ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Behavioral Health Service Record Documentation Standards OH MA-AD-1082 09/01/2022 Policy Type ADMINISTRATIVE Administrative Pol icy 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 publ ished 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 pat ient 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 low est 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 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 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 les s 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 ………………………………………………………………………………………… 9 F. Related Policies/Rules ………………………………………………………………………………………….. 9 G. Review/Revision History ……………………………………………………………………………………….. 9 H. References …………………………………………………………………………………………………………. 9 Behavioral Health Service Record Documentation Standards OH MA-AD-1082 Effective Date: 09/01/2022 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 Behavioral Health Service Documentation Standards 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 care/ treatment, rationale for orders, health risk factors, member s progress towards goals of the treatment plan, and response to treatment. C. Definitions Beh avioral Health-Behavioral Health is used as an umbrella term that includes mental health & substance use disorder conditions and developmental disabilities/delays, such as Autism. General Supervision-The supervisor must be available by telephone to provide assistance and direction if needed. Direct Supervision-The supervisor must be immediately available and interruptible to provide assistance and direction throughout the performance of the procedure; however, he or she does not need to be presen t in the room when the procedure is performed. 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. D. Policy I. General Service Documentation Standards A. General Requirements 1. Each member must have thei r own medical record. 2. Documentation must be legible. 3. Each page of the record must include the members name , and date of service . 4. Multiple pages must be numbered. 5. Documentation must include: a. Diagnosis b. Signature, date, and credentials of practitioner . 6. Documentation must indicate that the services(s) billed we re the services provided. a. If service is based on a timed service, the total number of timed minutes and/or start and stop time with service codes/type of treatment is documented. b. If service is based on a group of members, the following is included: Behavioral Health Service Record Documentation Standards OH MA-AD-1082 Effective Date: 09/01/2022 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.01. Documentation to support that the member was present at each session. If member is not present for the duration of the session , document start and stop time for the member. 02. Relationships/ names/credentials of other professionals present at each session. 03. Number of participants in group therapy/treatment . c. Service Code/Modifiers codes are appropriate for service and provider . d. Documentation must reflect the location of service using the appropriate Place of Service Code and/or, if rendered via tele-health, the location of the member and the location of the provider, as well as the modality of tele-health used to render the service. 7. Content of documentation must indicate the specific needs, intervention, and progress toward the goals of the treatment plan for each service rendered. Duplication of notes is not acceptable documentation practice. 8. Documentation must reflect medical necessity for payment of services provided and the specific needs/desires of the me mber that are reflected in the treatment plan . 9. Changes to documentation a. Electronic Medical Record Changes 01. Amendment, correction, or delayed entry is identified; and 02. A reliable way to identify the original content, the modified content, and the date and person modifying the record is provided. b. Paper Medical Record changes: 01. Change is clearly visible; 02. White out is not utilized; and 03. A single line is through an entry labeled with error, initialed, and dated. B. 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 03. Signature and date. C. Referral Documentation 1. Supports rationale for referral that includes who and what speci alty 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 . D. Laboratory Testing Documentation: 1. Documentation s upports rationale for test ; 2. An order for the test is present ; 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 . E. Preventative Care Documentation include the following when appropriate: Behavioral Health Service Record Documentation Standards OH MA-AD-1082 Effective Date: 09/01/2022 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.1. Evidence that preventative screenings/services w ere discussed, or referr al placed; 2. Risk assessments are completed (i.e. , substance use, suicide, depression); and 3. Cr isis/safety plan . II. Service Specific Documentation Expectations A. Diagnostic assessment documentation must include the following: 1. Presenting problem and/or history of present illness a. Current symptoms b. Changes in functional impairment or symptoms c. Onset of symptoms d. Circumstances leading to evaluation; 2. Evaluation of comorbid physical health concerns/needs; 3. Strengths-based assessment of member , where applicable; 4. Identification of natural, community, and professional supports , where applicable; 5. Evaluation of social dete rminant of health concerns/needs, where applicable; 6. Substance use history; 7. Past psychiatric /behavioral health treatment , including past psychiatric medications ; 8. Medical history; 9. Past Family and social history (PFSH); 10. Review of organ systems/body areas depending upon the level of the examination performed and coded, where applicable; 11. Current physical and behavioral health medications, including changes and prn medication utilization; 12. Allergies; 13. Standardized assessment tools/diagnosti c testing, results, and interpretation (i.e. , Clinical Institute Withdrawal Assessment or Alcohol (CIWA), Clinical Opioid Withdrawal Scale (COWS), Autism Diagnostic Observation Schedule (ADOS), Patient Health Questionnaire (PHQ), Columbia Suicide Severity Rating Scale (CSSRS) or Vanderbilt Diagnostic Rating Scales), if pertinent 14. Psychiatric assessment and mental status exam that includes , but is not limited to, the following: a. Description of patients judgment and insight; b. Assessment of mental status including orientation to time, place, and person; recent and remote memory; and mood and affect (i.e. , depression, anxiety, agitation). c. Constitutional including vital signs and general appearance; d. Attitudes and behavior described; e. Estimated intellectual and mem ory functioning and orientation; and 15. Summary, diagnosis, and plan. NOTE: Significant or abnormal findings need to be described in a narrative format. Behavioral Health Service Record Documentation Standards OH MA-AD-1082 Effective Date: 09/01/2022 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.B. Treatment plan documentation must include all of the following: 1. Type amount, frequency, and duration of any and all needed/known treatment services; 2. Provider of any and all needed/known treatment services; 3. Goals for any and all needed/known treatment services. Goals must be a. Mutually agreed upon; b. Age-appropriate; c. Quantifiable with target dates; d. Measurable with criteria for continued stay; e. Directly related to the admission reason if applicable; and f. Relevant to the diagnostic assessment, testing, and/or screening; 4. Interventions to be used ; 5. Frequency of review of the treatment plan. Frequency of review must be appropriate for the identified needs of the member and progress towards the associated goals; 6. Documentation that the treatment plan has been reviewed with the patient and, as appropriate, with family members, parents, legal guardians, custodians, or significant others. NOTE: If the member is unable or refuses to participate in the treatment planning or services, document reason given. 7. Estimated length of stay and/or course of treatment for any and/all treatments ;8. Criteria for discharge from treatment and completion of the treatment plan; 9. Applied Behavior Analysis (ABA) treatment plans must : a. Show a clear connection between the results of the behavioral assessment to the member specific goals. The goals must focus on identified areas of specific behaviors or targeted deficits. The goals must include baseline data, measurement, and mastery criteria to addres s the core deficits of Autism Spectrum Disorder (ASD); and b. Be based on members other daily activities. C. Inpatient/Outpatient psychiatric progress note includes the following, as applicable: 1. Per service code guidelines, documentation supports the specific r equirements based on the level of service billed. 2. Daily psychiatric inpatient progress note includes the following as applicable: a. Summary of what has occurred since previous day and current symptoms; b. Review of response to medications/side effects and prn utilization c. Mental Status Exam, include, but is not limited to: 01. Description of patients judgment and insight ; 02. Assessment of mental status including orientation to time, place, and person; recent and remote memory; and mood and affect (i.e. depression, anxiety, agitation); 03. Constitutional including vital signs and general appearance; Behavioral Health Service Record Documentation Standards OH MA-AD-1082 Effective Date: 09/01/2022 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.04. Attitudes and behavior described; 05. Estimated intellectual and memory functioning and orientation. d. Rationale for changes in medications or other interventions is clearly documented e. Reason for continued stay 3. Outpatient psychiatric progress note includes: a. Symptoms since last visit and current symptoms b. Changes in Family, social or medical history c. Mental Status Exam, includes, but is not limited to: 01. Description of pati ents judgment and insight; 02. Assessment of mental status including orientation to time, place, and person; recent and remote memory; and mood and affect (i.e. , depression, anxiety, agitation); 03. Constitutional including vital signs and general appearance; 04. Attitudes and behavior described; 05. Estimated intellectual and memory functioning and orientation; d. Rationale for changes in medications or other interventions is clearly documented. 