COVID-19 Vaccination

Admin istrative Policy StatementOHIO MEDICARE ADVANTAGE Policy Name Policy Number Date Effective COVID-19 Vaccination PAD-0080-OH-MAP 11/1/2022 Policy Type Medical ADMINISTRATIVE Pharmacy Reimbursement Administrative Policy Statement s prepared by CSMG Co. and its affiliates (including CareSource) are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy 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 whi ch 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals , Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the serv ice(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement 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. Table of Contents Administrative Policy Statement ……………………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 4 D. Policy ……………………………………………………………………………………………………………………. 4 E. Conditions of Coverage …………………………………………………………………………………………… 6 F. Related Policies/Rules …………………………………………………………………………………………….. 6 G. Review/Revision History ………………………………………………………………………………………….. 6 H. References ……………………………………………………………………………………………………………. 7 COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 2 A. Subject COVID-19 Vaccination B. Background The 2019 novel coronavirus, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes the disease known as coronavirus disease 2019 (COVID-19). The Food and Drug Administration (FDA) has issued full authorization for the Pfizer-BioNTech vaccine for prevention of COVID-19 for individuals 12 years and older and Moderna vaccine for prevention of COVID-19 for individuals 18 years and older. The Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EAU) for the following vaccines for the prevention of COVID-19: Pfizer-BioNTech for individuals 6 months and older, Moderna for individuals 6 months and older, Janssen for individuals 18 years and older for whom other COVID-19 vaccines are inaccessible or clinically inapprorpriate, and Novavax for individuals 12 years and older as of October 2022. The CDC recommends that the J&J COVID-19 vaccine only be considered in certain situations, due to safety concerns. The Pfizer-BioNTech, Moderna, and Novavax vaccines are offered as a two-dose series. The Janssen vaccine is offered as a single-dose vaccine. The EUA allows a third primary dose of Pfizer-BioNTech and Moderna vaccines for immunocompromised individuals and allows booster doses of Pfizer-BioNTech, Moderna, and Janssen. Pfizer-BioNTech Bivalent boosters are available for individuals 5 years and older and Moderna Bivalent boosters are available for individuals 6 years and older. The EUA allows the vaccines to be widely distributed in the United States. The Advisory Committee on Immunization Practices (ACIP) has issued interim recommendations for the use of Pfizer-BioNTech, Moderna, Novavax, and Janssen COVID-19 vaccines for the prevention of COVID-19 in the US. The interim recommendations are derived from the EAU of the vaccines, other data sources, general best practice guidelines for immunization, and expert opinion. Considerations will be updated as additional information becomes available or if additional vaccine products are authorized. The purpose of this policy is to provide background on the use of the vaccines in accordance with the ACIP interim recommendations, fact sheets, and the EAU fact sheets of the available COVID-19 vaccines. The following recommendations are derived from the latest guidelines and scientific based literature available: Pfizer COVID-19 Vaccine: Vaccination with the Pfizer-BioNTech COVID-19 vaccine consists of 2 doses (30 g, 0.3 mL each) administered intramuscularly, 3 weeks apart for age 12 years and older. For children age 5 through 11 years old, the vaccine consists of 2 doses (10 g, 0.2mL each) administered intramuscularly, 3 weeks apart. For individuals 6 months through 4 years old, the vaccine cosists of 2 doses ( 3 g, 0.2mL each) administered intramuscularly, 3 weeks apart followed by a third dose administered at least 8 weeks after the second dose. Pfizer-BioNTech COVID-19 Vaccine, Bivalent is authorized for use to prevent COVID-19 in individuals 5 years of age and older as a single booster COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 3 dose administered at least 2 months after either completion of primary vaccination with any authorized or approved monovalent COVID-19 vaccine, or receipt of the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine. For the Pfizer-BioNTech Bivalent formulation, a 0.2 mL dose (10 g) is administered IM to individuals age 5-11 years old and a 0.3 mL dose (30 g) is administered to indivudals 12 years and older. Pfizer-BioNTechs COVID-19 vaccinations come in multiple formulations including one for adult/adolescents in a vial with a purple cap, two for adult/adolescents in a vial with a grey cap, two for pediatric use (5 11 year olds) in a vial with an orange cap, and another for pediatric use (6 months 4 year olds) in a vial with a maroon cap. Formulations specific for adults /adolescents can not be used to prepare pediatric doses and vice versa. On December 11, 2020, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Pfizer-BioNTech COVID-19 vaccine in persons aged 16 years for the prevention of COVID-19. On May 10 th, 2021, the FDA expanded the EUA to include adolescents 12 through 15 years of age. On August 23, 2021, the FDA approved the Pfizer-BioNTech COVID-19 Vaccine for the prevention of COVID-19 caused by SARS-CoV-2 in individuals of 16 years old and older. The licensed vaccine is now marked as Comirnaty, can be interchanged with the EUA-authorized formulation of the Pfizer-BioNTech COVID-19 Vaccine for ages 12 years of age and older without presenting safety or efficacy concerns. On September 22, 2021, the FDA expanded the EUA to include a single booster dose of the Pfizer-BioNTech COVID-19 Vaccination booster dose, for all adults age 18 and older. On December 9, 2021, the FDA expanded this to include a single booster for age 16 and 17. The FDA has since updated bivalent booster recommendation to be administered at least 2 months after i nitial series or initial booster in individuals 5 years of age and older. On October 29, 2021, the FDA expanded the EUA to include children aged 5 through 11 years of age. On January 3, 2022, the FDA expanded the EUA to include a single booster dose in individuals 12 and older which has since been updated. On June 17, 2022, the Food and Drug Administration (FDA) issued Emergency Use Authorization (EUA) amendments for the mRNA-1273 (Moderna) COVID-19 vaccine for use in children aged 6 months 5 years, admi nistered as 2 doses (25 g, 0.25 mL each), 4 weeks apart, and BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine for use in children aged 6 months 4 years, administered as 3 doses (3 g, 0.2 mL each), at intervals of 3 weeks between doses 1 and 2 and 8 weeks between doses 2 and 3. COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 4 On October 12, 2022, the FDA amended the emergency use authorizations (EUAs) of the Moderna and Pfizer-BioNTech COVID-19 bivalent vaccines to authorize their use as a single booster dose in younger age groups . The Pfizer-BioNTech COVID-19 bivalent vaccine was authorized for administration as a single booster dose at least 2 months following completion of primary or booster vaccination in children 5 years of age and older. The recommendation for the Pfizer-BioNTech COVID-19 vaccine should be implemented in conjunction with ACIPs interim recommendation for allocating initial supplies of COVID-19 vaccines. The ACIP recommendation for the use of the Pfizer-BioNTech COVID-19 vaccine under FDA approval as well as the i nterim EUA will be updated as additional information becomes available. Before vaccination, the Fact Sheet or EUA Fact Sheet should be provided to recipients and caregivers. Providers should counsel Pfizer-BioNTech COVID-19 vaccine recipients about expec ted systemic and local reactogenicity. Additional clinical considerations, including details of administration and use in special populations (e.g., persons who are pregnant or immunocompromised or who have severe allergies) are available at www.cdc.gov Moderna COVID-19 Vaccine: Vaccination with the Moderna COVID-19 vaccine consists of 2 doses : 0.5 mL (100 g) each for individuals 12 years and older , 0.5 mL (50 g) each for individuals 6-11 years old, or 0.25 mL (25 g) each for children 6 months 5 years old administered intramuscularly, 4 weeks apart. Moderna COVID-19 Vaccine, Bivalent is authorized for use in individuals 6 years of age and older as a single booster dose administered at least 2 months after either completion of primary vaccination with any authorized or approved monovalent COVID-19 vaccine, or receipt of the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine. For the Moderna Bivalent formulation, a 0.25 mL dose (25 g) is administered IM to individuals age 6-11 years old and a 0.5 mL dose (50 g) is administered to indivudals 12 years and older. The Moderna COVID-19 vaccinations come in multiple different formulations including one for adult/adolescents 12 years and older in a vial with a red cap & light blue border, one for individuals 6 years and older in a vial with a dark blue cap & grey border, one for pediatric use (6 11 year olds) in a vial with a dark blue cap with a purple