatric Dentistry . Policy on hospitalization and operating room access for oral care of infants, children, adolescents, and individuals with special health care needs. Reference Manual of Pediatr ic Dent istry . 2025-2026:180 – 182. Accessed February 5, 2026. www.aapd.org 4. American Academy of Pediatric Dentistry . Policy on third-party reimbursement for management of patients with special health care needs. Reference Manual of Pediatr ic Dent istry . 2025-2026:193-196 . Accessed February 5, 2026. www.aapd.org 5. Anesthesia Services, OHIO ADMIN . CODE 5160-4-21 (20 24 ). Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 6. Committee on Quality Management and Departmental Administration. Continuum ofDepth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. American Society of Anesthesiologists. Updated October 23, 20 24 . Accessed February 5, 2026 . www.asahq.org 7. Conditions and Limitations, OHIO ADMIN . CODE 5160-2-03 (2022). 8. Dental Services, OHIO ADMIN . CODE 5160-5-01 (202 4). 9. General Provisions: Hospital Services, OHIO ADMIN . CODE 5160-2-02 (202 4). 10. Hospital Billing Guidelines . Ohio Dept of Medicaid ; 2021. Accessed February 5, 2026 . www.medicaid.ohio.gov 11. Medicaid Medical Necessity: Definitions and Principles, OHIO ADMIN . CODE 5160-1- 01 (2022). 12. Outpatient Hospital Reimbursement, OHIO ADMIN . CODE 5160-2-75 (202 4). Approved ODM 03/18/2026