4. Interactive Complexity documentation must include: a. Evidence of c ommunication factors that complicate the delivery of a behavioral health service during the delivery of the service. This may include: 01. The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care; 02. Caregiver emotions or behaviors that interfere with implementation of the treatment plan; 03. Evidence or disclosure of a sentinel event and mandated report to a third pa rty (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants; 04. Use of play equipment, physical devices, interpreter, or translator to overcome barriers to diagnostic or therapeutic interaction with a patient who is not fluent in the same language or who has not developed or lost expressive or receptive language skills to use or understand typical language. This does not include billing solely for the purpose of translation or interpretation services. b. Evidence of interactions with others or interventions to overcome communication factors that complicate the delivery of a behavioral service during the delivery of the services. This may include: 01. Interactions with individuals legally responsible for the care of a member, such as minors or adults with guardians; 02. Interactions with others involved with the care of a member during the service, such as adults accompanied by one or more participati ng family members or interpreter or language translator. This does not Behavioral Health Service Record Documentation Standards OH MA-AD-1082 Effective Date: 09/01/2022 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.include billing solely for the purpose of translation or interpretation services; 03. Interactions other third parties, such as child welfare agencies, parole or probation officers, or schools. D. Discharge plan documentation must include the following: 1. A discharge planning evaluation including, but not limited to assessment of the following: a. Treatment regimen was established; services including addressing rehabilitation needs; b. Connections were made with appropriate outpatient behavioral health resources, including community behavioral health resources; c. Scheduled follow-up appointments within 7-calendar days of discharge, and/or coordinating transportation to follow-up appointments ; d. Medication reconciliation occurred and prescriptions related to treatment regimen were available at discharge and /or e. Two weeks worth of medication was provided to the member at the time of discharge and/or f. Transportation to the pharmacy was scheduled; g. Availability of appropriate services which would include services such as medical, meals, and household services; h. Need for and feasibility of specialized medical equipment, or permanent physical modifications to the home; i. Capacity for self-care, or al ternatively to be cared for by others j. Criticality of the appropriate services; k. Readmission risk score or severity score; and l. Members access to appropriate services. 2. A provider should review of social determinants of health (SDoH) when determining if m ember is ready for discharge including, but not limited to: a. Cognitive status; b. Activity level and functional status; c. Current home and suitability for members condition (i.e. drug free environment); d. Availability of appropriate family or community suppor t; e. Ability to obtain medications and services; f. Ability to meet nutritional needs ; g. Potential barriers to care, such as homelessness and telephone availability; h. Availa bility of transportation for follow up care; and i. Availability of community services. 3. Documentation should support the following discharge standards: a. A discharge plan that includes the provider(s) responsible for follow up care (The discharge planning evaluation should be used as a guide in the development of the discharge plan); b. All necessary medical and behavioral health information pertinent to illness and treatment, post-discharge goals of care was provided to the appropriate post-acute care service providers at the time of discharge; Behavioral Health Service Record Documentation Standards OH MA-AD-1082 Effective Date: 09/01/2022 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.c. Coordination and/or referrals with the CareSource case manager, community agencies, and providers responsible for follow up care; d. Completion of medication reconciliation/management; e. Needed DME and supplies are in place prior to discharge; f. Scheduled appointments are listed with dates, times, names, telephone numbers and addresses ( m ental health practitioner follow-up is recommended within 7 days of dis charge for members with a mental illness) ; g. Crisis plan and notation that copy was provided to caregiver; and h. Member/guardian and family engagement as needed. III. Supervision Documentation Expectations A. General supervision documentation must include: 1. Dates o f supervision; 2. Start and end times; 3. Member identifying information; 4. Purpose of supervision; 5. Outcome of supervision, including any modification to treatment interventions and/or treatment plan; 6. Name/credentials of the supervisor and, if documenting for billing purposes, the National Provider Identifier number of the supervisor; 7. Type of supervision: general or direct; 8. Validation that supervision was rendered within the scope of the license/certification of the supervisor/supervisee; 9. Date and signature of supervisor/supervisee, including credentials B. ABA Supervision documentation must include: 1. Dates of supervision visit; 2. Start and end times of visit; 3. Names of individuals present at each session. If individual is not present for the duration of the visit, document start and stop time for that individual; 4. Relationships/credentials of individuals present at each session; 5. Review of services provided (number and type); 6. Review of data that will form the basis of a continued treatment plan; 7. Review of progress; 8. Results of monitoring tools to note progress; 9. Changes to treatment plan; 10. Collaboration of care among providers; and 11. Date, signature, and credentials of treating provider. IV. 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-dated entries; Behavioral Health Service Record Documentation Standards OH MA-AD-1082 Effective Date: 09/01/2022 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. Wri ting 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 NA F. Related Policies/Rules Medical Record Documentation Standards for Practitioners G. Review/Revision History DATES ACTIONDate Issued 4/28/2021 New PolicyDate Revised 05/01/2022 Removed Covid 19 red bo x; updated references Date Effective 09/01/2022 Date Archived H. References 1. Alper, E, OMalley, T, & Greenwald, J. (2020, July 16). Hospital discharge and readmission. Retrieved April 11, 2022 from www.uptodate.com . 2. American Psychiatric Association. Clinical Documentation. Retrieved April 11, 2022 from /www.psychiatry.org. 3. Bajorek, S. & McElroy, V. (2020, March 25). Patient Safety Primer. Discharge Planning and Transitions of Care. Retrieved April 11, 2022 from www.psnet.ahrq.gov. 4. The Behavior Analyst Certification Board. (2020, November). RBT Supervision and Supervisor Requirements. Registered Behavior Technician Handbook. Retrieved April 11, 2022 from www.bacb.com. 5. Centers for Medicare & Medicaid Services. (1997). Documentation Guidelines for Evaluation and Management Services. Retrieved April 11, 2022 from www.cms.gov. 6. Centers for Medicare & Medicaid Services. (2015, December). Electronic Health Records Provider. Retrieved April 11, 2022 from www.cms.gov. Behavioral Health Service Record Documentation Standards OH MA-AD-1082 Effective Date: 09/01/2022 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.7. Centers for Medic are & Medicaid Services. (2012, December 7). Pub 10-08 Medicare Program Integrity Transmittal 442. Retrieved April 11, 2022 from www.cms.gov. 8. Centers for Medicare & Medicaid Services. (2017, August). Evaluation and Management Services. Medicare Learning Ne twork ICN 006764. Retrieved April 11, 2022 from www.cms.gov. 9. Centers for Medicare & Medicaid Services. (2018, May). Complying with Medicare Signature Requirements Medicare Learning Network ICN 905364. Retrieved April 11, 2022 from www.cms.gov. 10. Centers for Medicare & Medicaid Services. (2020, April 6). Local Determination Article: Standard Documentation Requirement for All Claims Submitted to DME MACs (A55426). Retrieved April 11, 2022 from www.cms.gov. 11. Centers for Medicare & Medicaid Services. (2020 June 15 ). Medicaid Documentation for Behavioral Health Practitioners. Retrieved April 11, 2022 from www.cms.gov. 12. Center for Medicare & Medicaid Services. MLN Matters Number: MM3389. (2004, July 30). Retrieved April 11, 2022 from www.cms.gov. 13. Centers or Medicare & Medicaid Services. (2013, May 17). Revision to State Operations Manual (SOM), Hospital Appendix A Interpretive Guidelines for 42 CFR 482.43, Discharge Planning. Retrieved April 11, 2022 from www.cms.gov. 14. Centers for Medicare & Medicaid Services. (2020, January). Medical Mental Health. Retrieved April 11, 2022 from www.cms.gov. 15. The Council of Autism Service Providers. (2020). Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers. Retr ieved April 11, 2022 from www.casproviders.org 16. Medicaid. (n.d.) Follow-Up After Hospitalization for Mental Illness: Ages 18 and Older. Retrieved April 11, 2022 from www.medicaid.gov. 17. National Quality Forum. (2010 update). Safe Practices for Better Healthcare 2010 update Consensus Report. Retrieved April 11, 2022 from www.qualityforum.org. 18. National Transitions of Care Coalition. (n.d.). The NTOCC 7-Essential Elements. Retrieved April 11, 2022 from www.ntocc.org . 19. United States Code of Regulations. (2019, November 8). 410.38 Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions. Retrieved April 11, 2022 from www.ecfr.gov. 20. United States Code of Regulations. (1993, June 30). 414.224 Customized items. Retriev ed April 11, 2022 from www.ecfr.gov. 21. Patient Safety Network. (2019, September 7). Patient Safety Primer. Readmissions and Adverse Events After Discharge. Retrieved April 11, 2022 from www.psnet.ahrq.gov. 22. U.S. Code of Federal Regulation. (2019, September 30). 482.43 Condition of participation: Discharge planning. Retrieved April 11, 2022 from www.govregs.com .
ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Medical Necessity Determinations – OH MA – AD-0009 08/01/2022 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 industr y standards, and published MCO clinical policy guidelines. Medically necessary se rvices 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 m orbidity, 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 co nvenience 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. Administrativ e 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 Polic y 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. Accord ing 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 condi tions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ……. 5 H. References ………………………….. ………………………….. ………………………….. ……………………… 5 Medical NecessityDeterminations – OH MA – AD-0009Effective Dat e:08/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectMedical Necessity Determinations B. BackgroundThe term medical necessity has been used by health plans and providers to define benefit coverage. Medical necessity definitions vary among entities, including the Centers for Medica id and Medicare Services (CMS), the American Medical Association (AMA) and most healthcare insurance providers, but definitions most often incorporate the idea that healthcare services must be reasonable and necessary or appropriate, given a patients condition and the current standards of clinical practice. For all payors and insurance plans, even if a service is reasonable and necessary, coverage may be limited if the service is provided more frequently than allowed under a national coverage policy, a local medical policy, or a clinically accepted standard ofpractice.ICD-10-CM codes should support medical necessity for any services reported. Diagnosiscodes identify the medical necessity of services provided by describing the circumstances of the patients condition. To better support medical necessity for services reported, providers should apply universally accepted healthcare principles that are documented in the patients medical record, including diagnoses, coding with the highest level of spe cificity, specific descriptions of the patients condition, illness, or disease and identification of emergent, acute and chronic conditions. CareSource will determine medical necessity for a requested service, procedure, or product based on the hierarchy within this policy.C. Definitions Local Coverage Determination (LCD) – A determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether a particular item or service is covered on an intermediary or carrier wide basis under such parts. MCG Health – Developed care guidelines that are in strict accordance with the principles of evidence-based medicine and evidence-based best practices that direct informed care. Medically Necessary – Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or symptoms and meet accepted standards of medicine. Mental Health Parity and Addictions Equity Act (MHPAEA) A 2008 federal law that generally prevents group health plans and health insurance issuers that provide mental health and substance use disorder (MH/SUD) benefits from imposing less favorable benefi t limitations on those benefits than on medical/surgical coverage. National Co verage Determination (NCD) – A determination by the Secretary with respect to whether a particular item , service , or technology is covered nationally under this title, but does n ot include a determination of what code, if any, is assigned to a particular item or service covered under this title or a determination with respect to the amount of payment made for a particular item or service so covered. Medical NecessityDeterminations – OH MA – AD-0009Effective Dat e:08/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.D. PolicyI. 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 t he limitations that apply to medical conditions as covered under this policy. The reviewer will determine medi cal necessity based on the following hierarchy: A. Benefit contract language . B. Federal regulation or state regulation , including state waiver regulations when applicable. 1. CareSource makes coverage determinations in accordance with criteria defined by applicable state and federal guidelines. Specifically, CareSource complies with all current CMS payment policies and nation al coverage determinations (NCDs). 2. In the absence of an NCD, CareSource utilizes criteria outlined by applicable local coverage determinations (LCDs) under the direction of the local Medicare Administrative Contractor (MAC). When services are covered by LCDs from more than one MAC , outlining differing medical review policies NCD/LCD(CMS.gov)CareSource Medicare Advanta ge Policy MCG HealthIf no NCD/LCDMedical Review If no MCG HealthIf no CareSource MA Policy CareSource Medical Necessity Criteria Medicare Advantage Medical NecessityDeterminations – OH MA – AD-0009Effective Dat e:08/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.and/or criteria, CareSource will apply the LCD of the MAC with jurisdiction over the State where the member resides.C. CareSource medical policy statements. D. Nationally accepted evidence-based clinical guideline , such as MCG Health. E. Professional judgment of the medical or behavioral health reviewer based on the following potential resources , which may include but are not limited to the following : 1. Clinical practice guidelines published by consortiums of medical organizations and generally accepted as industry standard. 2. Evidence from two (2) published studies from major scientific or medical peer-reviewed journals that are less than five (5) years old preferred and less than ten ( 10 ) years required to support the proposed use for the specific medical condition as safe and effective. 3. National panels and consortiums such as NIH (National Institutes of Health), CDC (Centers for Disease C ontrol and Prevention), AHRQ (Agency for Healthcare Research and Quality), NCCN (National Comprehensive Cancer Network), Substance Abuse and Mental Health Services Administration (SAMHSA). Studies must be approved by a United States (US) institutional revi ew board (IRB) accredited by the Association for the Accreditation of Human Research Protection Programs, Inc. (AAHRPP) to protect vulnerable minors. 4. Commercial External Review Organizations (CERO), such as Up-to-Da te and Hayes, Inc. 5. Consultation from a like-specialty peer. 6. Specialty and sub-specialty societies listed below . This is not an all-inclusive list: Sub-specialty Specialty SocietyAddiction Medicine American Society of Addiction Medicine Cardiology American College of Cardiology Clinical Cardiac Electrophysiology Heart Rhythm Society Critical Care Medicine Society of Critical Care Medicine Endocrinology, Diabetes and Metabolism American Academy of Clinical Endocrinologists Endocrine Society Gastroenterology American Gastroenterological Association American College of Gastroenterology Geriatric Medicine American Geriatrics Society Gynecology American Congress of Obstetric ians and Gynecologists Society of Gynecologic Oncologists Gynecologic Oncology Society of Gynecologic Oncologists Hematology American Society of Hematology Hospice and Palliative Medicine American Academy of Hospice and Palliative Medicine Infectious Disease Infectious Disease Society of America Internal Medicine UpToDate Nephrology American Society of Nephrology Oncology American Society of Clinical Oncology Pediatrics American Academy of Pediatrics Psychiatry American Psychiatric Association American Academy of Child & Adolescent Psychiatry Medical NecessityDeterminations – OH MA – AD-0009Effective Dat e:08/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.Pulmonary Disease American College of Chest PhysiciansRheumatology American College of Rheumatology Sleep Medicine American Academy of Sleep Medicine Surgery of the Hand American Society for Surgery of the Hand E. Conditions of Coverage Coverage determinations for CareSource Medicare Advantage members are made in accordance with the applicable Centers for Medicare and Medicaid Services (CMS) payment policies, National and Local Coverage Determinations, Medicare Evidence of Coverage, and S ummary of Benefits documents. These documents and the other policies described herein are utilized to determine on a case-by-case basis limitations, exclusions and/or covered benefits of health services for our members. The fact that a physician has perfor med or prescribed a procedure or treatment, or that it may be the only available treatment for an injury, sickness, or behavioral health disorder, or that the physician has determined that a particular health care service is medically necessary or medically appropriate does not mean that the procedure or treatment is a covered service under the plan and does not guarantee claims payment. F. Related Policies/RulesNA G. Review/Revision HistoryDATES ACTIONDate Issued 10/20/2015Date Revised 12/11/2019 04/01/202001/25/202103/07/2022 Added rule, changed title, changed definitions, removed hyperlinks, removed graph, updated external review organizations and age restrictions. Added ASAM Added waiver regulation Annual review. Date Effective 08/01/202 2 Date Archived H. References 1. American Association of Professional Coders . What is Medical Necessity and Why Does It Matter? (2019, April 5). Retrieved March 4, 2022 from www.aapc.com. 2. American Medical Association. Definition of Medical Necessity. (n.d.) Retrieved March 4, 2022 from www.ama.com. 3. Social Security Administration. (2014, April 1). Determinations; Appeals Sec. 1869. [42 U.S.C. 1395ff] (a) Initial Determinations. Retrieved March, 7, 2022 from www.ssa.gov . 4. U.S. Centers for Medicare & Medicaid Services. (n.d.). Glossary. Retrieved March 7, 2022 from www.medicare.gov .
ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Experimental and Investigational Item or Service – OH MA – AD-0710 08/01/2022 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 authoriza tion 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 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 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 Cov erage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 4 Experimental and Investigational Item or Service-OH MA-AD-0710 Effective Date: 08/01/2022 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 Experimental or Investigational Item or Service B. Background Experimental or i nvestigational items or services are not covered. This p olicy defines the medical review decision process around such treatment requests. CareSource members have the right to refuse or participate in experimental or investigational i tems or services . C. Definitions Experimental or Investigational Items or Services-Medical, surgical, diagnostic, psychiatric, substance use disorders treatment or other health care services, technologies, equipment, supplies, treatments, procedures, therapies, biologics, drugs, or devices (each a Health Care Item or Ser vice) that, at the time CareSource has made a determination regarding coverage in a particular case, are: o Not approved by the United States Food and Drug Administration (FDA) to be lawfully marketed for the proposed use , o Not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use, o Determined by the FDA to be contraindicated for the specific use, o Subject to review and approval by any institutional review board or other body serving a similar function for the proposed use, and such final approval has not been granted, o The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight , o Provided as part of a clinical research protocol o r clinical trial or is provided in any other manner that is intended to evaluate the safety, toxicity, or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply , or o Provided pursuant to informed consent documents that describe the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply as experimental or investigational , or otherwise indicate that the safety, toxicity, or efficacy of the drug, biologic, device , diagnostic, product, equipment, procedure, treatment, service, or supply is under evaluation. Devices that are FDA approved under the Humanitarian Use Device exemption are not considered to be e xperimental or investigational. D. Policy I. Any Health Care item or service that CareSource determines in its sole discretion to be experimental or i nvestigational is not covered by CareSource. II. Any health care item or service not deemed experimental or investigational based on the criteria in Section C. may still be deemed experimental or investigational if it is not supported by credible research that soundly demonstrates that such item or service will have a measur able and beneficial health outcome . In determining whether such health care item or service is experimental or investigational, Experimental and Investigational Item or Service-OH MA-AD-0710 Effective Date: 08/01/2022 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.CareSource, i n its sole discretion, will consider the information and evidence from one or more of the sources in Section III below and assess whether: A. The scientific evidence is conclusory concerning the effect of the health care item or s ervice on health outcom es, B. The evidence demonstrates the health care item or s ervice improves net health outcomes of the total population for whom the item or s ervice might be proposed by producing beneficial effects that outweigh any harmful effects , C. The evidence demonstrates the health care item or s ervice has been shown to be as beneficial for the total population for whom the service might be proposed as any established alternatives , and D. The evidence demonstrates the health care item or s ervice has been shown to improve the net health outcomes of the total population for whom the service might be proposed under the usual conditions of medical practice outside clinical investigatory settings. III. When reviewing requests, CareSource will consider in formation and evidence from th e following non-exhaustive list: A. Published authoritative, peer-reviewed medical or scientific litera ture, or the absence thereof , B. Evaluations of national medical associations, consensus panels, and other technology evaluation bodies , C. Documents issued by and/or filed with the FDA or other federal, state or local agency with the authority to approve, regulate, or investigate the use of the drug, biologic, device, diagnostic, product, equipment, procedure, t reatment, service, or supply , D. Documents of an institutional review board or other similar body performing substantially the same function, E. Consent document(s) and/or the written protocol(s) used by p roviders studying substantially the same drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply , F. Medical records, or G. The opinions of consulting p roviders and other experts in the field. E. Conditions of Coverage NA F. Related Policies/Rules Medical Necessity Determinations policy G. Review/Revision History DATES ACTIONDate Issued 05/29/2019Date Revised 07/10/2019 10/14/2020 03/03/2021Changed title (used to be experimental or investigational technologies), updated entire policy Updated D. III Removed D. V. Updated definition, removed duplication, updated with Health Care Item or Service language, updated II.Experimental and Investigational Item or Service-OH MA-AD-0710 Effective Date: 08/01/2022 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.03/30/2022No changes; updated ref erences.Date Effective 08/01/2022 Date Archived H. References 1. Department of Health and Human Services Centers for Medicare & Medicaid Services. (2015, January 1). Medicare Coverage of Items and Services in Category A and BInvestigational Device Exemption (IDE) Studies MLN Matters MM8921. Retrieved March 4, 2022 from www.cms.gov . 2. ECFR. (n.d.). E-CFR Title 21 Part 312.21 Phases of an investigation. Retrieved March 4, 2022 from www.ecfr.gov . 3 . ECFR. (2019, June 21). E-CFR Title 21 Part 812 Investigational Device Exemptions. Retrieved March 4, 2022 from www.ecfr.gov . 4 . ECFR. (2019, June 21). E-CFR Title 21 Part 814 Premarket Approval of Medical Devices . Retrieved March 4, 2022 from www.ecfr.gov . 5 . ECFR. (2019, June 21). E-CFR Title 21 Part 600 Biological Products. Retrieved March 4, 2022 from www.ecfr.gov . 6 . ECFR. (2019, June 21). E-CFR Title 42 Part 405 Subpart BMedical Services Coverage Decisions That Relate to Health Care Technology Authority . Retrieved March 4, 2022 from www.ecfr.gov . 7. ECFR. (n.d.) 42 CFR Part 456 Utilization Control. Retrieved March 4, 2022 from www.ecfr.gov . 8. ECFR. (2019, April 16). 42 CFR 43 8.210 Coverage and authorization of services. Retrieved March 4, 2022 from www.ecfr.gov . The Administrative Polic y St ate ment d etai le d a bo ve h as r ecei ved due c on sidera tio n a s d efin ed i n the AdministrativeP olic y Sta tem ent Po lic y a nd i s a pp ro ved.
ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Against Medical Advice (AMA) – OH MA – AD-0806 08/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, n ationally 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 su pplies 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, o r 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 n ec-essary services also i nclude those services defined in any Evidence of Coverage documents, Medical Policy Statements, Pro-vider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ens ure an authorization or payment of ser-vices. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Ad-ministrative Policy Statement. If there is a conflict between the Administrative Policy St atement and the plan contract (i.e., Evi-dence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the det er-mination. 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 ContentsTable of Contents ………………………….. ………………………….. ………………………….. ………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. … 2 B. Background ………………………….. ………………………….. ………………………….. ………………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………… 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ………. 2 F.Related Policies/Rules ………………………….. ………………………….. ………………………….. ………… 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. ……… 3 H. References ………………………….. ………………………….. ………………………….. ……………………….. 3 Against MedicalAdvice (AMA) – OH MA – AD-0806Effective Dat e: 08/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectAgainst Medical Advice (AMA) B. Background Studies show that patients who are discharged against medical advice ( AMA ) are at higher risk for inadequately treated medical conditions, readmissions , and negative health outcomes when compared to planned discharge s. Documented r easons for leaving AMA may include lack of satisfaction with the treatment team or treatment team members, lack of satisfaction with the facility, general mistrust of medical sy stems , and a lack of health insurance and low socio-economic status. Research also indicates that previous medical diagnoses substantially impact rates of discharge against medical advice with psychiatric, substance abuse and human immunodeficiency virus p atients showing the most significant risk. Other factors for discharge AMA include being away from home or children or an underutilization of social support . C. Definitions Against Medical Advice (AMA) – A member chooses to leave the hospital or acute care setting before a practitioner writes the order for discharge. D. PolicyI. CareSource will only pay for services, procedures, and supplies rendered. II. The discharge status code on the submitted claim must indicate that the member left against medical advice. III. If a member leaves against medical advice in the emergency room and the facility has submitted a prior authorization for inpatient services, only the emergency room will be con sidered for payment. IV. Claims are subject to retrospective review , and CareSource reserves the right to adjust reimbursement in accordance with the policies above. E. Conditions of Coverage Member must be eligible at the time the service, procedure or supply wa s provided , and the s ervice, procedure, or supply must be a covered benefit. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable . Medical necessity reviews do not guaran tee reimbursement. All services, procedures, and supplies are subject to review for medical necessity. F. Related Policies/Rules NA Against MedicalAdvice (AMA) – OH MA – AD-0806Effective Dat e: 08/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.G. Review/Revision HistoryDATES ACTIONDate Issued 02/05/2020Date Revised 12/16/2020 02/09/2022 Annual review.Date Effective 08/01/2022Date Archived H. References 1. Albayati A, Douedi S, Alshami A, et al. Why Do Patients Leave against Medical Advice? Reasons, Consequences, Prevention, and Interventions. Healthcare (Basel) . 2021;9(2):111. Published 2021 Jan 21. doi:10.3390/healthcare9020111 . 2. Alper E, OMalley T, & Greenwald, J. (2021, September 30). Hospital Discharge and Readmission . Retrieved February 4, 2022 from www.uptodate.com . 3. Hasan O, Samad MA, Khan H, et al. Leaving Against Medical Advice from In – patients Departments Rate, Reasons and Predicting Risk Factors for Re-visiting Hospital Retrospective Cohort from a Tertiary Care Hospital. Int JHealth Policy Manag . 2019;8(8):474-479. Published 2019 Aug 1. doi:10.15171/ijhpm.2019.26 Retrieved February 4, 2022 from www.ncbi.nlm.nih.gov. 4. Khali li M, Teimouri A, Shahramian I, Sargolzaei N, YazTappeh JS, Farzanehfar M. Discharge against medical advice in paediatric patients. JTaibah Univ Med Sci . 2019;14(3):262-267. Published 2019 Apr 5. doi:10.1016/j.jtumed. 2019.03.001 Retrieved February 4, 202 2 from www.ncbi.nlm.nih.gov.
ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Provider Home Visits-OH MA-AD-1166 07/01/2022 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 dia gnosis 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 service s 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. Ple ase 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 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 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 me dical 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 Provider HomeVisits-OH MA-AD-1166Effective Date: 07/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectProvider Home Visits B. Background Provider home visits are medical care visits rendered in the home setting to an individual for the examination, diagnosis, and/or treatment of an injury or illness. For the purposes of this policy, home is defined as the individual’s place of residence, in cluding, private residence/domicile, assisted living facility, group homes, custodial care facility, long-term care facility, or skilled nursing facility. C. Definitions Home An individual’s place of residence, including, private residence/domicile, assiste d living facility, group homes, custodial care facility, long-term care facility, or skilled nursing facility. Participating Provider A provider that is contracted with CareSource to service our members. Place of Service (POS) A two-digit code that ind icates the setting in which a service was provided. Provider A physician with an MD or DO, a podiatrist, a nurse practitioner, or a physician assistant. Non-Participating Provider A provider that is not contracted with CareSource to service our members . Services Services that occur in the members place of residence that normally would be performed in an office/outpatient setting, such as, evaluation and management (E&M) visits, wound care, podiatry care, eye care, etc. D. Policy I. CareSource reimburses p articipating or non-participating providers for services performed in a members place of residence that usually can be performed at an office visit. A. CareSource will reimburse providers according to the Medica re fee schedule. B. Durable medical equipment (DME) services in the place of residence are subject to medical necessity review and should be provided by in network (participating) provider. C. Ancillary services such as labs and x-ray services in the place of residence are subject t o medical necessity review and should be provided by in network (participating) provider. II. Claim submission must include the appropriate Current Procedural Terminology (CPT) codes along with any applicable modifier with the appropriate place of service (POS) code.A. Place of service (POS) for provider services in the members place of residen ce should include one of the following: 1. POS 12 Home Provider HomeVisits-OH MA-AD-1166Effective Date: 07/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2. POS 13 Assisted Living3. POS 14 Group Home 4. POS 31 Skilled Nursing Facility (SNF) 5. POS 32 Long-term Facility 6. POS 33 Custodial Care/Rest Home III. CareSource reimburses for services that occur in the members place of residence that normally would be performed in an office/outpatient setting, such as, E&M visits, wound care, podiatry care, eye care, etc.A. CareSource members do not need to be confined to their place of residence to receive services, provided by a provider. B. The CareSource members medical record must document the medical necessity of the visit made in place of residence. C. A visi t cannot be billed by a provider unless the provider was actually present in the beneficiarys place of residence. IV. Services that are performed in the members place of residence may be subject to review. CareSource may request documentation of servic es performed. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. If medical necessity is not confirmed based on the documentation submitted, recoupment may occur. E. Conditions of CoverageN/A F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 01/01/2019 New policyDate Revised 8/19/2020 02/16/2022Removed modifier list . Updated references.Removed codes and references . Converted from PY – 0444 to AD-1166. Change d physician to provider to more inclusive. Approved at PGC. Date Effective 07/01/2022 Date Archived H. References NA
ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Policy Development Process – OH MA – AD-0901 06/01/2022 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 utilizati on 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 nec essary 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 discomf ort. 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 paymen t 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 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 Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 PolicyDevelopment Process – OH MA – AD-0901Effective Dat e: 06/ 01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved. A. SubjectPolicy Development Process B. Background CareSource utilizes a systematic way to develop policies through a standard operating procedure that improves efficiency, increases productivity and quality, and provides consistent policy products to stakeholders and others . This process starts with the identification of a policy need , including policy intent and triage, and then , tho rough research and collaboration leads CareSource to determine best practice for members. According to the tenets 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 or more restrictive than the limitations that apply to medical condi tions as covered by CareSource policies . C. Definitions Administrative Policies Policies written to provide guidance to providers on administration of behavioral or physical health benefits. AllMed A vendor with independent, external review specialists, who complete impartial medical reviews prior to final medical policy approval and implementation. Business Owner An individual who identifies a gap in information or benefits and recommends or requests that a topic be researched for possible creation or clarification of medical necessity criteria, reimbursement information or adm inistrative conditions to assist in providing consistent and quality services to CareSource members. The business owner supports the development of a policy. Clinical Policy Governance Committee (CPGC) The official governing body , comprised of medical an d behavioral health subject matter experts, among others, charged with the approval of new or revised clinical policies relating to medical necessity determinations. The CPGC is responsible for determining whether the proposed clinical policy is clearly de fined, clinically evidenced-based, assures a high level of member safety and quality of care, and articulates a business value. Medical/Clinical Policies Policies written with medical criteria , including current evidence-based research, best practice, studies, etc. , which will determine what the member must meet for the provider to deliver a service. PolicyTech Policy and procedure lifecycle management software for policy development and rev ision d esigned to centralize, build, and simplify policy and procedure workflows . Users have tools , such as workflow automation, document creation and review, remote access, versioning, audit-ready reporting, and employee assessments . Reimbursement Policy – Addresses a topic in what must be met from a provider regarding billing/claims criteria to receive reimbursement for services provided. Subject Matter Experts (SME) A person who is an authority on a particular topic or subject matter. PolicyDevelopment Process – OH MA – AD-0901Effective Dat e: 06/ 01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved. D. PolicyI. Pre-Policy Development A. The business owner enters a policy intake into PolicyTech to start the policy development or revision process. 1. To determine the intent, need, and priority of the request, c ollaboration occurs between the policy writer, business owner, member benefits coder, member benefits analyst, configuration, and an appropriate business owner such as a subject matter expert (SME), and/or medical director. 2. If it is determined that there is a need for a policy, a. Col laboration occurs between a multidisciplinary team to review codes and configuration, if applicable. b. Management will then determine if c odes need sent to analytics to provide the policy team with additional data , such as financial data, claims and/or usage of benefits by members. II. Policy DevelopmentA. The policy writer researches the topic to develop a draft of the policy . This includes, but is not limited to , the following resources : 1. State/federal regulations 2. State contracts 3. Milliman Care Guidelines (MCG) Health 4. Hayes 5. UpToDate 6. Policy Reporter 7. Provider and member materials 8. Professional society recommendations 9. Standard of care guidelines 10. Published studies 11. Feedback from external sources 12. Subject matter experts (i.e. medical and/ or behavioral) 13. EncoderPro B. After the policy is approved in the PolicyTech system on several levels by subject matter experts, management, writers, applicable departments and others, a final policy revision is review ed and approved by the following:1. Benefits, Coding and Support, 2. Configuration, 3. Independent, external medical review specialists, when applicable, 4. CPGC, and 5. State approval, if applicable. III. Post Policy DevelopmentProviders and members of the health partner community are notified of changes per CareSource marketing process. A standard operating procedure guides a standardized , consistent process that allows for adequate notice of new criteria or revisions as outlined by state or company req uirements.
