Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan 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.ADMINISTRATIVE POLICY STATEMENT Marketplace Policy Name & Number Date Effective Retrospective Authorization Review-MP-AD-1338 02/01/2025-09/30/2025 Policy Type ADMINISTRATIVE This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. State Specific Information ……………………………………………………………………………………….. 3 F. Conditions of Coverage ………………………………………………………………………………………….. 3 G. Related Policies/Rules ……………………………………………………………………………………………. 3 H. Review/Revision History …………………………………………………………………………………………. 3 I. References …………………………………………………………………………………………………………… 3 Retrospective Authorization Review-MP-AD-1338 Effective Date: 02/01/2025 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 2 A. SubjectRetrospective Authorization ReviewB. Background A retrospective review is a request for an initial review for an authorization of care, service, or benefit for which a prior authorization (PA) is required but was not obtained prior to the delivery of the care, service, or benefit. Occasionally, situations arise in which a PA cannot be reasonably obtained prior to care, service, or benefit. In these cases, CareSource will conduct a retrospective review of medical services received by members when the request is received within 30 days of the date of service or discharge. Retrospective reviews are performed by licensed clinicians who are supported by licensed physicians. A decision is rendered within 30 days of receipt of all necessary documentation. In the event of an adverse determination, the provider and/or member are notified of the decision and supporting rationale. C. Definitions Clinical Review Criteria The written screening procedures, decision abstracts, clinical protocols and practice guidelines used by CareSource to determine the medical necessity and appropriateness of health care services. Retrospective Authorization Review The process of reviewing and making a coverage decision for a service or procedure that has already been performed (eg, post service decision). Prior Authorization Utilization review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with CareSources requirement that the health care service or course of treatment, in whole or in part, be approved prior to provision. D. Policy I. CareSource considers retrospective authorization review appropriate when ANY of the following circumstances has occurred: A. A CareSource member is unable to advise the provider of plan enrollment due to a condition that renders the member unresponsive or incapacitated. B. The member is retrospectively enrolled which covers the date of service. C. Urgent service(s) requiring authorization was/were performed, and it would have been to the members detriment to take the time to request authorization. D. The new service was not known to be needed at the time the original prior authorized service was performed. E. The need for the new service was revealed at the time the original authorized service was performed. F. The service was directly related to another service for which prior approval has already been obtained and that has already been performed. Retrospective Authorization Review-MP-AD-1338 Effective Date: 02/01/2025 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 3 II. All retrospective authorization requests must be submitted within 30 calendar days of the date of service or date of discharge or as specified in a provider contract. III. Unless the CareSource member is transitioning and qualifies under the retroactive coverage requirements, retrospective reviews, which are requested greater than 30 days past date of service or date of discharge, will be administratively denied. Administrative denials do not require a review by a CareSource Medical Director. IV. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.E. State Specific InformationNA F. Conditions of Coverage NA G. Related Policies/Rules Medical Necessity Determinations H. Review/Revision History DATE ACTIONDate Issued 06/21/2023 New policy. Approved at Committee.Date Revised 11/06/2024 Periodic review. Updated references. Approved at Committee. Date Effective 02/01/2025 Date Archived 09/30/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy I. References1. CareSource Provider Manual Georgia-Marketplace. CareSource; 2024. Accessed October 21, 2024. www.caresource.com 2. CareSource Provider Manual Indiana, Kentucky, West Virginia-Marketplace. CareSource; 2024. Accessed October 21, 2024. www.caresource.com 3. CareSource Provider Manual Ohio-Marketplace. CareSource; 2024. Accessed October 21, 2024. www.caresource.com
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-MP-AD-1222 11/01/2024 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 s tandards, 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 wit hout which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements 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 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions ………………………………………………………………………………………………………….. 2 D. Policy ………………………………………………………………………………………………………………… 2 E. Conditions of Coverage ………………………………………………………………………………………… 5 F. Related Policies/Rules …………………………………………………………………………………………. 5 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 5 Program Integrity Provider Prepayment Review-MP-AD-1222 Effective Date: 11/01/2024 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. 2A. SubjectProgram Integrity Provider Prepayment Review B. Background CareSource Program Integrity (PI) operates a provider prepayment review program to detect, prevent, and correct fraud, waste, and abuse, and to facilitate accurate claim payments. Physicians and other healthcare professionals may have the right to appeal results of reviews. C. Definitions Provider Prepayment Review Reviews of medical record documentation and comparison billed services. Program Integrity (PI) The proper management and functioning of a health insurance program to ensure that it is providing quality and efficient care while using funds from taxpayer dollars appropriately and with minimal waste. Certified Professional Coder (CPC) The certified professional coder credential is offered through the American Academy of Professional Coders (AAPC). Professional coding is medical coding that is conducted in a professional environment, such as a physician's office, outpatient setting, or hospital. Registered Health Information Administrator (RHIA) A professional who handles patient health information. The RHIA role requires certification and must adhere to standards such as the Health Insurance Portability and Accountability Act and other privacy and security rules. Registered Health Information Technician (RHIT) A certified professional who stores and verifies the accuracy and completeness of electronic health records and analyzes patient data with the goal of controlling healthcare costs and improving patient care. Soft Denial A denial applied to claims which are selected as part of the prepayment review audit . Soft denials do not require an appeal to resolve . Upload records to the CareSource Provider Portal for the denied claim . Soft denials are identified in the remittance advice by RARC code 127 Missing patient medical record for this service.D. Policy I. A provider prepay review involves reviewing medical records compared to services billed prior to claim adjudication. Providers are placed on prepay review to monitor for improper billing of medical claims including but not limited to the following reasons: A. overutilization of services B. billing for items or services not rendered C. selection of wrong CPT/HCPCS code or supplies D. lack of medical necessity E. billing/dispensing unnecessary services F. procedure repetition G. upcoding Program Integrity Provider Prepayment Review-MP-AD-1222 Effective Date: 11/01/2024 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. 