border, and another for pediatric use (6 months 5 year olds) in a vial with a dark blue cap & majenta border. Formulations specific for adults/adolescents can not be used to prepare pediatric do ses and vice versa. On December 18, 2020, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Moderna COVID-19 vaccine in persons aged 18 years for the prevention of COVID-19. COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 5 On August 12, 2021, the FDA expanded the EUA to allow for an additional dose to be given to certain immunocompromised individuals. On October 20, 2021, the FDA amended the Moderna COVID-19 Vaccine EUA to allow for a single booster dose, for all adults age 18 and older. The FDA has since updated bivalent booster recommendation to being administered at least 2 months after initial series or initial booster in individuals 6 years of age and older. On June 17, 2022, the Food and Drug Administration (FDA) issued Emergency Use Authori zation (EUA) amendments for the mRNA-1273 (Moderna) COVID-19 vaccine for use in children aged 6 months 5 years, administered as 2 doses (25 g, 0.25 mL each), 4 weeks apart, and BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine for use in children aged 6 months 4 years, administered as 3 doses (3 g, 0.2 mL each), at intervals of 3 weeks between doses 1 and 2 and 8 weeks between doses 2 and 3. On October 12, 2022, the FDA amended the emergency use authorizations (EUAs) of the Moderna and Pfizer-BioNTech COVID-19 bivalent vaccines to authorize their use as a single booster dose in younger age groups . The Moderna COVID-19 bivalent vaccine is authorized for administration as a single booster dose at least 2 months following completion of primary or booster vaccinati on in children 6 years of age and older. Use of all COVID-19 vaccines authorized under an EUA, including the Moderna COVID-19 vaccine, should be implemented in conjunction with ACIPs interim recommendations for allocating initial supplies of COVID-19 vacc ines (3). The ACIP recommendation for the use of Moderna COVID-19 vaccine under EAU is interim and will be updated as additional information becomes available. The interim recommendation and clinical considerations are based on use of the Moderna COVID-19 vaccine under an EUA and might change as more evidence becomes available. Before vaccination, the EUA Fact Sheet should be provided to recipients and caregivers. Providers should counsel Moderna COVID-19 vaccine recipients about expected systemic and local reactogenicity. Additional clinical considerations, including details of administration and use in special populations (e.g., persons who are pregnant, immunocompromised or who have a history of severe allergic reactions) are available at www.cdc.govJanssen COVID-19 Vaccine: Vaccination with the Janssen COVID-19 vaccine consists of a single dose (0.5mL) administered intramuscularly and a single booster dose at least 2 months after completing primary vacc ination in individuals 18 years of age and older. On February 27, 2021, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 6 Janssen COVID-19 vaccine as the first single-shot COVID-19 vaccine in individuals 18 years of age or older for the prevention of COVID-19. The use of the Janssen COVID-19 vaccine under the EUA should be implemented in conjunction with ACIPs interim recommendations for allocating initial supplies of COVID-19 vaccines. The interim rec ommendations and clinical considerations are based on use of the Janssen COVID-19 vaccine under an EUA and might change as more evidence becomes available. On October 20, 2021, the FDA expanded the EUA to include a single booster dose of the Janssen (Johns on and Johnson) COVID-19 Vaccination booster dose for adults age 18 and older. The single booster must be administered at least 2 months after completion of the primary vaccine dose. The single booster dose is the same dosage as the initial vaccine (0.5mL) . Janssen COVID-19 vaccine should be considered for individuals 18 years and older for whom other COVID-19 vaccines are inaccessible or clinically inapprorpriate. The CDC recommends that the J&J COVID-19 vaccine only be considered in certain situations, due to safety concerns such as TTS. Before vaccination, the EUA Fact Sheet should be provided to the recipient and caregivers. Providers should counsel Janssen COVID-19 vaccine recipients about any expected systemic and local reactogenicity. Additional cl inical considerations, including details of administration and use in special populations (e.g., persons who are pregnant. Immunocompromised or who have a history of severe allergic reactions) are available at www.cdc. gov. Novavax COVID-19 Vaccine: Vaccination with the Novavax COVID-19 vaccine consists of 2 doses (0.5 mL each) administered intramuscularly, 3 weeks apart for age 12 years and older. The vaccine is authorized for emergency use as a two-dose primary series. On July 19th, 2022, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Novavax COVID-19 vaccine in persons aged 18 and older as a primary 2-dose series for vaccination in the prevention of COVID-19. Us e of all COVID-19 vaccines authorized under an EUA, including the Novavax COVID-19 vaccine, should be implemented in conjunction with ACIPs interim recommendations for allocating initial supplies of COVID-19 vaccines. The interim recommendations and clini cal considerations are based on use of the Novavax COVID-19 vaccine under an EUA and might change as more evidence becomes available. FDA since updated recommendations to include individuals aged 12 years of age and older. Before vaccination, the EUA Fact Sheet should be provided to recipients and caregivers. Providers should counsel Novavax COVID – COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 7 19 vaccine recipients about expected systemic and local reactogenicity. Additional clinical considerations, including details of administration and use in special populations (e.g., persons who are pregnant, immunocompromised or who have a history of severe allergic reactions) are available at www.cdc.gov Guidance for COVID-19 Vaccination Boosters Indviduals age 5 years and older (or 6 years and older for Moderna) may get the updated (bivalent) booster . Individuals should no longer receive an original (monovalent) Pfizer-BioNTech or Moderna booster. For individuals with prior COVID-19 infection, experts have recommended that indiv iduals get a booster dose at least 3 months after symptoms began, or if asymptomatic, after the first positive test. Chlidren under 5 years of age are not yet eligible to receive any booster. For those who received the Janssen COVID-19 vaccination as their primary vaccine, if eligible, should receive a single vaccine booster at least 2 months after receiving their dose. Any FDA-approved or authorized COVID-19 vaccination can be used as a booster dose. Novavax is not currently authorized to be used as a boos ter and is only authorized for primary dose series. On October 21, 2021, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the COVID-19 Booster Shots for those who received a mRNA primary COVID-19 vaccination (Pfizer-BioNTech or Moderna), if eligible, should receive a single vaccine booster. The FDA has since updated the booster recommendations several times with the most recent recommendation on October 12, 2022. On October 12, 2022, the FDA amended the emergency use authorizations (EUAs) of the Moderna and Pfizer-BioNTech COVID-19 bivalent vaccines to authorize their use as a single booster dose in younger age groups. The Pfizer-BioNTech COVID-19 bivalent vaccine was authorized for administration as a single booster dose at least 2 months following completion of primary or booster vaccination in children 5 years of age and older . The Moderna COVID-19 bivalent vaccine is authorized for administration as a s ingle booster dose at least 2 months following completion of primary or booster vaccination in children 6 years of age and older. Note: Additional Vaccines Newly developed vaccines are still moving through the clinical trial process before submission for regulatory approval. CareSource is closely monitoring FDA approval of these vaccines. COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 8 C. Definitions Emergency Use Authorization (EUA) A mechanism to facilitate the availability and use of medical countermeasures, including vaccines, during public healt h emergencies. Vaccine Adverse Event Reporting System (VAERS) A national early warning system to detect possible safety problems in vaccines used in the United States. Immunization Information System (IIS) A confidential, population-based, computerized databases that record all immunization doses administered by participating providers to persons residing within a specific geopolitical area. D. Policy I. COVID-19 vaccination providers participating in the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program are required to sign a CDC COVID-19 Vaccination Program Provider Agreement. Providers are responsible for adhering to all requirements outlined in the agreement. II. Providers must follow the prioritization schedule as determined by the states and/or the Department of Healths plan for distributing the vaccines (e.g., Phase 1a includes healthcare personnel, Phase 1b includes persons 75 years of age, etc.): A. COVID-19 