Modifier 26 and TC: Professional and Technical Component

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 26 and TC: Professional and Technical Component – OH MCD-PY-1474 06/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 26 and TC: Professional and Technical Component B. BackgroundAccording to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), a modifier is used to report that a service or procedure has been altered by a specific circumstance without changing its definition or code. Modifiers may also convey additional information about a service, such as when the service was performed more tha n once, unusual events occurred, or a service was performed by more than 1 provider and/or in more than 1 location. Current Procedural Terminology (CPT) codes offer providers a uniform language forreporting medical services and procedures to increase accuracy and efficiency, and for administrative purposes such as claims processing and developing guidelines for medical care review. Certain procedures described by a single CPT code consist of 2distinct components: the professional component and the technical component. When the professional component is performed separately by a provider, it is identified by appending modifier 26. In this scenario, the facilit y bills the technical component using the same CPT code with modifier TC. This allows the professional and technical components of the service to be billed separately by the provider and the facility. C. Definitions Global Procedure /Service Represents both the professional and technical component as a complete procedure or service and is i dentified by reporting the procedure without modifier 26 or TC. Modifier 26 ( Professional Component) Used to indicate when a provider or other qualified health care professional renders the supervision and interpretation portion of a service or procedure and the preparation of a written report. Modifier TC (Technical Component) Used to indicate the technical personnel, equipment, supplies and institutional charges 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. Modifier 26 is appended to the appropriate CPT code to indicate that only the professional component of a service is being billed. B. Modifier 26 is also used to report the professional component of a test when the provider performs the service while using equipment owned by a hospital or facility. Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 III. Modifier TCA. Modifier TC is appended to the appropriate CPT code to indicate that only the technical component of a service is being billed. B. Reimbursement for the technical component is generally made to the facility or practice the provides the supplies, equipment, and/or clinical staff such as technicians. C. Payment for the technical component includes the practice expense and the malpractice expense associated with the service. D. Hospitals are typically exempt from appending modifier TC because hospitals are presumed to be billing for the technical component of any onsite service. IV. Global Procedure/ ServiceA. A global service is reported by submitting the eligible CPT code without modifier 26 or TC. Reimbursement includes the equipment, supplies, and technical support, as well as interpretation and reporting of test results.B. Modifiers are not necessary to report a global service because payment for both components is included in the reimbursement. V. ExclusionsA. Do not append modifier 26 when there is a dedicated code to describe only the professional component of a service (eg, 93010 electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). B. Do not append modifier TC when there is a dedicated code to describe only the technical component of a service (eg, 93005 electrocardiogram: tracing only, without interpretation and report). C. CareSource does not allow reimbursement for use of modifier 26 or modifier TC when 1. reported with an Evaluation and Management (E&M) code 2. a dedicated code exists that describes the professional component only, the technical component only , or the global test only of a selected diagnostic test VI. Duplicate billingA. CareSource considers the following scenarios to be duplicate billing when submitted for the same member on the same date of service. Only the first charge approved by CareSource is eligible for reimbursement. All subsequent charges are considered duplicate services and are not eligible for separate reimbursement. 1. when 1 provider reports a global procedure and a different provider reports the same procedure with modifier 26 or modifier TC 2. when 1 provider reports a procedure with modifier 26 and a different provider reports a global procedure 3. when 1 provider reports a procedure with modifier TC and a different provider reports a global procedure Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 VII. CareSource may request documentation for post-payment review of claims submitted with modifier 26 or modifier TC. If documentation is not provided, CareSource may recoup previously paid claim. E. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement of claims m ay be subject to limitations and/or qualifications. Reimbursement will be established based on a review of the actual services provided to a member and will be determined when the claim is received for processing. To ensure HIPAA compliance, please use sel f-service channels for member eligibility verification. 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 teeclaim payment.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 09/10 /2025 02/25/2026Periodic Review. Updated background, definitions,D.II,III,IV,V,VI. Change physician to provider where applicable. Updated References. Approved at Committee. Periodic review. Edited for clarity and updated references. Approved at Committee. Date Effective 06/01/2026 Date Archived H. References1. CPT code set overview . American Medical Association. Updated January 23, 2026 . Accessed January 28, 2026 . www.ama-assn.org 2. Medicare Claims Processing Manual Chapter 23 – Fee Schedule Administration and Coding Requirements . Centers for Medicare and Medicaid Services. Updated December 19, 2025 . Accessed January 28, 2026 . www.cms.gov 3. Modifiers Recognized by Ohio Medicaid . Ohio Dept of Medicaid; Updated November 3, 2025 . Accessed January 28, 2026 . www.medicaid.ohio.gov 4. What are medical coding modifiers? AAPC. Updated August 19, 2022. Accessed January 28, 2026. Approved b y ODM 03/06/2026Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5

Doula Services

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Doula Services-OH MCD-PY-1591 05/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Doula Services-OH MCD-PY-1591Effective Dat e: 05/01/2026The 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 . D oulas provide advocacy, physical, educational, and emotional support during pregnancy , and reimbursement of doula services will 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 p eriods: 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 services 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 membership and the OAC rule. E. Conditions of CoverageI. Claims submission must include a ppropriate HCPCS codes and any applicable modifiers. II. Documentation must be submitted upon CareSources request .III. 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 sche dule for appropriate codes.Doula Services-OH MCD-PY-1591Effective Dat e: 05/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 IV. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to both participating and nonparticipating providers and facilities. V. 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 03/12/2025 New policy. Approved at Committee.Date Revised 02/11/2026 Annual Review. Updated reference. Approved at Committee. Date Effective 05/01/2026 Date Archived H. References1. Doula Services, OHIO ADMIN . CODE 5160-8-43 (2025). ODM approved 02/20/2026