3H. billing for services outside of provider specialtyII. Placement on prepayment review will require the provider to submit medical records for all identified claims allowing CareSource to review the medical records in comparison to the billed services. A. Claims selected for prepayment review will be soft denied. B. Provider must upload medical records to the CareSource Provider Portal . It is not necessary to appeal a soft denial. C. Failure to submit medical records to CareSource in accordance with this provision will result in claim remaining denied. D. Failure to meet minimal documentation standards, such as member name and date of service on each page of the medical record, a signed dated order, and a valid provider signature, will result in claim denial. E. Providers must bill timely and accurate claims while under prepayment review. III. CareSource uses widely recognized sources to conduct reviews which includes, but is not limited to, the following: A. Centers for Medicare and Medicaid Services (CMS) guidelines, as stated in Medicare manuals B. Medicare local and national coverage determinations C. CareSource published policies (Administrative, Medical and Reimbursement), code-editing policies and CareSource provider manuals D. National Uniform Billing Guidelines from the National Billing Committee E. American Medical Association Current Procedural Terminology (CPT) guidelines F. Current American Medical Association Healthcare Common Procedure Coding System (HCPCS) Level II G. ICD 10-CM official guidelines for coding and reporting H. American Association of Medical Audit Specialists national healthcare billing audit guidelines I. Industry-standard utilization management criteria and/or care guidelines, such as MCG guidelines (current edition on date of service) J. Food and Drug Administration guidance K. National professional medical societys guidelines and consensus statements L. Publication from specialty societies, such as the American Society for Parenteral and Enteral Nutrition, the Substance Abuse and Mental Health Service Administration, and the American Association of Neuromuscular & Mental Health Services Administration M. Nationally recognized, evidence-based published literature including, but not limited to, sources such as Medscape, the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) IV. The Program Integrity Provider Prepayment Review Team is comprised of clinical review and coding specialists who maintain CPC, RHIA , or RHIT designations. The team reviews provider documentation to determine whether the claim is appropriate for payment Program Integrity Provider Prepayment Review-MP-AD-1222 Effective Date: 11/01/2024 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. 4based on criteria including, but not limited to, provider documentation which establishes the following: A. Services were provided according to CareSource policy requirements. B. Members were benefit eligible on the date the services were provided. C. Prior authorization was obtained, if required by policy. D. Providers and staff were qualified, as required by state or federal law. E. The provider possessed the proper license, certification, or other accreditation requirements specific to the providers scope of practice at the time the service was provided to the member.V. Providers whose claims (or claim lines) are determined not payable via coding review audit after medical records submi ssion may dispute or appeal, whichever is appropriate, within timely filing limitations as outlined in the provider manual. Providers and/or billing managers may reach out directly to the program integrity prepayment review team to discuss specific claim denials. VI. Release from prepayment review includes the following steps : A. CareSource will review provider accuracy monthly to determine if the provider is eligible for release from prepayment review. Eligibility is as follows: 1. The provider has demonstrated a high accuracy rate on claim submissions for 3 consecutive months . 2. The volume of claims submissions remained consistent with the volume before prepayment review. 3. Provider maintains a high rate of records returned after soft denial. B. Once released from prepayment review, the provider/provider group will receive notification in writing as to the effective end date of review . Providers who demonstrate accurate billing practices and have been removed from prepayment review may be subject to future follow up reviews to ensure continued compliance with billing practices. C. If the provider fails to satisfy the requirements above, the following may be necessary: 1. If after 12 months on prepayment review the provider fails to satisfy the requirements under subsection A, CareSource may do the one of following: a. outreach to provider to educate on claim accuracy issues b. require a corrective action plan c. deny payment for services rendered during a specified period of time d. terminate the provider agreement 2. If a provider has been on a prepayment review for 12 months, CareSource may terminate the provider agreement i n the following conditions: a. no billing activity for 6 months b. claim submission volume during review period is not consistent with the volume before prepayment review Program Integrity Provider Prepayment Review-MP-AD-1222 Effective Date: 11/01/2024 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. 5E. Conditions of CoverageN/A F. Related Policies/Rules N/A G. Review/Revision History DATES ACTION Date Issued 01/08/2020 New Policy Date Revised 08/19/2020 07/20/2022 08/02/2023 08/14/2024(E-v oted)Updated Section VII . Editorial updates only. Added definition Soft Denial. Removed 30 day requirements and substitutes all identified claims Removed old section III. Removed IV.A.2. Removed old section Vi. And VII. Added new IV. Release from prepayment review. Approved at Committee. Annual review. Approved at Committee. Removed from section D. II. CareSource will provide a written notice to the provider/provider group advising the effective date of prepayment review. Date Effective 11/01/2023 Date Archived H. ReferencesN/A