vaccine providers are prohibited from selling USG-purchased COVID-19 vaccine, receiving any inducement (whether direct or indirect) for vaccinating (or providing COVID-19 vaccine to be used for vaccinating) and individual who is not currently eligible to receive COVID-19 vaccine as a member of a group currently authorized under prioritization specified by CDC/ACIP, the state/territorys governor or other relevant public health authority, or otherwise diverting COVID-19 vaccine from the CDC COVID-19 Vaccination Program. III. The members age must be within the age group that is authorized to receive the COVID-19 vaccination: A. Pfizer-BioNTech: age 6 months or greater; B. Moderna: age 6 months or greater; C. Janssen: age 18 years or greater; D. Novavax: age 12 years or greater. IV. The vaccination provider must follow the vaccine schedule as outlined in the EUA fact sheet. A. Pfizer-BioNTech: 2 doses, 21 days apart; third dose 28 days apart for those who have undergone solid organ transplantation or have a diagnosis with an equivalent level of immunocompromise; B. Moderna: 2 doses, 28 days apart; third dose 28 days apart for those who have undergone solid organ transplantation or have a diagnosis with an equivalent level of immunocompromise; C. Janssen: 1 dose for primary vaccination; D. Novavax: 2 doses, 21 days apart; E. People ages 6 months through 64 years, and especially males ages 12 through 39 years, may consider getting the 2nd primary Pfizer-BioNTech, Moderna, or Novavax 8 weeks after the 1st dose. V. The provider must communicate to the individual receiving the vaccine or their caregiver, information consistent with the Fact Sheet for Recipients and Caregivers prior to receiving the vaccine. COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 9 VI. The vaccination provider must follow the storage and handling instruction of the vaccine as outlined in the EUA fact sheet of the individual vaccine. VII. The vacci nation provider must include vaccination information in the state/local jurisdictions Immunization System (IIS) or other designated system: A. All COVID-19 vaccination providers must report COVID-19 vaccine inventory daily into VaccineFinder. In some jurisdi ctions, providers may report vaccine inventory to the jurisdictions IIS for the jurisdiction to upload into VaccineFinder. B. COVID-19 vaccination providers must document vaccine administration in their medical record systems within 24 hours of administration; and use their best efforts to report administration data to the relevant system for the jurisdiction (i.e., IIS) as soon as practicable and no later than 72 hours after administration. VIII. The vaccination provider is responsible for mandatory reporting of any significant adverse events to the Vaccine Adverse Event Reporting System (VAERS). A. The following adverse events are required to be reported in addition to any other events if later revised by the CDC: 1. Vaccine administration errors, whether error is assoc iated with an adverse event (AE) or not. 2. Serious AEs regardless of causality. Serious AEs are defined as: a. Death; b. A life-threating AE; c. Inpatient hospitalization or prolongation of existing hospitalization; d. A persistent or significant incapacity or substanti al disruption of the ability to conduct normal life functions; e. A congenital anomaly/birth defect; f. An important medical event that based on appropriate medical judgement may jeopardize the individual and may require medical or surgical intervention to prevent one of the outcomes listed above; g. Cases or Multisystem Inflammatory Syndrome; h. Cases of COVID-19 that result in hospitalization or death. B. Providers are encouraged to report to VAERS any additional clinically significant adverse event following vaccination, even if they are not sure if vaccination caused the event. C. Providers should also report any additional select AEs and/or any revised safety reporting requirements per FDAs conditions of authorized use of vaccine(s) throughout the duration of any COVID-19 vaccine being authorized under an EUA. IX. Claims Reimbursement and Member Cost Share A. All FDA-authorized COVID-19 vaccines will be covered at no cost for members during the public health emergency. B. Vaccine providers must administer the vaccine regardless of the members ability to pay or verify health insurance coverage status. C. Vaccine providers may not seek reimbursement, including through balance billing, from the vaccine recipient. D. Vaccine providers may seek appropriate reimbursement from a program or plan that covers COVID-19 vaccine administration fees for the vaccine recipient. E. Providers may bill the CareSource medical benefit through our standard claim process. COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 10 F. Pharmacies should submit claims through their pharmacy claims platform through our pharmacy benefits manager, Express Scripts. E. Conditions of Coverage All FDA-approved or authorized COVID-19 vaccines do not require any prior-authorization and will be covered at no cost for members. Please refer to the Reimbursement Policy for more details. HCPS and CPT Codes: Pfizer-BioNTech COVID-19 Vaccine o 91300 vaccine o 0001A 1 st dose administration o 0002A 2nd dose administration o 0003A 3rd dose administration o 0004A 4th dose administration Moderna COVID-19 Vaccine o 91301 vaccine o 0011A 1st dose adm inistration o 0012A 2nd dose administration o 0013A 3rd dose administration o 0014A 4th dose administration Janssen COVID-19 Vaccine o 91303 vaccine o 0031A administration Novavax COVID-19 Vaccine o 91304-vaccine o 0041A-1 st dose administration o 0042A-2nd dose administration Quantity Limit: Only one vaccine is allowed per member for primary series. Member may receive a different booster vaccine than reveived for their primary series. Pfizer-BioNTech and Moderna COVID-19 Vaccine: Four doses are allowed per member. Janssen COVID-19 Vaccine: Two dose s are allowed per member. Novavax COVID-19 Vaccine: Two doses are allowed per member. Quantity limit is subject to change as more vaccines become available for use. F. Related Policies/Rules COVID-19 Vaccine Reimbursement Policy G. Review/Revision History DATE S ACTIONDate Issued 12/18/2020 New PolicyDate Revised 02/28/2021 Policy revised to include information about Janssen COVID-19 vaccine.COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 11 09/01/2021 11/30/2021 12/09/2021 3/4/2022 10/ 20/2022Policy revised to update age for Pfizer vaccine, and update vaccine schedule for Pfizer and Moderna vaccine. Policy revised to update age for Pfizer vaccine, Pfizer vaccination approval, vaccine schedules for all booster shots. Policy revised to update f or Pfizer vaccine booster age Policy revised to update for new booster dose length Policy revised to update for newly authorized Novavax primary series, bivalent Pfizer and Moderna booster shots and updated age recommendations for primary and booster ser ies.Date Effective 11/1/2022 Date Archived H. References 1. Oliver SE, Gargano JW, Marin M, et al. The Advisory Committee on Immunization Practices Interim Recommendation for Use of Pfizer-BioNTech COVID-19 Vaccine United States, December 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1922-1924. 2. Oliver SE, Gargano JW, Marin M, et al. The Advisory Committee on Immunization Practices Interim Recommendation for Use of Moderna COVID-19 Vaccine United States, December 2020. MMWR Morb Mortal Wkly Rep. 2021;69(5152):1653-1656. 3. Oliver SE, Gargano JW, Marin M, et al. The Advisory Committee on Immunization Practices Interim Recommendation for Use of Janssen COVID-19 Vaccine United States, February 2021. MMWR Morb Mortal Wkly Rep. ePub: 2 March 2021. 4. Centers for Disease Control and Prevention (CDC). (2021). Emergency Use Authorization (EUA) of the Pfizer-BioNTech COVID-19 Vaccine to Prevent Coronavirus Disease 2019 (COVID-19) [Fact Sheet]. 5. Centers for Disease Control and Prevention (CDC). (2020). Emergency Use Authorization (EUA) of the Moderna COVID-19 Vaccine to Prevent Coronavirus Disease 2019 (COVID-19) [Fact Sheet]. 6. Centers for Disease Control and Prevention (CDC). (2021). Emergency Use Authorization (EUA) of the Janssen COVID-19 Vaccine to Prevent Coronav irus Disease 2019 (COVID-19) [Fact Sheet]. 7. Ohio Department of Medicaid. COVID-19 vaccine administration billing guidelines. 8. Centers for Disease Control and Prevention (CDC). (2021). COVID-19 Vaccination Booster Shots. Updated November 9, 2021. Accessed Nov ember 12, 2021. https://www.cdc.gov/media/releases/2021/p1021-covid-booster.html 9. U.S. Food & Drug Administration. Coronavirus Disease 2019 (COVID-19). Updated October 7, 2022. Accessed October 10, 2022 . https://www.fda.gov/emergency-preparedness-and-response/counterterrorism-and-emergin g-threats/coronavirus-disease-2019-covid-19 10. Centers for Disease Control and Prevention (CDC). Interim Recommendation of the Advisory Committee on Immuniastion Practices for Use of the Novavax COVID-19 Vaccine. August 5, 2022. Accessed October 10, 2022. ht tps://www.cdc.gov/mmwr/volumes/71/wr/mm7131a2.htm The Administrative Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the Administrative Polic y Sta te m ent Polic y a nd i s a pp ro ved. COVID-19 Vaccination OHIO MEDICARE ADVANTAGEPAD-0080-OH-MAP Effective Date: 11/1/2022 12