ADMINISTRATIVE POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Court Mandated Health Services OH MA AD – 0799 03/01/2022 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 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 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. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 2 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 2 Co urt Man d atedHealth Services OH MA AD-0799Effective Dat e: 03/01/2022 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. SubjectCourt Mandated Health Services B. Background Court mandated health services are treatments ordered as a result of criminal, civil or custodial judicial proceedings. There services may include withdrawal management, medication assisted treatment , community based services, behavioral health inpatient or outpatient treatment , medica l inpatient or outpatient treatment and /or other treatment related to one s overall health. C. Def initions Court Mandated Health Services Court order issued upon the decision of a judge or the result of a judicial proceeding f or health-related services. D. Policy I. Court mandated health services are subject to all existing CareSource policies and procedures including medical necessity determination and prior authorization as necessary. II. If court ordered health services are determined to not m eet medical necessity criteria, the member will be ref erred to care management to ensure access to the proper treatment and services and assist in coordination of necessary care. E. Conditions of Coverage F. Related Policies/Rules G. Review/Revision History DATES ACTIONDate Issued 02/19/2020 New PolicyDate Revised 11/10/2021 Reviewed, no changes Date Effective 12/25/20/30 Date Archived H. Ref erences 1. N/A
ADMINISTRATIVE POLICY STATEMENTOHIO MEDICARE ADVANTAGE Policy Name Policy Number Date Effective Readmission AD-09 73 12/01/202 1 Policy Type Medical ADMINISTRATIVE Pharmacy Reimbursement Administrative Policy Statement s 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 t he patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Me mber Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment ofservices. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the serv ice(s) referenced in theAdministrative 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 . 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 C ontentsAdministrative Policy Statement ………………………….. ………………………….. ………………………….. . 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 7 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 ReadmissionOHIO MEDICARE ADVANTAGEAD-09 73 Effective Date: 12/01/2021 2 A. SubjectReadmission B. Background Within 3 weeks of discharge, approximately 20% of patients have adverse events. Many of these events that occurred are preventable. Among the preventable events are adverse drug events, hospital-acquired infections, and procedural complications. Systematic problems during the transition of care between inpatient and outpatient providers is often the basis for adverse events to occur after discharge. Patients, families, and caregivers may not be adequately equipped after being discharged from the hospital. They may not have the proper resources or equipment,may not understand the medications changes, may go through a post-hospitalization syndrome making the patient vulnerable to falls or infections, or may be responsible to follow up on pending test result s or on scheduling additional outpatient testing/appointments. Up to 50% of people are instructed to schedule an appointment after discharge; and due to the lack of understanding of the reasons or where to call, they do not schedule the appointment. Pert inent information from the hospital may not have been provided to the patients nextprovider(s) in a timely manner. This delay in transfer of patient information leaves the next provider not knowing information such as what conditions still need addressed ,changes in medications, which tests were completed while in the hospital, and which test results were pending at the time of discharge. Around 40% of patients were discharged with test results pending. The discharge plan/instructions may not have been patient specific as to their literacylevel, social determinants, learning style, or current health status. Deficiencies in communication or understanding related to the discharge plan, can lead to confusion, non-adherence , and adverse events.The purpos e of this policy is to improve the quality of acute care and transitional carethat is being rendered to the members of CareSource. This includes but is not limited to the following: 1. improve communication between the patient, caregivers and clinicians, 2. provide the patient with the education needed to maintain their care at home to prevent a readmission, 3. perform pre discharge assessment to ensure patient is ready to be discharged, and 4. provide effective post discharge coordination of care. dischar ged, and 4. provide effective post discharge coordination of care.C. Definitions Readmission Admissions to an acute, general, short-term hospital occurring less than 31 calendar days from the date of discharge from the same or another acute, general, short-term hospital. Neither the day of discharge nor the day of admission are counted when determining whether a readmission has occurred. ReadmissionOHIO MEDICARE ADVANTAGEAD-09 73 Effective Date: 12/01/2021 3 Planned Readmission A non-acute admission for a scheduled procedure for limited types of care to include: obstetri cal delivery, transplant surgery and maintenance chemotherapy/radiotherapy/immunotherapy. Potentially Preventable Readmission (PPR) A readmission within a specific time frame that is clinically related and may have been prevented had appropriate care and/or transitional follow-up care been provided during the initial hospital stay and discharge process. A PPR is determined when, base d on CareSource guidelines, it is determined that the patient was discharged prematurely or had ineffective transitional care. Premature Discharge Occurs when a member is discharged even though they should have remained in the hospital for further testi ng or treatment or was not medically stable at the time of discharge. A member is not medically stable when the member’s condition is such that it is medically unsound to discharge or transfer the patient. Evidence such as elevated temperature, postoperati ve wound draining or bleeding, or abnormal laboratory studies on the day of discharge indicate that a member may have been prematurely discharged from the hospital. Symptoms that had onset or were present during a previous admission and subsequently worsen ed, leading to a readmission, are a possible indicator of a premature discharge. Discharge prior to establishing the safety or efficacy of a new treatment regimen is also considered a premature discharge. Same or Similar Condition A condition or diagnos is that is the same or a similar condition as the diagnosis or condition that is documented on the initial admission. Same Day CareSource delineates same day as midnight to midnight of a single day. Ineffective Discharge Planning Readmissions will be reviewed for adequacy of follow-up care and outpatient management using accepted practice guidelines and treatment protocols. Documentation should support that reasonable attempts by the hospital were taken to address placement and a ccess-to-treatment difficulties, including but not limited to, collaboration with social services and connecting member to community resources. Examples of ineffective discharge planning include, but are not limited to, inadequate medication management, la ck of communication with providers delivering the follow-up care, inadequate outpatient follow up or treatment, failure to address rehabilitation needs such as inability to provide self-care, and failed discharge/transfer to another facility such as lack o f orders or medication reconciliation. Appropriate Post-discharge Site of Care Determinants of appropriate site include, but are not limited to, assessment of the medical, functional, and social aspects of a members illness. D. Policy I. This administra tive policy defines the payment rules for hospitals and acute care facilities that are reimbursed for inpatient or observational services for the following categories: A. Same day readmission or observational stay for a related condition . B. Same day readm ission or observational stay for an unrelated condition . C. Planned readmissions and/or leave of absence . D. Unplanned admissions to an acute, general, short-term hospital occurring less than 31 calendar days from the date of discharge from the same or an other acute, general, short-term hospital . ReadmissionOHIO MEDICARE ADVANTAGEAD-09 73 Effective Date: 12/01/2021 4 II. An administrative review of all readmissions will take place based on the following Medicare readmission review criteria:A. Same day readmission or observational stay for a related condition criteria: 1. CareSource will conduct an administrative review to ensure that billing guidelines were followed based on Chapter 3, Section 40.2.5 (Repeat Admissions) in the Medicare Claims Processing Manual which requires that the acute, general, short-term hospital combine the two admissions on one claim. 