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Medical Record Documentation Standards for Practitioners-MP-AD-1243 09/01/2024 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 s tandards, 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 wit hout which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements 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 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 6 F. Related Policies/Rules ………………………………………………………………………………………….. 6 G. Review/Revision History ……………………………………………………………………………………….. 6 H. References …………………………………………………………………………………………………………. 6 Medical Record Documentation Standards for Practitioners-MP-AD-1243 Effective Date: 09/01/2024 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. 2A. Subject Medical Record Documentation Standards for Practitioners B. Background Medical record documentation is a fundamental element required to support medical necessity and is the foundation for coding and billing. Documentation relays important information such as, but not limited to, assessments completed, services provided, coordination of services, timeliness of care, plan of treatment, rationale for orders, health risk factors, member s progress, and response to treatment. C. Definitions A Valid Signature for Services Provided or Ordered o May be handwritten or electronic: CMS permits stamped signatures if you have a physical disability and can prove to a CMS contractor you are not able to sign due to that disability , and o Is legible or can be validated by comparing to a signature log or attestation statement . Certificate of Medical Necessity (CMN) A written statement by a practitioner attesting that a particular item or service is medically necessary for an individual . D. Policy I. Medical Documentation A. General requirements 1. Each member has his/her own medical record. 2. Entries are legible . 3. Each page of the record includes the members name and date of service. 4. Entries include a. Date of service b. Signature, date, and credentials of practitioner 5. Documentation indicates that the services(s) billed we re the services provided. a. If CPT is based on a timed service, the total number of timed minutes and/or start and stop time with CPT codes/type of treatment is documented. b. If CPT is based on a group of members, the following is included 01. Documentation to support that the member was present at each session. If the member is not present for the duration of the visit, document start and stop time for the member. 02. Relationships/credentials of individuals present at each session. 03. Number of participants in group therapy/treatment. c. CPT/ modifiers /p lace of service codes are appropriate for service and provider . d. Note reflect s the location of service. Medical Record Documentation Standards for Practitioners-MP-AD-1243 Effective Date: 09/01/2024 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. 36. Documentation reflect s medical necessity for payment of services provided and utilization of resources as it relates to the service provided and the needs/desires of the member. 7. Documentation includes a problem list that includes significant illness or medical and behavioral conditions found in history or previous encounters. 8. When making changes in paper medical record a. Change is clearly visible. b. White out is not utilized. c. A single line is through an entry labeled with error, initialed, and dated. 9. When making changes in electronic medical records a. Amendment, correction, or delayed entry is identified. b. A reliable way to identify the original content, the modified content, and the date and person modifying the record is provided. 10. When documentation is over multiple pages a. Additional pages from a continuation of a note are clearly identified. b. Continuous pages contain 01. Member name 02. Date of service 03. Page number 11. Content of documentation show s the specific needs of the member for each encounter. Duplication of another note is not acceptable. 12. Best practice standards require documentation to be written within 24 hours of the clinical or therapeutic activity and signed and dated within 14 days. B. Evaluation and management documentation 1. Per CPT guidelines, documentation supports the specific requirements based on the level of service billed. These include: a. Time b. Medical Decision Making c. Complexity 2. Complexity documentation may include: a. Self-limited or minor problems b. Stable chronic c. Acute, uncomplicated illness or injury d. Undiagnosed new problem with uncertain prognosis e. Chronic illnesses with severe exacerbation, progression, or side effects of treatment 3. Risks associated with Social determinants of health (SDOH) are documented, if applicable. C. Consents 1. Consents are maintained in the medical record and include a. Consent to treatment, refusal to consent, or withdrawal of consent b. Authorization for release of information c. Signature and date B. Referral documentation 1. Supports rationale for referral that includes who and what specialty member is referred to . Medical Record Documentation Standards for Practitioners-MP-AD-1243 Effective Date: 09/01/2024 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. 42. Demonstrates evidence of a. Coordination of referrals to specialty practitioners b. Physician review of or documentation of collaboration notes C. Laboratory Testing Documentation (ie, labs, x-rays, biopsies) 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 . 5. Evidence of a ppropriate timely f ollow up on test results with member . D. Preventative Care Documentation, when appropriate 1. Records include a. An age-appropriate immunization record b. Evidence that preventative screenings/services are offered. c. Risk assessments are completed as appropriate ( ie, substance use, suicide , depression) . d. Cr isis/safety plan as appropriate . II. Durable Medical Equipment (DME) Prosthetics Orthotics and Supplies Documentation Requirements A. Detailed Written Order and Documentation includes 1. The members name 2. Item of DME ordered (ie, written description, HCPCS Code, brand name, model number ). 3. Prescribing practitioners National Provider Identifier (NPI) 4. Signature of the ordering practitioner 5. Date of the order 6. If order is for a supply a. Frequency of use b. Quantity to be dispensed 7. Duration of use , 8. Certificate of Medical Necessity (CMN), if required. a. If a CMN is not required, a prescription with diagnoses is included. 9. Information that demonstrates that the item is medically necessary. 10. Any changes in the members treatment plan or needs 11. Proof of delivery (see II. D.) B. Refill Documentation 1. Documentation of a request for refill must be either a written document received from the member or a contemporaneous written record of a phone conversation/contact between the supplier and the member. 2. The refill request must occur and be documented before shipment. 3. A retrospective attestation statement by the supplier or member is not sufficient. 4. The refill record must include a. Members name or authorized representative, if different from the member . b. A description of each item that is being requested. Medical Record Documentation Standards for Practitioners-MP-AD-1243 Effective Date: 09/01/2024 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. 