Pass-Through Billing

ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Pass-Through Billing-OH MA-AD-0817 03/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements pre pared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there i s a conflict between the Administrative Policy Statement 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. According to the rules of Men tal 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 ………………………….. ………………………….. ………………………….. …….. 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 2 H. References ………………………….. ………………………….. ………………………….. ……………………. 2 Pass-Through Billing-OH MA-AD-0817 Effective Date: 03/01/2023 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectPass-th rough B illing B. Background NA C. Definitions Pass-through billing Pass-through billing occurs when the ordering physician, professional provider, facility or ancillary provider requests and bills for a service, but the service is not performed by the ordering physician, professional provider, facility or ancillary provider. You may only bill for services that you or your staff perform. D. Policy I. CareSource does not permit pass-through billing. A. CareSource will only reimburse providers for services performed by the provider or by the staff that are under the direct supervision of the provider who bills for the services. B. Providers must bill CareSource only for those services which they or their direct employees perform. Provide rs will not bill, charge, seek payment for or submit any claims to CareSource, nor will they have any recourse against CareSource or any of its members for amounts related to the provision of pass-through billing. E. Conditions of Coverage NA F. Related Policies/Rules NA G. Review/Revision History DATES ACTIONDate Issued 04/29/2020 New policyDate Revised 10/ 26/2022 No changes Date Effective 03/01/2 023 Date Archived H. References NA

Trading Partners

ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Trading Partners-OH MA-AD-0087 02/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the E vidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Cove rage) will be the controlling document used to make the determination. 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 limita tions 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 ………………………….. ………………………….. ………………………….. …….. 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 2 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Trading Partners-OH MA-AD-0087Effective Dat e: 02/01/2023 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectTrading Partners B. BackgroundCareSource accepts electronic claims submissions to increase the efficiency of claims processing. CareSource has specific requirements regarding electronic claims submission. This policy applies to providers who want to directly connect with CareSource for electronic filing along with Trading Partners and Clearinghouses not already contracted with CareSource and the electronic claims submission process. C. Definitions Clearinghouses/Trading Partners Companies that function as intermediaries who forward cla ims information from healthcare providers to insurance payers. Direct Connections Direct electronic claims submissions to CareSource without the use of a clearinghouse/trading partner. Electronic Data Interchange (EDI) The computer-to-computer exchange of business data. D. PolicyI. CareSource only allows direct connections for EDI transactions with contracted Trading Partners/Clearinghouses, states and Centers for Medicare and Medicaid Services (CMS). II. CareSource will not contract or approve direct connections with providers (e.g. ,hospitals, labs, offices, practitioners, etc.).III. New direct connection requests will not be granted unless they are fully documentedand approved by CareSources I nformation Technolog y and Operations ExecutiveLeadership. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATES ACTIONDate Issued 04/05/2018Date Revised 2/19/2020 01/19/202210/12/2022Annual update completed. No changes Annual review. No changesNo changesDate Effective 02/01/2023 Date Archived Trading Partners-OH MA-AD-0087Effective Dat e: 02/01/2023 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.H. References NA