Obstetrical Care-Total Cost for Freestanding Birthing Centers

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939 05/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. …………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………….. ……… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. ………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ………………… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………………. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………………. 4 H. References ………………………….. ………………………….. ………………………….. ………………………….. ………. 4 Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939Effective Dat e: 05/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectObstetrical Care-Total Cost for Free standing Birthing Centers B. BackgroundObstetrical care refers to health care treatment given in relation to pregnancy and delivery of a newborn child. This includes care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members receive in a hospital or birthing center, as well as all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician . Submission of claims for reimbursement will serve as the providers certification ofthe medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. The total obstetrical care code is only to be used by Freestanding Birthing Centers. Allother practitioners must not bill and will not be reimbursed for total care obstetrical codes.C. Definitions Freestanding Birthing Center (FBC) Freestanding facilities that are not considered hospitals, providing peripartum care for low-risk women with uncomplicated, singleton term vertex pregnancies expected to have an uncomplicated birth. Initial and Prenatal Visit Practitioner visit to determine if a member is pregnant. Pregnancy For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days or 40 weeks. Prenatal Profile Initial laboratory services. Total Obstetrical Care Antepartum care, delivery, and postpartum care. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and management (E/M) codes are utilized when services were provided to diagnose the pregnancy. These are not part of antepartum Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939Effective Dat e: 05/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 care.B. Risk Appraisal-Case Management Referral 1. Providers may complete the Pregnancy Risk Assessment Form (PRAF) any time there is a change in condition during the pregnancy. Use code H1000 and append modifier 33 or TH as appropriate on the associated claim to indicate that an assessment form was submitted. 2. Any eligible woman who meets any of the risk factors listed on the form is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those services. C. Total Obstetrical Care 1. Total obstetrical care code is CPT 59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care. 2. A corresponding obstetrical diagnosis with appropriate trimester must be listed on the claim. An ICD-10 code from category Z34 should be listed as the first diagnosis for routine obstetric care. 3. Services included that are not to be billed separately (not all inclusive): a. admission history b. admission to hospital c. artificial rupture of membranes d. care provided for an uncomplicated pregnancy , including delivery , as well as antepartum and postpartum e. visits each month up to 28 weeks gestation f. visits every other week from 29-36 weeks gestation g. visits weekly from 36 weeks until delivery h. fetal heart tones i. hospital/office visits following vaginal delivery j. initial/subsequent history k. management of uncomplicated labor l. physical exams m. recording of weight/blood pressures n. routine chemical urinalysis o. routine prenatal visits p. successful vaginal delivery after previous cesarean delivery q. vaginal delivery with or without episiotomy or forceps E. Conditions of CoverageIn the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee of claimspayment. Reimbursement for claims may be subject to limitations and/or qualifications.Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939Effective Dat e: 05/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 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 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.The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates.CODES DESCRIPTION 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care H1000 Pre natal care, at risk assessment F. Related Policies/RulesObstetrical Care-Unbundled Cost G. Review/Revision HistoryDATE ACTIONDate Issued 7/22/2020Date Revised 10/26/2022 10/11/2023 11/06/2024 04/ 23 /2025 02/11/2026Annual review with e ditorial changes. References updated.Annual review. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Periodic review. Updated D.1.B.1.PRAF submission clarification and added modifier. Annual review. Updated conditions of coverage. Updated references. Approved at Committee. Date Effective 05/01/2026 Date Archived H. References1. ACOG Committee Opinion no. 736: optimizing postpartum care. Obstet Gynecol . 2018;131(5):e140-e150. Reaffirmed 2025. doi:10.1097/AOG.0000000000002633 2. ACOG Committee Opinion no. 761 : cesarean delivery on maternal request. Obstet Gynecol . 2019;133(1)e73-e77. Reaffirmed 2024. doi:10.1097/AOG.0000000000003006 3. ACOG Committee Opinion no. 831 : medically indicated late-preterm and early-term deliveries. Obstet Gynecol . 2021;138(1)e35-e39. doi:10.1097/AOG.0000000000004447 4. American Academy of Professional Coders. How-to modifier 22. March 4, 2021. Accessed January 7, 2026. www.aapc.com 5. Caughey AB, Cahill AG, Guise JM, et al; Safe prevention of the primary cesarean Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939Effective Dat e: 05/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 delivery. Am JObstet Gynecol . 2014;210(3):179-193. doi:10.1016/j.ajog.2014.01.0266. Freestanding Birth Center Services, OHIO ADMIN CODE 5160-18-01 (2023). 7. Limitations on Elective Obstetric Deliveries, OHIO ADMIN CODE 5160-1-10 (2015). 8. Managed Care: Definitions, OHIO ADMIN CODE 5160-26-01 (2022). 9. Reproductive Health Services: Pregnancy-Related Services, OHIO ADMIN CODE 5160-21-04 (2025). 9. Modifiers Recognized by Ohio Medicaid . Ohio Dept of Medicaid; 2011. Revised November 3, 2025. Accessed January 9, 2026. www.medicaid.ohio.gov 10. Scope of Specialized Nursing Services, OHIO REVISED CODE 4723.43 (2020). 11. Testing Newborns Definitions, OHIO REVISED CODE 3701.503 (2024). Approved by ODM 02/19/2026