2. If the member is readmitted during the same day as the initial admission for the same or a related condition and both the initial and the subsequent admission are billed separately, CareSource will deny the claim as separate DRGs. The facility must submit the i nitial admission and the subsequent admission on one claim to receive reimbursement. B. Same day readmission or observational stay for an unrelated condition criteria: 1. CareSource will conduct an administrative review to ensure that billing guidelines were followed based on Chapter 3, Section 40.2.5 (Repeat Admissions) in the Medicare Claims Processing Manual which requires that the acute, general, short-term hospital to bill the claims separately but the claim that contains an admission date that is th e same as the discharge date must include condition code B4 as indicated in the Medicare billing guidelines. C. Planned readmission and/or leave of absence criteria: 1. When a readmission to the same acute care facility or hospital is expected and the member does not require a hospital level of care during the timeframe between the two admissions, the member may be placed on leave of absence by the provider. a. CareSourc e follows the Medicare Inpatient Hospital Services billing guidelines found in the Medicare Claims Processing Manual, Chapter 3 for leave of absence billing guidelines which requires that the facility submit one claim and receive one combined DRG payment f or both admissions. b. Examples of a planned readmission include, but are not limited to, situations where surgery could not be scheduled immediately due to scheduling availability, a specific surgical team that is needed for the procedure is not availabl e, bilateral staged surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin at the time of initial admission. c. CareSource reserves the right to request medical records to determine if the claim was prope rly billed. d. Leave of absence does not apply to cancer chemotherapy or similar repetitive treatments. D. Unplanned readmission criteria: 1. CareSource will review the clinical documentation on all readmissions to determine if the second admission was a potentially preventable readmission (PPR) based on the following guidelines: a. The readmission is due to a premature discharge of patient. b. Based on medically appropriate professionally recognized standard of health care, the member could have recei ved the care from the readmission during the first admission. ReadmissionOHIO MEDICARE ADVANTAGEAD-09 73 Effective Date: 12/01/2021 5 c. The readmission is due to ineffective discharge planning.01. The following should be completed prior to discharge: (1). A discharge planning evaluation including, but not limited to assessment of the following: i. The likelihood of the need for appropriate post-hospital; services including addressing rehabilitation needs; ii. Appropriate arrangements for post-hospital car e; iii. Availability of appropriate services which would include services such as medical, transportation, meals, and household services; iv. Need for and feasibility of specialized medical equipment, or permanent physical modifications to the home; v. Capacity for self-care, or alternatively to be cared for by others vi. Criticality of the appropriate services; vii. Readmission risk score or severity score; and viii. Members access to appropriate services. 02. A provider should take into account a number of factors when determining if member is ready for discharge including, but not limited to: (1). Cognitive status; (2). Activity level and functional status; (3). Current home and suitability for members condition (i.e. stairs); (4). Availabili ty of family or community support; (5). Ability to obtain medications and services; (6). Ability to meet nutritional needs (7). Availability of transportation for follow up care; and (8). Availability of community services. 03. Documentation should su pport the following discharge standards: (1). A discharge plan that includes the provider(s) responsible for follow up care (The discharge planning evaluation should be used as a guide in the development of the discharge plan); (2). All necessary medical information pertinent to illness and treatment, post-discharge goals of care was provided to the appropriate post-acute care service providers at the time of discharge; (3). Coordination and/or referrals with the CareSource case manager, community agencies, and providers responsible for follow up care; (4). Completion of medication reconciliation/management; (5). Needed DME and supplies are in place prior to discharge; (6). Scheduled appointments are listed with dates, times, names, telephone numbers and addresses; and (7). Member/guardian and family engagement as needed. E. Member non-adherence with treatment plan will be considered for payment if all of the following cri teria is adequately documented: 1. Physician orders were appropriately communicated to the member; 2. The member or guardian is mentally competent and capable of following the discharge instructions; 3. The member or guardian made an informed decision not to follow the discharge instructions; and 4. The nonadherence is clearly documented in the medical r ecord. ReadmissionOHIO MEDICARE ADVANTAGEAD-09 73 Effective Date: 12/01/2021 6 NOTE: A readmission may be medically necessary but may also be deemed preventable. F. The following readmission criteria listed below are excluded from this readmission policy and if billed appropriately, claims will be reviewed for payment:1. If the member is being transferred from an out-of-network to an in-network facility or if the member is being transferred to a facility that provides care that was not available at the initial facility; 2. Transfers to distinct psychiatric units within th e same facility. When transferring within the same facility, documentation must show that the diagnosis necessitating the transfer was psychiatric in nature and that the patient received active psychiatric treatment; 3. If the readmission is part of plann ed repetitive treatments or staged treatments, such as chemotherapy or staged surgical procedures; 4. Readmissions where the discharge status of the first discharge was left against medical advice (AMA); 5. Obstetrical readmissions; and 6. Behavioral health readmissions. NOTE: Errors made at the receiving facility unrelated to the orders it received upon transfer (e.g., falls, treatment delivery failure) will not result in a payment denial for the readmission.III. Prior authorization of the initial or subsequent inpatient sta y or admission to observation status is not a guarantee of payment and are subject to administrative review as well as review for medical necessity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without m edical records will automatically deny which will result in a denial of the claim. IV. Post Service Review Process:A. CareSource reserves the right to monitor and review claim submissions to minimize the need for post-service claim adjustments as well as review payments retrospectively. 1. Medical records for both admissions must be included with the claim submission to determine if the admission(s) is appropriate or is considered a readmission. a. Failure for the acute care facility or hospital to pr ovide complete medical records will result in an automatic denial of the claim. b. If the included documentation determines the readmission to be an inappropriate or medically unnecessary, the hospital must be able to provide additional documentation to C areSource upon request or the claim will be denied. c. If the readmission is determined at the time of documentation review to be a preventable readmission, the reimbursement for the readmission will be combined with the initial admission and paid as one claim to cover both, or all, admissions. ReadmissionOHIO MEDICARE ADVANTAGEAD-09 73 Effective Date: 12/01/2021 7 E. Conditions of CoverageNA F. Related Policies/Rules NA G. Review/Revision History DATES ACTIONDate Issued 03/01/2019 New policyDate Revised 11/11/2020 08/04 /2021Changed from PY-0774, Updated background,definitions, D. I and II (added D., E., F. 6.) Changed post payment to post service in D. IV. and D.IV A. Removed peer to peer and appeals language in D. IV. B. Updated references. Approved at PGC. Date Effective 12/01/2021 Date Archived H. References 1. McIlvennan, C. K., Eapen , Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803.McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803. 2. Centers for Medica re & Medicaid Services. (20 20 , August 24). Hospital Readmission Reduction Program. Retrieved July 12, 2021 from www.cms.gov 3. Centers for Medicare & Medicaid Services. (2014, November 10). Quality Improvement Organization Manual Chapter 4 Case Review. Retrieved July 12, 2021 from www.cms.gov 4. Centers for Medicare & Medicaid Services. (202 1, March 31). Medicare Claims Processing Manual Chapter 3 Inpatient Hospital Billing. Retrieved July 12, 2021 from www.cms.gov 5. Alper, E, OMalley, T, & Gree nwald, J. (202 1, Ju ne 10). Hospital discharge and readmission. Retrieved July 12, 2021 from www.uptodate.com 6. National Transitions of Care Coalition. (n.d.). The NTOCC 7-Essential Elements. Retrieved July 12, 2021 from www.ntocc.org 7. U.S. Code of F ederal Regulation. (2019, September 30). 482.43 Condition of participation: Discharge planning. Retrieved July 12, 2021 from www.govregs.com 8. Center for Medicare & Medicaid Services. MLN Matters Number: MM3389. (2004, July 30). Retrieved July 12, 202 1 from www.cms.gov 9. National Quality Forum. (2010 update). Safe Practices for Better Healthcare 2010 update Consensus Report. Retrieved July 12, 2021 from www.qualityforum.org 10. Centers for Medicare & Medicaid Services. (20 20 , February 21). Revision to State Operations Manual (SOM), Hospital Appendix A Interpretive Guidelines for 42 CFR 482.43, Discharge Planning. Retrieved July 12, 202 1 from www.cms.gov ReadmissionOHIO MEDICARE ADVANTAGEAD-09 73 Effective Date: 12/01/2021 8 11. Bajorek , S. & McElroy, V. (2020, March 25). Patient Safety Primer. DischargePlanning and Transitions of Care. Retrieved July 12 , 202 1 from www.psnet.ahrq.gov 12. Patient Safety Network. (2019, September 7). Patient Safety Primer. Readmissions and Adverse Events After Discharge. Retrieved July 12 , 202 1 from www.psnet.ahrq.gov The Administrative Policy Statement detailed abo ve has recei ved due con sideration as defined inthe Administrative Policy Statement Policy and is app roved.