Continuity of Care

ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Continuity of Care-OH MA-AD-0744 02/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the E vidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Cove rage) will be the controlling document used to make the determination. 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 limita tions 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. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Co n tin uity o f Care-OH MA-AD-0744 Effective Dat e: 02/01/2023 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.A. SubjectContinuity of Care B. Background Co ntinuity of Care (COC) p ro vides newly enrolled members meeting specific criteria continued care with a f o rmer or no n-participating provider , including acute ho spitals , during transition to a p articipating p rovider. COC also may ap ply to existing members who are impacted when a p articipating p rovider , practitioners and g eneral acute care ho spitals , terminates an agreement with CareSo urce. In o rder to ensure care is no t d isrupted or interrupted, the COC p rocess b eco mes a b ridge of coverage , allowing members to transition from an o ld p lan to CareSource o r f ro m a terminated provider to a CareSource participating provider. The American Academy of Family Physicians (AAFP) defines C OC as the process b y which the p atient and his/her physician-led care team are cooperatively involved in o ngoing health care manag ement toward the shared g oal of hig h-quality, cost-effective medical care. A recent study revealed that COC improve s physician-patient relationships, medical outcomes and also red uces healthcare co sts. C. Def initions Continuity of Care – A p ro cess for assuring that care is d elivered seamlessly across a multitud e of delivery sites and transitions in care throughout the co urs e of the disease p ro cess (NCQA) . Acute Condition – A med ical or b ehavioral condition that involves a sudden onset of symp toms due to an illness, injury or o ther medical problem req uir ing p rompt medical attentio n with a limited duration . Chronic Cond ition – A medical or b ehavioral health condition due to a d isease, illness, o r o ther med ical pro blem that is complex in natu re and persists without cure, worsens over an extend ed p eriod of time or req uires ongoing tr eatment to maintain remission or p revent d eterio ration . Primary Care Provider (PCP) – A netwo rk p hysician, network p hysician g roup, advanced p ractice nurse or advanced practice nurse group trained in family medicine (general practice), internal med icine, or p ediatrics responsible for pro viding and /or coordinatin g all covered services for network b enefits . Participating Provider – A p rovider who has entered into a co ntractual arrangement with CareSo urce, o r another o rganization that has an ag reement with CareSource to provide certain co vered services or certain ad ministration functions for the network associated with the Evid ence of Co verage (EOC ). A n etwork provider may also b e a no n-network p rovider for o ther services or p roducts that are no t covered b y the contractual arrangement with CareSo urce as covered services . Non-Participating Provider – A p rovider who has no t entered into a contractual arrangement with CareSo urce , a lso known as an out-of-network p rovide r. Postpartum Period – A span of at least sixty days, b eginning on the d ate a wo mans p reg nancy end s and end ing o n the last d ay of the month in which the sixtieth day falls. Terminal Illness – An illness with a life expectancy of 6 months or less if the illness runs a no rmal c o urse . Transition of Care – A set of actions designed to ensure the coordination and continuity of health care as p atients transfer b etween d ifferent locations or d ifferent levels of care within the same lo cation. Co n tin uity o f Care-OH MA-AD-0744 Effective Dat e: 02/01/2023 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.D. PolicyI. CareSo urce supports continuity of care to ensure consistent healthcare services are d elivered through proper coordination , combined with information sharing among p roviders to enh ance a p atient focused approach . CareSource will honor p rior authorizations (PA) that were ap p ro ved by the members original Care Manag ement Org anization ( CMO ) f or at least 30 d ays d uring transition to CareSource. This includes existing and uncompleted care treatment p lans and scheduled services with non-participating providers. COC services may b e sub ject to a medical necessity review. Req uests will be accepted from a member o r a p ro vider o n beha lf of a member. II. COC services will be p rovided when ONE of the following o ccurs:A. When a health p artner is terminated from the CareSource network and that termination was no t related to a fraud or q uality of care issue; B. When a newly enro lled member req uests continuation of care f ro m the no n-p articipating health p artner who was treating the member p rior to enrollment; OR C. When a newly enro lled member is o r will be receiving services for which a p rior autho rizatio n (PA) was received fro m another payer. III. CareSo urce ensures that prior authorization req uirements are no t ap plied to the following:A. Emerg ency services B. Urg ent care C. Crisis stabilization for b ehavioral health care D. Inp atient sub stance ab use treatment E. Family p lanning services F. Out-of-area renal dialysis services G. Co mmunicable d isease services, including sexually transmitted infection (STI) and human immuno deficiency viruses ( HIV ) testing . Other services as specified in the Centers f o r Medicare & Medicaid Servoces (CMS) – State Memorandum of Und erstand ing (MOI). Members have the o ption of using an alternative medication witho ut a PA when ap plicable. IV. To co o rdinate care and facilitate transition, COC services will be p rovided for 30 d ays to a p articipating o r non-participating provider and may be subject to a medical necessity review, includ ing the following services: A. Co ntinuity of care req uests for non-network primary care providers are ap proved for 30 d ays of service, allowing the no n-network provider time to transfer care to an in-network p rimary care p rovider. B. Fo r i np atient and outpatient nehavioral health care all prior authorizations ap proved by Med icaid fee for service (FFS) will b e honored. C. Med ical hospitalization D. Extend ed care o r skilled care E. Po st emergency care 1. When a memb er is seen in the emergency department ( ED) by a no n-participating p hysician, follow-up care with non-participating p hysicians will o nly be covered for 30 d ays. 2. Fo llo w-up care beyond 30 d ays will be subject to a medical necessity review. F. Ho me health services G. Private duty nursing H. Sp ecialized medi cal care I. Sp ecialized durable medical equipment Co n tin uity o f Care-OH MA-AD-0744 Effective Dat e: 02/01/2023 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.V. Co ntinuity of Care will b e p rovided when an o n-going treatment plan is in p lace and are sub ject to a medical necessity review for the following services: A. Med ical hospitalizat ed members already enro lled in a CMO and hospitalized in ANY f acility will remain the responsibility of the current CMO at the time of transition, including all p ro f essional services, until the member is d ischarged from the facility for the current ad mission. B. Nursing facility care When an ad ult member is currently receiving care in a nursing facility o n the effective d ate o f enro llment, CareSource will cover the nursing facility care at the same facility until a med ical necessity review is completed and , if applicable, a transition to an alternative lo cation has been documented in the members care p lan. C. Preg nancy 1. A co ntinuity of care authorizatio n will b e granted for newly enrolled members who are p reg nant , and o ne of the following o ccurs: a. The memb er is in the third trimester and has established a relationship with an o b stetrician and/or delivery ho spital. b. The memb er is in the first or second t rimester, has an established relationship with an o b stetrician, n and has a hig h risk condition, such as p reterm labor req uiring p rogesterone therapy. D. Po stpartum care Mo thers will be covered for p ostpartum care for up to 12 weeks following delivery with the no n-p articipating p rovider or associate within the p rovider group who performed the d elivery. E. Dialysis F. Chemo therap y and rad iation therapy when a member has been pla ced in a chemo therapy and /or rad iati on treatment plan and until the treatment plan is completed. G. Majo r o rg an or tissue transplantation services which are in p rocess or have been autho rized . H. Surg ical care when a member has been placed in a surg ical care treatment p lan and until that treatment p lan is completed , including scheduled inpatient o r outpatient surgeries ap p ro ved and/or pre-certified. I. Physical therapy, speech therapy, occupational therapy, rehabi litation therapy coverage will b e p ro vided for the first 60 days or until the benefit limit of 30 visits is reached, whichever is completed first. VI. Co ntinuity of Care Pro cessIf a no n-p articipating p roviders services meet med ical necessity and the co ntin uity o f care p o licy, the no n-p articipating p ro vider will need to sig n a Sing le Case Ag reement (SCA ag reement ). VII. Co ntinuity o f care p rio r autho rization req uests f o r services f ro m no n-p articipating sp ecialists will b e d etermined based on the treatmen t p lan received. When participating p roviders are not availab le to provide the needed services after the initial determination, the authorization period may b e extended. E. Conditions of CoverageN/A Co n tin uity o f Care-OH MA-AD-0744 Effective Dat e: 02/01/2023 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.F. Related Policies/RulesN/A G. Review/Revision History DATES ACTIONDate Issued 09/04/2019Date Revised 0/28/2022 Ed itorial changes made and references up dated. Date Effective 02/01/2023 H. Ref erences 1. American Academy of Family Physicians. C o ntinuity of care, d efinition of [Internet] Leawood (KS): American Academy of Family Physicians; 2015. [cited 2017 Sep 7]. 2. Kim JH, Park EC, Kim TH, Lee Y. Ho spital charges and continuity of care for o utpatients with hyp ertension in South Korea: a nationwi de population-based cohort study from 2002 to 2013. Ko rean JFam Med. 2017;38:242 248.

Emergency Department Electrocardiogram (EKG_ECG)

ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Emergency Department Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation-OH MA-AD-1085 01/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and publish ed MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbo oks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. 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 EmergencyDepartment Electrocardiogram (EKG/ECG) In terpretation and Imaging Interpretation-OH MA-AD-1085Effective Date: 01/01/2023 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectEmergency Department Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation B. Background An electrocardiogram (EKG/ECG) is a non-invasive test that records the electrical activity of the heart. It is used when a possible cardiac issue occurs and the patient is seen in the Emergency Department due to an emergency medical condition. An electrocardi ogram (EKG/ECG) may need to be performed to address the situation quickly. The recording is reviewed by a physician who provides an interpretation and written report. An EKG/ECG may be reported as the technical aspect only, the interpretation and written r eport only, or both aspects together as one service. C. Definitions Electrocardiogram (EKG/ECG) – A test that records the electrical activity of the heart. For the purpose of this policy , EKG will be used to represent both EKG and ECG. Emergency medical condition – A medical condition with sudden severity and onset that , in the absence of immediate medical attention , could plac e the patient’s health in serious jeopardy , including labor and delivery, but not routine prenatal or postpartum care, or services related to an organ transplant procedure. Imaging – Several different technologies that are used to view the human body in order to diagnose, monitor, or treat medical conditions. D. Policy I. Electrocardiogram (EKG/ECG) Interpretation A. CareSource considers EKG interpretation medically necessary when EKG interpretations are completed in the Emergency Department (Place of service (POS) 23). B. CareSource will reimburse the first EKG interpretation claim that is received f or the member on the date of service. 1. If another claim for the same EKG interpretation is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service. 2. CareSource will not reimbur se for duplicate claims, for the same service on the same date of service for the same member, without the appropriate modifier. C. If a second EKG interpretation is medically necessary, on the same date of service, before the member is discharged, modifi er 76 or modifier 77 must be appended to the second EKG interpretation for reimbursement. EmergencyDepartment Electrocardiogram (EKG/ECG) In terpretation and Imaging Interpretation-OH MA-AD-1085Effective Date: 01/01/2023 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.II. Imaging InterpretationA. CareSource considers EKG interpretation medically necessary when imaging interpretation are completed in the Emergency Department (P lace of service (POS) 23). B. CareSource will reimburse the first imaging interpretation claim that is received for the member on the date of service. 1. If another claim for the same imaging interpretation is received for reimbursement, CareSource will on ly reimburse the first claim received for the same member on the same date of service. 2. Care Source will not reimburse for duplicate claims, for the same service on the same date of service for the same member, without the appropriate modifier. C. If a second imaging interpretation is medically necessary, on the same date of service, before the member is discharged, modifier 76 or modifier 77 must be appended to the second imaging interpretation for reimbursement. III. CareSource expects providers to wo rk with other departments, within their organization, to determine which department will submit the claim to prevent duplicate claim submissions. E. Conditions of Coverage CareSource expects provider to use appropriate standard billing guidelines. Modifiers and Place of service codes are listed below only as a reference. Modifier Description 26 Professional Component 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional Place of Service Description 23 Emergency Room-Hospital – a portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. F. Related Poli cies/Rules NA G. Review/Revision History DATES ACTIONDate Issued 03/31/2021 New policyDate Revised 09/14/2022 No changes. Date Effective 01/01/2023 Date Archived EmergencyDepartment Electrocardiogram (EKG/ECG) In terpretation and Imaging Interpretation-OH MA-AD-1085Effective Date: 01/01/2023 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.H. ReferencesNA