Acupuncture Services

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Acupuncture Services-OH MCD-PY-0152 05/01/2026 Policy Type REIMBURSEMENT Table of Contents A. Subject ………………………………………………………………………………………………………………………………. 2 B. Background ……………………………………………………………………………………………………………………….. 2 C. Definitions ………………………………………………………………………………………………………………………….. 2 D. Policy …………………………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ……………………………………………………………………………………………………… 3 F. Related Policies/Rules ……………………………………………………………………………………………………….. 3 G. Review/Revision History …………………………………………………………………………………………………….. 4 H. References ………………………………………………………………………………………………………………………… 4 Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of 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. Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2026 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. Subject Acupuncture ServicesB. Background 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. During an acute pain problem, a medical acupuncturist may be able to prevent its progression to chronic pain, thereby eliminating the need for long-term opioid therapy. C. Definitions Acupuncturist An 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 Acupuncture 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. migraines B. low back pain C. cervical (neck) pain D. osteoarthritis hip E. osteoarthritis of knee F. acute post-operative pain G. acute 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. Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2026 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 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 fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT DescriptionCode 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) 97813 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/AAcupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2026 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 G. Review/Revision HistoryDATE ACTIONDate Issued 10/31/2013 New PolicyDate Revised 10/31/2013 New Allowed Services 06/06/201604/30/202005/25/2022 Removed III. D. Shoulder Pain05/24/2023 Updated references. No changes. Approved at committee.01/17/2024 Updated references. No changes. Approved at Committee01/15/2025 Updated references. No changes. Approved at Committee01/14/2026 Updated background. Updated references. Approved atCommitteeDate Effective 05/01/2026 Date Archived H. References 1. Acupuncture Services, O HIO ADMIN . C ODE 5160-8- 51 (2021). 2. License to Practice, OHIO REV . C ODE 4762.02 (2023). 3. Niruthisard S, Ma Q, Napadow V. Recent advances in acupuncture for pain relief. Pain Rep. 2024;9(5):e1188. Published 2024 Sep 13. doi:10.1097/PR9.0000000000001188 4. Non-Institutional Fee Schedule, Appendix DD, O HIO ADMIN . C ODE 5160-1- 60 (2025). Approved by ODM on 02/12//2026

Interest Payments

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Interest Payments-OH MCD-PY-1324 05/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 2 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments-OH MCD-PY-1324Effective Date: 05/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectInterest Payments 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 necessity. 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 ProviderAgreement, CareSource does not pay interest on Ohio Medicaid claims. 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. Interest Payments-OH MCD-PY-1324Effective Date: 05/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 F. Related Policies/RulesNA 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 01/14/2026 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 Updated references. Approved at Committee Date Effective 05/01/2026 Date Archived H. References1. Definitions, O HIO R EV . C ODE 5164.01(C) (2023). 2. Ohio Medicaid Contract, Appendix J, 4. Accessed November 28, 2025. www.managedcare.medicaid.ohio.gov 3. Timely Claims Payment, 42 C.F.R. 447.45(b) (2022). Approved by ODM 02/11/2026