5c. Date of the refill request. d. For consumable supplies ie, those that are used up (eg, ostomy or urological supplies, surgical dressings, etc.) the supplier must assess the quantity of each item that the member still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date. C. Verbal Orders 1. When services are provided and based on a physicians verbal orders, a nurse or other qualified practitioner responsible for furnishing or supervising the ordered services must document the orders in the patients clinical record, and sign, date, and time the orders. 2. Verbal orders must be followed up with written orders. 3. Suppliers must maintain the written physicians order to support medical necessity in the event of a post-payment review, D. Proof of Delivery 1. Proof of Delivery includes the following: a. Member s name b. Delivery a ddress d. Item of DME ordered (ie, written description, HCPCS Code, brand name, model number ). e. Quantities delivered. f. Date delivered. g. Member or designee receipt signature with date, and date of s ignature. h. Relationship of anyone signing the delivery ticket as a designee of the patient . i. There is a specific statement for the patient to initial stating that they attest that they are satisfied with the way the orthotic or prosthesis device(s) fit and that they were trained on the proper usage and care of the device(s) . j. Signature of the supplier and date the item was provided to the member . 2. If shipped using a third-party, a shipping tracking slip or returned postage-paid delivery invoice is acceptable. 3. CareSource is able to determine from the delivery documentation that the supplier properly coded the item(s) , that the item(s) delivered were the same item(s) submitted for reimbursement, and that the items were intended for and received by a specific member. E . Custom item documentation includes 1. Evidence that the item was uniquely constructed or substantially modified for a specific member . 2. Description and physician orders. 3. Evidence that item is so different from another item for the same purpose that the two items cannot be grouped together for pricing purposes. III. Falsified Documentation Medical Record Documentation Standards for Practitioners-MP-AD-1243 Effective Date: 09/01/2024 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d. 6A. 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-dat ing entries 4. Writing over 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 based on an incomplete record may result in a reversal of the original denial if the information supplied includes pages or components that were part of the original medical record but were not submitted on the initial review. E. Conditions of Coverage N/A F. Related Policies/Rules Behavioral Health Record Documentation Standards for Practitioners G. Review/Revision History DATES ACTIONDate Issued 03/04/2020Date Revised 04/14/2021 04/13/2022 05/25/2022 05/24/2023 05/22/2024 Removed BH Documentation . Updated references. No changes; Updated references Per Program Integrity added Refill Documentation and Verbal Orders to section II Added sec.I.A.12 for completion and signature. Updated references. Approved at committee. Per 2024 CMS , removed History and Examinations from E&M section. Added complexity requirements. Updated references; Policy approved by Committee . Date Effective 09/01/2024 Date Archived H. References1. Complying with Medicare Signature Requirements Medicare Learning Network ICN 905364. Centers for Medicare & Medicaid Services; 2018. Accessed April 19, 2024. www.cms.g ov 2. Customized Items, 42 C.F.R. 414.224 (2021). Medical Record Documentation Standards for Practitioners-MP-AD-1243 Effective Date: 09/01/2024 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d. 73. Documentation Guidelines for Evaluation and Management Services. Centers for Medicare & Medicaid Services ; 1997. Accessed April 19, 2024. www.cms.gov 4. Documentation Matters Toolkit. Centers for Medicare & Medicaid Services. July 15, 2020. Accessed April 24, 2024. www.cms.gov 5. Electronic Health Records Provider. Centers for Medicare & Medicaid Services ; 2015. Accessed April 19, 2024. www.cms.gov 6. Evaluation and Management Services. Medicare Learning Network ICN 006764. Centers for Medicare & Medicaid Services; 2017. Accessed April 19, 2024. www.cms.gov 7. Local Determination Article: Standard Documentation Requirement for All Claims Submitted to DME MACs (A55426). Centers for Medicare & Medicaid Services; 2020. Accessed April 19, 2024. www.cms.gov 8. Progress Notes, O HIO ADMIN . CODE 5122-27-04 (2019). 9. Pub 10-08 Medicare Program Integrity Transmittal 442. Centers for Medicare & Medicaid Services ; 2012 . Accessed April 19, 2024. www.cms.gov 10. United States Code of Regulations. (2021). 414.224 Customized items. Accessed April 19, 2024. www.ecfr .gov.
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Trading Partners-MP-AD-1254 08/01/2024 Kentucky inactive as of 01/01/2026 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 s tandards, 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 wit hout which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements 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 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. State-Specific Information ……………………………………………………………………………………… 2 F. Conditions of Coverage ………………………………………………………………………………………… 2 G. Related Policies/Rules ………………………………………………………………………………………….. 2 H. Review/Revision History ……………………………………………………………………………………….. 2 I. References …………………………………………………………………………………………………………. 3Trading Partners-MP-AD-1254 Effective Date: 08/01/2024 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d. 2A. SubjectTrading Partners B. Background CareSource accepts electronic claims submissions to increase the efficiency of claims processing. CareSource has specific requirements regarding electronic claims submission. This policy applies to providers who want to directly connect with CareSource for electronic filing along with Trading Partners and Clearinghouses not already contracted with CareSource and the electronic claims submission process. C. Definitions Clearinghouses/Trading Partners Companies that function as intermediaries who forward claims information from healthcare providers to insurance payers. Direct Connections Direct electronic claims submissions to CareSource without the use of a clearinghouse/trading partner. Electronic Data Interchange (EDI) The computer-to-computer exchange of business data. D. Policy I. CareSource only allows direct connections for EDI transactions with contracted Trading Partners/Clearinghouses, states , and Centers for Medicare and Medicaid Services (CMS). II. CareSource will not contract or approve direct connections with providers (eg, hospitals, labs, offices, practitioners ). III. New direct connection requests will not be granted unless fully documented and approved by CareSources Information Technology and Operations e xecutive l eadership. E. State-Specific Information NA F. Conditions of Coverage NA G. Related Policies/Rules NA H. Review/Revision History DATE ACTIONDate Issued 10/12/2022 New policyDate Revised 04/ 24 /2024 Annual review. Updated references. Approved at Committee. Trading Partners-MP-AD-1254 Effective Date: 08/01/2024 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d. 3Date Effective 08/01/2024Date Archived I. References1. Definitions, 45 C.F.R. 160.103 (2024). 2. Medicare HIPAA Eligibility Transaction System (HETS) Trading Partner Agreement (TPA). Centers for Medicare & Medicaid Services. Accessed February 19, 2024. www.cms.gov 3. Standard Companion Guide Transaction Information. Centers for Medicare & Medicaid Services; 2013. Accessed February 19, 2024. www.cms.gov