Program Integrity Provider Prepayment Review

Pain Management Providers

MEDICAL POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Pain Management Providers-OH MA-AD-1104 10/01/2022 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized uti lization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy 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, dysfunctio n 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or pay ment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Ev idence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. 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 Pain ManagementProviders-OH MA-AD-1104Effective Dat e: 10/01/2022 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMED ICAL Policy Statement Policy and is approved.A. SubjectPain Management Providers B. Background Practitioners who have obtained additional education/certification to practice in the field of pain medicine are able to help members manage and treat their pain . C. Definitions American Board of Medical Specialties (ABMS) An organization of medical specialty boards with shared goals and standards related to the certification of medical specialists. Certification includes initial specialty and subspecialty certification, as well as maintenance of certification throughout the physicians career. American Board of Pain Medicine (ABPM) An organization that administers a psychometrically developed and practice-related examination in the field of Pain Medicine to qualified candidate s. Physicians who have successfully completed the ABPM credentialing process and examination will be issued certificates as specialists in the field of Pain Medicine and designated as Diplomates of the American Board of Pain Medicine. American Osteopathic Association (AOA) An organization of osteopathic specialty boards with shared goals and standards related to the certification of osteopathic specialties. Certification includes primary certification, certification of special or added qualifications and osteopathic continuous certification. Pain Management The medical discipline concerned with the diagnosis and treatment of the entire range of painful disorders. D. Policy I. All the following criteria must be met for physicians to achieve successful credentialing as pain management specialists: A. Successful completion of residency in a pertinent residency program , such as: Neurology; Neurosurgery; Physical Medicine and Rehabilitation; Anesthesiology; and B. Board certification in one of the above specialti es, as recognized by ABMS, AOA, or ABPM; and C. Successful completion of fellowship training in pain medicine or anesthesiology certification in pain management; and D. Additional board certification in Pain Management by one of the following pathways is preferr ed: 1. American Board of Anesthesiology, subspecialty in Pain Medicine ; 2. American Board of Physical Medicine and Rehabilitation, subspecialty in Pain Medicine ; 3. American Board of Psychiatry and Neurology, subspecialty in Pain Medicine ; Pain ManagementProviders-OH MA-AD-1104Effective Dat e: 10/01/2022 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMED ICAL Policy Statement Policy and is approved.4. American Osteopathic Boar d of Anesthesiology, certification of added qualifications in Pain Management ; 5. American Osteopathic Board of Neuromusculoskeletal Medicine, certification of added qualifications in Pain Management ; 6. American Osteopathic Board of Physical Medicine and Rehabi litation, certification of added qualifications in Pain Management ; 7. American Board of Pain Medicine (not an ABMS or AOA specialty). II. Physicians board certified in one of the above specialties, but without additional pain management fellowship training or certification (anesthesia route) will not be credentialed in pain management. III. Primary care physicians and specialists other than those listed above will not be credentialed as pain management physicians. Those physicians who receive additional training in pain management and intend to do a non-interventional pain management practice will not be credentialed or listed as pain management physicians but will be privileged to do pain management as part of their general medical practice depending on current level of training and experience. IV. All physicians who do not meet requirements IA-IC will be reviewed at credentialingcommittee for further consideration.E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATES ACTIONDate Issued 05/12/2021 New policyDate Revised 05/25/2022 Annual Review: updated policy to match internal criteria Date Effective 10/01/2022 Date Archived H. References 1. American Board of Medical Specialties. (2022). ABMS Guide to Medical Specialties 2022. Chicago IL. Retrieved May 4, 2022 from www.abms.org . 2. Specialties and Subspecialties. (2021). American Osteopathic Association Board Certification. Retrieved April 23, 20 21 from www.certification.osteopathic.org . 3. Certification and American Board of Pain Medicine MOC Examinations. (2022). American Board of Pain Medicine. Retrieved May 5, 2022 from www.abpm.org .

Molecular Diagnostic Testing

ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Molecular Diagnostic Testin g-OH MA-AD-1194 10/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy 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 diseas e, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. 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 Molecular Diagnostic Testing-OHMA-AD-1194Effective Dat e: 10/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectMolecular Diagnostics Testing B. Background Molecular diagnostic testing (MDT) , following a diagnosis or suspected diagnosis, can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes polymerase chain reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example 0.1 mg of DNA from a single cell, to achieve DNA analysis in a sh orter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. All facilities in the United States that perform laboratory te sting on human specimens forhealth assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the U.S. Food and Drug Admi nistration (FDA ) for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have low risk for erroneous results, this does not mean that waived tests are completely error-proof. Car eSource may periodically require review of a providers office testing policies and procedures when performing CLIA – waived tests. C. Definitions Polymerase Chain Reaction (PCR) – A laboratory method used to look for certain changes in a gene or chromosome, which may help find and diagnose a genetic condition or a disease. It may also be used to look at pieces of the DNA of certain bacteria, viruses, or other microorganisms to help diagnose an infection. D. PolicyI. CareSource considers conventio nal testing, such as rapid antigen direct tests, direct fluorescent antibody testing and cultures, as lower cost and should be utilized before the higher cost molecular diagnostic testing by PCR. II. Providers should utilize the conventional testing firs t.A. If conventional testing is:1. Positive no further testing is medical ly necessary. 2. Negative the members presenting symptoms support the diagnosis, then MDT by PCR testing is medically necessary to confirm diagnosis. Examples of relevant diagnoses are, but not limited to, gastroenteritis, streptococcal pharyngitis, acute hepatitis, Shi gellosis. B. Exception to the above are diagnosis of diseases complicating pregnancy. III. CareSource may request documentation to support medical necessity . Molecular Diagnostic Testing-OHMA-AD-1194Effective Dat e: 10/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.E. Conditions of CoverageNA F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 05/25/2022 New policyDate Revised Date Effective 10/01/2022 Date Archived H. References 1. National Cancer Institute at the National Institutes of Health (n.d.). Polymerase chain reaction. Retrieved on 05/03/2022 from www.cancer.gov.