ADMINISTRATIVE POLICY STATEMENTOHIO MEDICARE ADVANTAGE Policy Name Policy Number Date Effective Itemiz ed Bill ing AD-0859 02/01/2021 Policy Type Medical ADMINISTRATIVE Pharmacy Reimbursement Administrative Policy Statement s 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 prol onged, 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 ofservices. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the serv ice(s) referen ced in theAdministrative 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 . 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 C ontentsAdministrative Policy Statement ………………………….. ………………………….. ………………………….. . 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Itemized BillingOHIO M EDICARE ADVANTAGEAD-0859 Effective Date: 02/01/2021 2 A. SubjectItemized Billing B. Background Itemized bill review is the analysis of inpatient facility itemized billing statement against CareSource policies, industry standard guidelines, as well as State and/or Federal billing guidelines. CareSource may request an itemized bill for an inpatient facility claim to verify that billed revenue codes represent charges for appropriately billed it ems, supplies and services. Routine items, supplies, and services are to be included in the primary inpatient room and board charge and are not separately reimbursable. C. Definitions Inpatient Hospital Claim Claims submitted for a member who has been admitted by a physician order to an inpatient hospital bed for purposes of receiving inpatient services Itemized Bill-A comprehensive list of all services and goods provided during the inpatient hospital stay, listing the costs and descriptions associated with the service and/or good. D. Policy I. CareSource follows the CMS Provider Reimbursement Manua l Guidelines, chapter 22 section 2202.6 and 2203. A. Routine services defined by CMS chapter and section above are services included by the provider in a daily servic e charge-sometimes referred to as the room and board charge. B. Routine services are composed of two broad components: (1) general routine service and (2) special care units (SCU), including coronary care units (CCU) and intensive care units (ICU). Included in routine services are the regular room, dietary services, nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not app licable. II. The following supplies, items, and services are typically not separately billable and therefore are not reimbursable from the general room and board charge or primary service charge. This list is examples only and is not an all-inclusive list.A. Supplies and Equipment such as 1. Capital/medical equipment 2. Fluroscope 3. Oximetry 4. Rental equipment 5. Routine supplies 6. Hydration flushes Itemized BillingOHIO M EDICARE ADVANTAGEAD-0859 Effective Date: 02/01/2021 3 B. Implants and SuppliesC. Inpatient Private Duty Nursing III. If upon review of the itemized bill, charges are determined to be in excess of State orFederal reimbursement guidelines or CareSource specific policy reimbursement will be reduced accordingly. IV. Provider exception requests to reimbursement reductions may be requested via standard Provider Appeal process to include supportin g documentation (e.g. medicalrecords or op notes to support requested payment exception).E. Conditions of CoverageF. Related Policies/Rules G. Review/Revision History DATES ACTIONDate Issued 10/14/2020 New PolicyDate Revised Date Effective 02/01/2021 Date Archived H. References 1. CMS Provider Reimbursement Guidelines retrieved September 19, 2020 from www.cms.gov The Administrative Policy Statement detailed abo ve has recei ved due con sideration as defined in the Administrative Policy Statement Policy and is app roved.
Admin istrative Policy StatementOHIO MEDICARE ADVANTAGE Policy Name Policy Number Date Effective Addiction Medicine and Buprenorphine Providers AD-0731 02/01/2021 Policy Type Medical ADMINISTRATIVE Pharmacy Reimbursement Administrative Policy Statement s 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 cl inical 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 a lternative, 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, a nd/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 theAdministrative 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 contr olling 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 limitations that are less fav orable than the limitations that apply to medical conditions as covered under this policy.Table of C ontentsAdministrative Policy Statement ………………………….. ………………………….. ………………………….. . 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Addiction Medicine and Buprenorphine ProvidersOHIO MEDICARE ADVANTAGEAD-0731 Effective Date: 02/01/2021 2 A. SubjectAddiction Medicine and Buprenorphine Providers B. BackgroundPractitioners who have obtained additional education/certification to practice in the field of addiction medicine or to be a buprenorphine provider are able to help members manage their addiction. C. DefinitionsNA D. PolicyI. The following criteria and conditions must be met for prescribers to achieve successful credentialing with the following specialties: A. Addiction Medicine 1. Unrestricted MD or DO license; and a. Holds one of the following: 01. Certification by the American Board of Addiction Medicine; 02. Subspecialty certification in Addiction Medicine by the American Board of Preventive medicine; 03. Subspecialty certification in Addiction Psychiatry by the American Board of Psychiatry and Neurology; 04. Certificate of added qualification in Addiction Medicine from the American Osteopathic Association; or 05. Completion of accredited resid ency/fellowship in Addiction Medicine or Addiction Psychiatry 2. Unrestricted licensed Nurse Practitioner a. Completed Nurse Practitioner Substance Use Disorder Medical Education Project (NP-SUDMedEd) training. B. Buprenorphine provider 1. Unrestricted MD or DO licens e a. Registered with the Drug Enforcement Administration to dispense schedule III, IV, and Vmedications for treatment of pain and have a special identification number for prescribing buprenorphine for opioid dependency treatment; and b. Completed required training for treatment and management of patients with opioid use disorders provided by an organization that Secretary of Health and Human Services deems appropriate i.e. American Society of Addiction Medicine, the American Academy of Ad diction Psychiatry, the American Medical Association, the American Osteopathic Association, the American Psychiatric Association 2. Other Practitioners with an unrestricted license – Nurse Practitioner, Clinical Nurse Specialist, Certified Registered Nurse A nesthetist, Certified Nurse Midwife, or Physician Assistants a. Must be in an office based setting; b. Registered with the Drug Enforcement Administration to dispense schedule III, IV, and Vmedications for treatment of pain and have a Addiction Medicine and Buprenorphine ProvidersOHIO MEDICARE ADVANTAGEAD-0731 Effective Date: 02/01/2021 3 special identification num ber for prescribing buprenorphine for opioid dependency treatment; c. Completed required training for treatment and management of patients with opioid use disorders provided by an organization that the Secretary of Health and Human Services deems appropriate (i.e. The American Society of Addiction Medicine, American Academy of Addiction Psychiatry, American Medical Association, American Osteopathic Association, American Nurses Credentialing Center, American Psychiatric Association, American Association of Nur se Practitioners, American Academy of Physician Assistants); d. Training or experience that demonstrates the ability to treat and manage opioid-dependent members; and e. If applicable, is supervised by or works in collaboration with a qualifying physician as not ed in I.B.1. C. All of the above provider types must comply with current state regulations . E. Conditions of CoverageF. Related Policies/Rules G. Review/Revision History DATES ACTIONDate Issued 01/01/2020Date Revised 09/30/2020 Updated nurse practitioner requirements. Date Effective 02/01/ 2021 Date Archived H. References 1. National Association of State Alcohol and Drug Abuse Directors, Inc. Comprehensive Addiction and Recovery Act of 2016. Retrieved September 22, 2020 from www.nasadad.org 2. Legal Information Institute. 21 US Code 823. Registration requirements. (2018). Retrieved September 22, 2020 from www.law.cornell.edu/ 3. Substance Abuse and Mental Health Services Administration Buprenorphine Waiver Management (2019). Retrieved September 22, 2020 from www.samhsa.gov 4. American Society of Addiction Medicine. Public Policy Statement on How To Identify a Physician Recognized for Expertness in the Diagnosis and Treatment of Addiction and Related Health Conditions (2016). Retrieved September 22, 2020 from www.asam.org The Administrative Policy Statement detailed abo ve has recei ved due con sideration as defined in the Administrative Policy Statement Policy and is app roved.
© Copyright CareSource 2026. All rights reserved.
System Details