Payment to Out of Network Providers

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

Coordination of Benefits

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

Chiropractic Care

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Chiropractic Care-OH MCD-PY-1328 03/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Chiropractic Care-OH MCD-PY-1328Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectChiropractic Care B. BackgroundChiropractic is a healthcare field that focuses on disorders affecting the musculoskeletal and nervous systems, along with their effects on overall health. Doctors of Chiropractic (DCs) utilize a conservative approach to healthcare that includes patient as sessment, diagnosis, and treatment. In addition to manual therapies such as spinal manipulation, DCs are trained to recommend therapeutic and rehabilitative exercises and to offer advice on nutrition, lifestyle, and dietary habits. They address a variety o f conditions, including but not limited to back pain, neck pain, joint pain in the arms or legs, and headaches. The core services provided by chiropractors are a key strategy for the prevention, diagnosis, and conservative (non-drug) management of back pain and spinal disorders.This approach can help some patients minimize or avoid the need for more invasive interv entions, such as prescription opioid pain medications and surgery.C. Definitions Acute Subluxation Treatment for a new injury defined by x-ray or physician exam resulting in an expected improvement in, or arre st of, progression in the members condition. Billing Provider A chiropractor, mechanotherapist, profession al medical group, hospital , or fee-for-service clinic as noted by the Ohio Administrative Code (OAC) . Maintenance Therapy A therapy that is performed to treat a chronic, stable condition or to prevent deterioration. Rendering Providers A chiropractor or a mechanot herapist eligible to provide spinal manipulation . D. PolicyI. CareSource follows the O AC for payment of spinal manipulation . II. Payment may be made for manual correction to correct a spin al subluxation determined by x-ray or physician exam for a condition that is acute and episodic in nature. When the maximum therapeutic benefit has been met, ongoing therapy is considered maintenance therapy and is not medically necessary. III. Payment may be made for the following services:A. spinal ma nipulation 1. chiropractic manipulative treatment (CMT); spinal, 1 to 2 regions 2. chiropractic manipulative treatment (CMT); spinal, 3 to 4 regions 3. chiropractic manipulative treatment (CMT); spinal, 5 regions B. diagnostic imaging to determine the existence of a subluxation 1. spine, entire; survey study, anteroposterior and lateral Chiropractic Care-OH MCD-PY-1328Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 2. spine, cervical; anteroposterior and lateral3. spine, cervical; anteroposterior and lateral; minimum of four views 4. spine, cervical; anteroposterior and lateral; complete, including oblique and flexion and/or extension studies 5. spine, thoracic; anteroposterior and lateral views 6. spine, thoracic; complete, with oblique views; minimum of four views 7. spine, thoracolumbar; anteroposterior and lateral views 8. spine, lumbosacral; anteroposterior and lateral views 9. spine, lumbosacral; complete, with oblique views 10. spine, lumbosacral; complete, including bending views IV. All services performed must be medically necessary and related to the treatment of a specifi c medical complaint. A. To determine medical necessity, CareSource requires all of the following: 1. a primary diagnosis of subluxation (ie, lumbar and/or sacral) 2. a secondary diagnosis that supports the treatment provided ( eg , osteoarthritis, congeni tal musculoskeletal deformities of the spine) B. Manual manipulation must have a direct therapeutic relationship to the members condition as documented in the medical record. The lack of documentation specifying the relationship between the members condition and treatment shall result in the service be ing ineligible for reimbursement. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesMedical Necessity Determination Policy G. Review/Revision HistoryDATE ACTIONDate Issued 05/26/2021Date Revised 04/12/2023 01/31/202411/19 /202 5Annual review: Title modified. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Periodic review. Updated the background and references. Approved at Committee. Date Effective 03/01/2 026 Date Archived H. References1. Chiropractic Services, OHIO ADMIN . CODE 5160-8-11 (2022). Chiropractic Care-OH MCD-PY-1328Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 ODM approved 12/ 01/2025

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