Medical Record Documentation Standards for Practitioners

ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Medical Record Documentation Standards for Practitioners-OH MA-AD-0761 10/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan c ontract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagn osis 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 ………………………………………………………………………………………… 6 F. Related Policies/Rules ………………………………………………………………………………………….. 6 G. Review/Revision History ……………………………………………………………………………………….. 6 H. References …………………………………………………………………………………………………………. 6 Medical Record Documentation Standards for Practitioners-OH MA-AD-0761 Effective Date: 10/01/2022 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.A. Subject Medical Record Documentation Standards for Practitioners B. Background Medical record documentation is a fundamental element required to support medical necessity and is the foundation for coding and billing. Documentation relays important information, such as, but not limited to, assessments completed, services provided, coordination of services, timeliness of care, plan of treatment, rationale for orders, health risk factors, member s progress, and response to treatment. C. Definitions A Valid Signature for Services Provided or Ordered-o May be handwritten or electronic ; CMS permits stamped signatures if you have a physical disability and can prove to a CMS contractor you are not able to sign due to that disability ; and o Is legible or can be validated by comparing to a signature log or attestation statement . Certificate of Medical Necessity (CMN) – A written statement by a practitioner attesting that a particular item or service is medically necessary for an individual . D. Policy I. Medical documentation A. General requirements 1. Each member has thei r own medical record . 2. Entries are legible . 3. Each page of the record includes the members name and date of service. 4. Entries include: a. Date of service; and b. Signature, date, and credentials of practitioner . 5. Documentation indicates that the services(s) billed we re the services provided. a. If CPT is based on a timed service, the total number of timed minutes and/or start and stop time with CPT codes/type of treatment is documented. b. If CPT is based on a group of members, the following is included: 01. Documentation to support that the member was present at each session. If member is not present for the duration of the visit, document start and stop time for the member. 02. Relationships/credentials of individuals present at each session. 03. Number of participants in group therapy/treatment . c. CPT/ modifiers /p lace of service codes are appropriate for service and provider . d. Note reflect s the location of service. Medical Record Documentation Standards for Practitioners-OH MA-AD-0761 Effective Date: 10/01/2022 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.6. Documentation reflect s medical necessity for payment of services provided and utilization of resources as it relates t o the service provided and the needs/desires of the member. 7. Documentation includes a problem list that includes significant illness or medical and behavioral conditions found in history or previous encounters. 8. When making changes in paper medical record: a. Change is clearly visible; b. White out is not utilized; and c. A single line is through an entry labeled with error, initialed, and dated. 9. When making changes in electronic medical records: a. Amendment, correction or delayed entry is identified; and b. A rel iable way to identify the original content, the modified content, and the date and person modifying the record is provided. 10. When documentation is over multiple pages: a. Additional pages from a continuation of a note are clearly identified; and b. Continuous pages contain: 01. Member name ; 02. Date of service; and 03. Page number . 11. Content of documentation show s the specific needs of the member for each encounter. Duplication of another note is not acceptable. B. Evaluation and management documentation 1. Per CPT guidelines, documentation support s the specific requirements based on the level of visit billed. 2. History documentation includes: a. Chief complaint , reason for the visit; b. History of present illness (HPI); c. Medical history; d. Review of systems (ROS) to identify signs and/or symptoms; and e. Past family and social history (PFSH) . 3. Examination documentation includes: a. Constitutional includ ing vital signs and general appearance; and b. Up to 11 organ systems/body areas depending upon the level of the examination performed and coded. 4. Complexity documentation includes: a. Diagnoses and treatment options ; b. Any labs, radiology or other diagnostic tests ordered/results reviewed; c. Any counseling/coordination of care, which can include time spent face to face; and d. Assessment and medical plan of care details. C. Consents 1. Are maintained in the medical record. a. Consent includes: 01. Consent to treatment, refusal to consent, or withdrawal of consent; and/or 02. Authorization for release of information; and Medical Record Documentation Standards for Practitioners-OH MA-AD-0761 Effective Date: 10/01/2022 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.03. Signature and date. D. Referral Documentation 1. Supports rationale for referral that includes who and what specialty member is referred to ; and 2. Demonstrates evidence of : a. Coordination of referrals to specialty practitioners ; and b. Physician review of or documentation of collaboration notes . E. Laboratory Testing Documentation (i.e., labs, x-rays, biopsies) : 1. Documentation s upports rationale for test ; 2. An order for the test is pre sent ; 3. How test results will guide treatment plan is evident; 4. Evidence of physician review of results ; and 5. Evidence of a ppropriate timely f ollow up on test results with member . F. Preventative Care Documentation-when appropriate 1. Records include: a. An age-appropriate immunization record; b. Evidence that preventative screenings/services are offered; c. Risk assessments are completed as appropriate (i.e. , substance use, suicide , depression) ; and d. Cr isis/safety plan as appropriate . II. Durable Medical Equipment Prosthetics Orthotics and Supplies Documentation Requirements A. Detailed Written Order and Documentation includes: 1. The members name; 2. Item of DME ordered ( i.e. written description, HCPCS Code, brand name, model #) ; 3. Prescribing practitioners National Provider Identifier (NPI) ; 4. Signature of the ordering practitioner ; 5. Date of the order ; 6. If order is for a supply: a. Frequency of use. b. Quantity to be dispensed; 7. Duration of use ; 8. Certificate of Medical Necessity (CMN) if required. a. If a CMN is not required, a prescription with diagnoses is included; 9. Information that demonstrates that the item is medically necessary ; 10. Any changes in the members treatment plan or needs ; and 11. Proof of delivery (see II. D.). B. Refill Documentation 1. Documentation of a request for refill must be either a written document received from the member or a contemporaneous written record of a phone conversation/contact between the supplier and the member. 2. The refill request must occur and be documented before shipment. 3. A retrospective attestation statement by the supplier or member is not sufficient. Medical Record Documentation Standards for Practitioners-OH MA-AD-0761 Effective Date: 10/01/2022 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.4. The refill record must include: a. Members name or authorized representative, if different from the member; b. A description of each item that is being requested; and c. Date of the refill request. d. For consumable supplies i.e., those that are used up (e.g., ostomy or urological supplies, surgical dressings, etc.) the supplier must assess the quantity of each item that the member still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date. C. Verbal Orders 1. When services are provided on the basis of a physicians verbal orders, a nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services must document the orders in the patients clinical record, and sign, date, and time the orders. 2. Verbal orders must be followed up with written orders. 3. Suppliers must maintain the written physicians order to support medical necessity in the event of a post-payment review, D. Proof of Delivery 1. Proof of Delivery includes the following: a. Member s name ; b. Delivery a ddress; c. Item of DME ordered (i.e. , written description, HCPCS Code, brand name, model #) ; d. Quantities delivered; e. Date delivered; f. Member or designee receipt signature with date; and date of s ignature; g. Relationship of anyone signing the delivery ticket as a designee of the patient ; h. There is a specific statement for the patient to initial stating that they attest that they are satisfied with the way the orthotic or prosthesis device(s) fit and that they were trained on the proper us age and care of the device(s) ; and i. Signature of the supplier and date the item was provided to the member . 2. If shipped using a third-party, shipping tracking slip or returned postage-paid delivery invoice is acceptable. 3. CareSource is able to determine from the delivery documentation that the supplier properly coded the item(s) , that the item(s) delivered are the same item(s), submitted to for reimbursement, and that the items are intended for and received by a specific member. E . Custom item documentation includes: 1. Evidence that the item was uniquely constructed or substantially modified for a specific mem ber; 2. Description and orders of a physician; and 3. Evidence that item is so different from another item for the same purpose that the two items cannot be grouped together for pricing purposes. Medical Record Documentation Standards for Practitioners-OH MA-AD-0761 Effective Date: 10/01/2022 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.III. Falsified Documentation A. Providers are reminded that deliberate falsification of medical records is a felony offense and is viewed seriously when encountered. Examples of falsifying records include: 1. Creation of new records when records are requested; 2. Back-dating entries; 3. Post-date d entries; 4. Writing over, or 5. Adding to existing documentation (except where described in amendments, late entries, or corrections). B. Corrections to the medical record legally amended prior to claims submission and/or medical review will be considered in determining the validity of services billed. If these changes appear in the record following payment determination based on medical review, only the original record will be reviewed in determining payment of services billed. C. Appeal of claims denied on the basis of an incomplete record may result in a reversal of the original denial if the information supplied includes pages or components that were part of the original medical record but were not submitted on the initial review.E. Conditions of Coverage N/A F. Related Policies/Rules Behavioral Health Record Documentation Standards for Practitioners G. Review/Revision History DATES ACTIONDate Issued 03/04/2020Date Revised 04/14/2021 04/13/2022 05/24/2022 Removed BH Documentation . Updated references. No changes; Updated references Per SIU added Refill Documentation and Verbal Orders to section II. Date Effective 10/01/2022 Date Archived H. References 1. Centers for Medicare & Medicaid Services. (1997). Documentation Guidelines for Evaluation and Management Services. Retrieved March 18, 2022 from www.cms.gov. 2. Centers for Medicare & Medicaid Services. (2020, July 15). Documentation Matters Toolkit . Retriev ed March 18, 2022 from www.cms.gov. 3. Centers for Medicare & Medicaid Services. (2015, December). Electronic Health Records Provider. Retrieved March 18, 2022 from www.cms.gov . Medical Record Documentation Standards for Practitioners-OH MA-AD-0761 Effective Date: 10/01/2022 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.4. Centers for Medicare & Medicaid Services. (2012, December 7). Pub 10-08 Medicare Program Integrity Transmittal 442. Retrieved March 18, 2022 from www.cms.gov. 5. Centers for Medicare & Medicaid Services. (2017, August). Evaluation and Management Services. Medicare Learning Network ICN 006764. Retrieved March 18, 2022 from www.cms.gov. 6. Centers for Medicare & Medicaid Services. (2018, May). Complying with Medicare Signature Requirements Medicare Learning Network ICN 905364. Retrieved March 18, 2022 from www.cms.gov. 7. Centers for Medicare & Medicaid Services. (2020, April 6). Local Determination Article: Standard Documentation Requirement for All Claims Submitted to DME MACs (A55426). Retrieved March 18, 2022 from www.cms.gov . 8. United States Code of Regulations. (2019, November 8). 410.38 Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions. Retrieved March 18, 2022 from www. ecfr.gov. 9. United States Code of Regulations. (1993, June 30). 414.224 Customized items . Retrieved March 18, 2022 from www. ecfr.gov.