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Against Medical Advice-MP-AD-1241 07/01/2024 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and suppo rted 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, th ose 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, dysfunct ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medic ally 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 betwee n 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 A ddiction 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 2 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Against Medical Advice-MP-AD-1241Effective Dat e: 07/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectAgainst Medical Advice B. BackgroundStudies show that approximately 1-2% of all hospitalizations result in discharge against medical advice (AMA) . Discharges AMA are at higher risk for inadequately treated medical conditions, readmissions, and negative health outcomes when compared to planned discharges. Docu mented reasons for leaving AMA may include lack of satisfaction with the treatment team , treatment team members, or facility , a general mistrust of medical systems, underutilization of social support, and/or a lack of health insurance or low socio-economic status. Additionally, research indicates that some previously diagnosed conditions substantially impact rates of AMA discharge. Patients with psychiatric conditions, substance abuse disorders, and human immunodeficiency virus are at the most significant r isk for an AMA discharge. 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. Also known as self – directed 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 AMA .III. If a member leaves AMA in the emergency room and the facility has submitted a prior authorization for inpatient services, only the emergency room will be considered for payment. IV. Claims are subject to retrospective review, and CareSource reserves the right to adjust reimburseme nt in accordance with the policies above .E. State-Specific InformationN/A F. Conditions of CoverageMember must be eligible at the time the service, procedure , or supply was provided, and the service, 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 guarantee reimbursemen t. All services, procedures, and supplies are subject to review for medical necessity. Against Medical Advice-MP-AD-1241Effective Dat e: 07/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 G. Related Policies/RulesMedical Necessity Determinations H. Review/Revision HistoryDATE ACTIONDate Issued 10/12/2022 Archived individual policies (IN AD-0793, GA AD-0794, KYAD-0791, OH AD-0789, WV AD-0790). Date Revised 03/27/2024 Annual review: removed (AMA) from title, revised background, added to AMA definition, revised conditions of coverage, and updated references . Approved at Committee. Date Effective 07/01/2024 Date Archived I. References1. 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. doi:10.3390/healthcare9020111 2. Alper E, OMalley T, Greenwald J. Hospital discharge and readmission . UpToDate. Updated February 3, 2023. Accessed March 8, 2024 . www.uptodate.com 3. Hasan O, Samad MA, Khan H, et al. Leaving against medical advice from in-patient departments rate, reasons and predicting risk factors for re-visiting hospital retrospective cohort from a t ertiary care hospital. Int JHealth Policy Man . 2019;8(8):474-479. doi:10.15/2019.26 4. Holmes EG, Cooley BS, Fleisch SB, et al. Against medical advice discharge: a narrative review and recommendations for a systematic approach. Am JMed . 2021;134(6):721-726. doi:10.1016/j.amjmed.2020.12.027 5. Khalili M, Teimouri A, Shahramian I, et al. Discharge against medical advice in paediatric patients. JTaibah Univ Med Sci . 2019;14(3):262-267. doi:10.1016/j.jtumed.2019.03.001 6. Levenson J. Psychological factors affecting o ther medical conditions: management. UpToDate. Updated September 19, 2022. Accessed March 8, 2024 . www.u ptodate.com 7. Spooner KK, Saunders JJ, Chima CC, et al. Increased risk of 30-day hospital readmission among patients discharged against medical advice: a nationwide analysis. Ann Epidemiol . 2020;52:77-85. doi:10.1016/j.annepidem.2020.07.021 8. Tan SY, Feng JY, Joyce C, et al. Association of hospital discharge aga inst medical advice with readmission and in-hospital mortality. JAMA Netw Open . 2020;3(6):e206009. doi:10.1001/jamanetworkopen.2020.6009
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Residential Treatment Services – Mental Health-MP-AD-1265 05/01/2024 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by Care Source 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 guid elines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements 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) referenc ed 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 m ake 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 limitatio ns that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Residential Treatment Services – Mental Health-MP-AD-1265Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectResidential Treatment Services Mental Health B. Background Mental health services are provided along a continuum of care where the level of care varies dependent on the type and intensity of services provided. These services involve an integrated system of care , ranging from outpatient services to residential treatment, that offers comprehensive services based on member needs and examines factors such as support systems available, prior life experiences, and behavioral, physical, gender, cultural, cognitive, and/or social factors . Treatment of behavioral health (BH) conditions is dependent on a diagnosi s based oncriteria found in the most current edition of the Diagnostic and Statistical Manual ofMental Disorders (DSM) . Appropriate assessment and diagnosis ensure s that care is delivered consistently with industry-standard criteria and evidence-based tr eatment measures. C. Definitions Inpatient Services – BH services provided during an inpatient admission or confinement for acute inpatient services in a hospital or treatment setting on a 24 – basis under the direct care of a physician , including psychiatric hospitalization, inpatient detoxification, and emergency evaluation and stabilization. Intensive Outpatient Services Services addressing BH issues provided by BH facilities, group practices or clinics for at least 3 hours of treatm ent per day at least 2 to 3 days per week and usually a step down from acute inpatient care, partial hospitalization care, or residential care but a step up from traditional outpatient services. Outpatient Services – BH services provided to a member on an ambulatory basis in an office or clinic setting, typically weekly or biweekly , including diagnostic evaluation, psychological testing, and psychotherapy. Partial Hospitalization – Structured, multimodal, active treatment for behavioral health or substance use disorders less than 24 hours including individual, group and/or family psychotherapy, member education and training, and diagnostic services focusing on member reintegration into society. Residential Treatment Services for BH issues that can include individual, family and group therapy, nursing services, medication assisted treatment, detoxification (ambulatory or subacute) and pharmacological therapy in a congregate living community with 24-hour support. D. PolicyI. Prior authorization is required for residential treatment services for mental health diagnoses . CareSource follows MCG for medical necessity reviews. Residential Treatment Services – Mental Health-MP-AD-1265Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 II. BillingA. Reimbursement is considered a bundled , all-inclusive per diem service payment . Concu rrent billing of individual services is not reimbursable. B. Residential treatment services are not reimbursable for non-participating facilities or providers without a mutually agreed upon need for and negotiated single case agreement (SCA). C. Resident ial treatment is not reimbursable in situations where ho using arrangements are un available or unsuitable , and the inclusion of therapy services as part of treatment does not warrant covera ge in this situation. D. Payments are made at the group level , not at the individual, rendering provider level. Rendering provider is not necessary on either UB04 or CMS1500 forms. 1. For UB04 billing, revenue code 0900 should be used with identified procedure code. 2. CMS 1500 claims are process by CareSource onl y when the place of service is 56 (Psychiatric Residential Treatment Center ). E. In the event of any conflict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes along with appropriate modifiers, if applicable. The following list(s) of codes is provi ded as a reference only, may not be all inclusive, and is subject to updates. HCPCS Code DescriptionH0018 Behavioral Health; short-term residential (nonhospital residential treatment program), without room and board, per diem H0019 Behavioral Health; long-term residential (nonmedical, nonacute care in residential treatment program with stay typically longer than 30 days), without room and board, per diem F. State-Specific InformationNA G. Related Policies/Rules Medical Necessity Determi nations H. Review/Revision HistoryDATE ACTIONDate Issued 11/30/2022 Archived individual policies (GA AD-1140, IN AD-1139,KY AD-1136, OH AD-1138, WV AD-1137) Date Revised 02/14/2024 Annual review. Updated references. Approved at Committee. Date Effective 05/01/2024 Date Archived Residential Treatment Services – Mental Health-MP-AD-1265Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 I. References1. Anorexia Nervosa, Residential Care : B-001-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 2. Anxiety Disorders, Residential Care : B-002-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 3. Attention Deficit and Disruptive Behavior Disorders, Residential Care : B-003-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.c areguidelines.com 4. Autism Spectrum Disorders, Residential Care : B-012-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 5. Bipolar Disorders, Residential Care : B-004-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 6. Bulimia Nervosa, Binge-Eating Disorder, and Other Specified Feeding or Eating Disorders, Residential Care : B-005-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 7. Dementia, Residential Care : B-007-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 8. Diagnostic and Statistical Manual of Mental Disorders (5th ed, Text Revised) . American Psychiatric Association; 2022. Accessed December 12, 2023. doi:10.1176/appi.b ooks.9780890425787 9. Eating Disorders, Residential Behavioral Health Level of Care, Adult : B-904-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 10. Eating Disorders, Residential Behavioral Health Level of Care, Child or Adolescent: B-913-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 11. Georgia Marketplace Evidence of Coverage . CareSource; 2024. Accessed December 12, 2023. www.caresource.com 12. Indiana Marketplace Evidence of Coverage . CareSource; 2024. Accessed December 12, 2023. www.caresource.com 13. Kentucky Marketplace Evidence of Coverage . CareSource; 2024. Accessed December 12, 2023. www.caresourc e.com 14. Major Depressive Disorder, Residential Care : B-008-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 15. Ohio Marketplace Evidence of Coverage . CareSource; 2024. Accessed December 12, 2023. www.caresource.com 16. Persistent Depressive Disorder (Dysthymia), Residential Care : B-009-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 17. Obsessive Compul sive and Related Disorders, Residential Care : B-030-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 18. Other Psychiatric Disorders, Residential Care : B-010-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com Residential Treatment Services – Mental Health-MP-AD-1265Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 19. Other Psychotic Disorders, Residential Care : B-011-RES. MCG . 27 th ed. UpdatedSeptember 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 20. Place of service code set. Centers for Medicare and Medicaid Services. Updated September, 2023. Accessed February 1, 2024. www.cms.gov 21. Posttraumatic Stress Disorder, Residential Care : B-013-RES. MCG . 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 22. Residential Behavioral Health Level of Care, Adult: B-901-RES. MCG. 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 23. Residential Behavioral Health Level of Care, Child or Adolescent: B-902-RES. MCG. 27 th ed. Updated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 24. Schizophrenia Spectrum Disorders, Residential Care : B-014-RES. MCG . 27 th ed. Upd ated September 21, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 25. West Virginia Marketplace Evidence of Coverage . CareSource; 2024. Accessed December 12, 2023. www.caresource.com
ADMINISTRATIVE POLICY STATEMENT Marketplace Policy Name & Number Date Effective Partial Hospitalization Program – Mental Health-MP-AD-1263 05/01/2024-08/31/2024 Policy Type ADMINISTRATIVE This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 3 F. State-Specific Information ………………………………………………………………………………………. 3 G. Related Policies/Rules ……………………………………………………………………………………………. 3 H. Review/Revision History …………………………………………………………………………………………. 