Claims Editing and Review

ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Claims Editing and Review-OH MA-AD-1184 09/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology asses sment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosi s 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, dysfunctio n of a body organ or part, or significant pain and discomfort. These services mee t 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 Evidence of Cove rage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please r efer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Cove rage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavio ral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. …………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………….. ……… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. ………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ………………… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………………. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………………. 4 H. References ………………………….. ………………………….. ………………………….. ………………………….. ………. 4 Claims Editing and Review-OH MA-AD-1184 Effective Dat e: 09/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectClaims Editing and Review B. BackgroundAll health care providers are expected to utilize the same standard coding sets and rules to codify the services provided during encounters with patients. This codification is used to bill insurance carriers for reimbursement, known as a claim. In the codification process, there are rules that must be followed to appropriately codify the encounter into a claim, which is then sent to the insurance carrier for reimbursement. All claims submitted to CareSource for reimbursement consideration are subject to claims editing. This ensures that appropriate coding sets are used and rules are appliedin billing by the provider. This also ensures the appropriate reimbursement is made to the provider for the services rendered. This policy is to outline the source of edits and rules used by CareS ource, but not limited to.C. Definitions NA D. Policy I. To ensure appropriate and timely reimbursement for services rendered to enrollees, CareSource utilizes automated claims editing to enforce appropriate coding and billing practices by providers when submitting claims. A. Appropriate coding and billing of claims allows for the accurate adjudication and reimbursement for services rendered to a CareSource enrollee. B. All claims submitted to CareSource are subject to this editing. II. CareSource mode ls edits and rules on:A. Industry standard coding rules, manuals, guidelines, directives, and relevant state and federal regulations for claims editing. B. Resources used to source these coding and billing standards include, but are not limited to, the following list: 1. X12 or ASC X12 – The Accredited Standards Committee (ASC) X12 – claim submission rules and edits applied to inbound electronic claims – www.x12.org. 2. WEDI SNIP or SNIP – Workgroups for Electronic Data Interchange Strategic National Implementation Process claim submission rules and edits applied to inbound electronic claims related to HIPAA compliant file exchanges. 3. Current Procedural Terminology (CPT) Manual from AMA (American Medical Association). 4. HCPCS – Healthca re Common procedure Coding System Level II coding guidelines. 5. UB Editor – Manual from the American Hospital Association (AHA) Coding directives. Claims Editing and Review-OH MA-AD-1184 Effective Dat e: 09/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.6. ICD-10-CM manual.7. Center for Medicare and Medica id (CMS) rules and notifications: a. CMS Billing r ules and instructions (www.cms.gov). b. Medicare NCCI Instructions/ Manual. c. Medicaid NCCI Instructions/ Manual. d. NCD & LCD Bulletins. e. National Physician Fee Schedule (NPFS) instructions. 8. Food and Drug Administration (FDA) guidelines (www.fda.gov). 9. Center of Disease Control (CDC) guidelines (www.cdc.gov). 10. U.S. Preventive Services Task Force (www.uspreventiveservicestaskforce.org). 11. State Agencies (as appropriate for enrollees coverage) a. Ohio Department of Medicaid (medicaid.ohio.gov). b. Ohio Department of Insurance (insurance.ohio.gov). c. Georgia Department of Community Health (dch.georgia.gov). d. Georgia Office of Insur ance and Safety (oci.georgia.gov ). e. Indiana Department of Insurance (in.gov/idoi). f. Kentucky Department of Insurance (insurance.ky.gov). g. West Virginia Offices of the Insurance Commissioner (wvinsurance.gov). h. Arkansas Department of Human Services (humanservices.arkansas.gov). 12. State and National recognized Medical Association and Specialty Experts including, but not limited to: a. American College of Radiology. b. American Academy of Pediatrics. c. Ohio State Chiropractic Association. d. American College of Obstetricians and Gynecologists. 13. CareSources Website (www.caresource.com) a. Policies. b. Provider Manuals. c. Provider Notifications. III. CareSource strives to keep our editing current with all changes as they occur; as such, edits may be added, modified, or removed based on changes, clarifications and new directives received from these resources and any other resources that may be come appli cable. IV . CareSource sends providers the outcomes of the edits through the standard Explanation of Payment (EOP) process. Providers EOPs indicate the failures by the use of industry standard CARC and RARC coding system. The provider can obtain additional details information via CareSources Provider Portal(www.caresource.com) and reviewing the Provider Manual on-line, as well.V. Providers may file a dispute and provide additional information to support the providers position for reconsideration of reimburseme nt. Instruction to file a disputerelated to a denial or reject of a claim can be found at our websiteClaims Editing and Review-OH MA-AD-1184 Effective Dat e: 09/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.(www.caresource.com), please refer to the Provider Manual, under Claim Dispute Process.E. Conditions of Coverage NA F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 04/27/2022 New policyDate Revised Date Effective 09/01/2022 Date Archived H. References NA

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