3 I. References …………………………………………………………………………………………………………… 4 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 ex pected 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 alter native, 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 less favorable than the limitations that apply to medical conditions as covered under this policy. Partial Hospitalization Program – Mental Health-MP-AD-1263 Effective Date: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 2 A. SubjectPartial Hospitalization ProgramMental HealthB. Background Mental health (MH) services are provided along a continuum of care where the level of care varies dependent on the type and intensity of services provided. These services involve an integrated system of care, ranging from outpatient services to residential treatment, that offers comprehensive services based on member needs and examines factors such as support systems available, prior life experiences, and behavioral, physical, gender, cultural, cognitive, and/or social factors. Partial Hospitalization Program (PHP) levels of care provide day treatment for members in a setting that is intensively structured, 3 or more hours per day or evening available 5 days a week. Treatment is provided by a multidisciplinary team of behavioral health (BH) professionals, and daily, skilled nursing and ps ychiatric care are available. Treatment of BH conditions is dependent on a diagnosis based on criteria found in the more current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Appropriate assessment and diagnosis ensures that care is delivered consistently with industry-standard criteria and evidence-based treatment measures. C. Definitions Concurrent Review A request for prior authorization (PA) or a predetermination that is submitted before or during the course o f receiving a health care service. Inpatient Services BH services provided during an inpatient admission or confinement for acute inpatient services in a hospital or treatment setting on a 24-hour basis under the direct care of a physician, including psychiatric hospitalization, inpatient detoxification, and emergency evaluation and stabilization. Intensive Outpatient Services Services addressing BH issues provided by BH facilities, group practices, or clinics for at least 3 hours of treatment per day at least 2 to 3 days per week and are usually a step down from acute inpatient care, partial hospitalization care, or residential care but a step up from traditional outpatient services. Outpatient Services BH services provided to a member on an ambulatory basis in an office or clinic setting, typically weekly or biweekly, including diagnostic evaluation, psychological testing, and psychotherapy. Partial Hospitalization Structured, multimodal, active treatment for BH less than 24 hours including individual, group and/or family psychotherapy, member education and training, and diagnostic services focusing on member reintegration into society. Residential Treatment Services for BH issues that can include individual, family and group therapy, nursing services, medication assisted treatment, detoxification (ambulatory or subacute) and pharmacological therapy in a congregate living community with 24-hour support. Retrospective Review A request for medical review that is submitted after the health care service has been received. Partial Hospitalization Program – Mental Health-MP-AD-1263 Effective Date: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 3 D. PolicyI. Prior authorization is required after 5 days per calendar year. CareSource follows MCG criteria for all reviews of medical necessity. II. Billing A. H0035 is the Healthcare Common Procedure Coding System (HCPCS) code for behavioral health partial hospitalization, less than 24 hours, per diem. B. Reimbursement is considered a bundled service payment. Concurrent billing of individual services is not reimbur sable. C. PHP is an outpatient service. D. PHP is not reimbursable for non-participating facilities or providers without a mutually agreed upon need for and negotiated single case agreement (SCA). E. Payments are made at the group level, not at the individual, rendering provider level. Rendering provider is not necessary on either UB04 or CMS1500 forms. For UB04 billing, the following revenue codes should be used with identified procedure code: 1. 0912-Partial hospitalization, less intensive (3-5 hour s half day) 2. 0913-Partial hospitalization, intensive (6+ hours full day) F. In the event of any conflict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and Current Procedural Terminology (CPT) codes along with appropriate modifiers, if applicable. F. State-Specific Information West Virginia: Benefits for the first 5 days partial hospitalization services will be provided without any retrospective review of medical necessity. Benefits beginning day 6, and every 6 days thereafter, is subject to concurrent review of medical necessity of the services. G. Related Policies/Rules Medical Necessity Determinations H. Review/Revision History DATE ACTIONDate Issued 11/30/2022 Archived individual policies (GA AD-0955, IN AD-0968, KYAD-0969, OH AD-0971, WV AD-0970) Date Revised 06/21/2023 02/14/2024D. I. changed to days (match PA List). Approved atCommittee. Annual review. Updated references. Approved at Committee. Date Effective 05/01/2024 Date Archived 08/31/2024 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy . Partial Hospitalization Program – Mental Health-MP-AD-1263 Effective Date: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 4 I. References1. Anorexia Nervosa, Partial Hospital Program: B-001-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 2. Anxiety Disorders, Partial Hospital Program: B-012-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 3. Attention-Deficit and Disruptive Behavior Disorders, Partial Hospital Program: B-003-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 4. Autism Spectrum Disorders, Partial Hospital Program: B-012-PHP. MCG. 27th ed. Updated September 1, 2023. Acces sed February 1, 2024. www.careweb.careguidelines.com 5. Bipolar Disorders, Partial Hospital Program: B-004-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 6. Bulimia Nervosa, Binge-Eating Disorder, and Other Specified Feeding or Eating Disorders, Partial Hospital Program: B-005-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 7. Dementia, Partial Hospital Program: B-007-PH P. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 8. Diagnostic and Statistical Manual of Mental Disorders (5th ed, Text Revised). American Psychiatric Association; 2022. Accessed December 12, 2023. doi:10.1176/appi.books.9780890425787 9. Eating Disorders, Partial Hospital Behavioral Health Level of Care, Adult: B-904-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 10. Eating Disorders, Partial Hospital Behavioral Health Level of Care, Child or Adolescent: B-913-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 11. Georgia Marketplace Evidence of Coverage. CareSource; 2024. Accessed December 12, 2023. www.caresource.com 12. Indiana Marketplace Evidence of Coverage. CareSource; 2024. Accessed December 12, 2023. www.caresource.com 13. Kentucky Marketplace Evidence of Coverage. CareSource; 2024. Accessed December 12, 2023. www.c aresource.com 14. Major Depressive Disorder, Partial Hospital Program: B-008-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 15. Partial Hospital Behavioral Health Level of Care, Adult: B-901-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 16. Partial Hospital Behavioral Health Level of Care, Child or Adolescent: B-902-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 17. Persistent Depressive Disorder (Dysthymia), Partial Hospital Program: B-009-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com Partial Hospitalization Program – Mental Health-MP-AD-1263 Effective Date: 05/01/2024 The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in the ADMINISTRATIVE Policy Statement Policy and is approved. 5 18. Obsessive-Compulsive and Rela ted Disorders, Partial Hospital Program: B-030-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 19. Ohio Marketplace Evidence of Coverage . CareSource; 2024. Accessed December 12, 2023. www.caresource.com 20. Other Psychiatric Disorders, Partial Hospital Program: B-010-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 21. Other Psychotic Disorders, Partial Hospital Program: B-011-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 22. Posttraumatic Stress Disorder, Partial Hospital Program: B-013-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 23. Schizophrenia Spectrum Disorders, Partial Hospital Program: B-014-PHP. MCG. 27th ed. Updated September 1, 2023. Accessed February 1, 2024. www.careweb.careguidelines.com 24. West Virginia Marketplace Evidence of Coverage. CareSource; 2024. Accessed December 12, 2023. www.caresource.com
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Experimental or Investigational Item or Service-MP-AD-1354 05/01/2024 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 s tandards, 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 wit hout which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements 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 less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. State-Specific Information ……………………………………………………………………………………… 4 F. Conditions of Coverage ………………………………………………………………………………………… 4 G. Related Policies/Rules ………………………………………………………………………………………….. 4 H. Review/Revision History ……………………………………………………………………………………….. 4 I. References …………………………………………………………………………………………………………. 4 Experimental or Investigational Item or Service-MP-AD-1354 Effective Date: 05/01/2024 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. 2A. SubjectExperimental or Investigational Item or Service B. Background Experimental and/or investigational items or services are not covered. This includes, among other things, services or procedures considered to be investigational, cosmetic, or not medically necessary . This polic y defines the medical review decision process around such treatment requests. CareSource members have the right to refuse or participate in experimental or investigational items or services. Providers are encouraged to inform members in advance when they may be financially responsible for the cost of non-covered or excluded services. C. Definitions CPT Category III codes a set of temporary (T) codes assigned to emerging technologies, services, and procedures. These codes are intended to be used for data collection to substantiate more widespread usage or to provide documentation for the Food and Drug Administration (FDA) approval process. 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, or 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 or 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 o provided pursuant to informed consent documents that describe the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply as e xperimental or i nvestigational, 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 o The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical tria l set forth in the FDA regulations, regardless of whether the trial is Experimental or Investigational Item or Service-MP-AD-1354 Effective Date: 05/01/2024 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. 3actually subject to FDA oversight. This includes diagnostic testing for purposes of possible inclusion in a clinical trial Devices that are FDA approved under the Humanitarian Use Device exemption are not considered to be experimental or investigational. Drugs used in Phase 4 trials may be covered if they are part of the formulary .D. Policy I. Any health care item or service that CareSource determines in its sole discretion to be experimental or investigational is not covered. 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 measurable and beneficial health outcome. In determining whether such health care item or service is experimental or investigational, CareSource, in 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 service on health out comes B. the evidence demonstrates that the health care item or service improves net health outcomes of the total population for whom the item or service might be proposed by producing beneficial effects that outweigh any harmful effects C. the evidence demonstrates that the health care item or service has been shown to be as beneficial for the total population for whom the service might be proposed as any established alternatives D. the evidence demonstrates that the health care item or service 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 information and evidence from the following non-exhaustive list: A. published authoritative, peer-reviewed medical or scientific literature, 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, treatment, serv ice, or supply D. documents of an institutional review board or other similar body performing substantially the same function Experimental or Investigational Item or Service-MP-AD-1354 Effective Date: 05/01/2024 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d. 4E. consent document(s) and/or the written protocol(s) used by providers studying substantially the same drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply F. m edical records G. o pinions of consulting providers and other experts in the fieldE. State-Specific Information NA F. Conditions of Coverage NA G. Related Policies/Rules Clinical Trial Coverage Medical Necessity Determinations policy H. Review/Revision History DATES ACTIONDate Issued 01/31/2024 New Policy. Approved at Committee.Date Revised Date Effective 05/01/2024 Date Archived I. References1. Biological Products, 21 C.F.R. 600 .2-.90 (202 3). 2. Coverage and Authorization of Services, 42 C.F.R. 438.210 (2022). 3. EPSDT-A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents . Centers for Medicare & Medicaid Services; 2020. HHS-0938-2014-F-1347. Accessed January 8, 2024. www.hhs.gov 4. Investigational Device Exemptions, 21 C.F.R. 812.1- .46 (2023). 5. Medical Services Coverage Decisions That Relate to Health Care Technology, 42 C.F.R. 405.201- .215 (2022). 6. Medicare Coverage of Items and Services in Category A and BInvestigational Device Exemption (IDE) Studies . Centers for Medicare & Medicaid Services; 2015. MLN Matters MM8921. Accessed January 8, 2024. www.cms.gov 7. Phases of an Investigation, 21 C.F.R. 312.21 (2023). 8. Premarket Approval of Medical Devices, 21 C.F.R. 814.1 -.19 (2023). 9. Utilization Control, 42 C.F.R. 456.1-. 725 (2022).
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Cystic Fibrosis Testing-MP-AD-1219 05/01/2024 Policy Type ADMINISTRATIVE Administrative Poli cy 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 publi shed 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 pati ent 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 lowe st 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 Hand books, 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 c ontrolling 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Cystic Fibrosis Testing-MP-AD-1219Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectCystic Fibrosis Testing B. BackgroundCystic fibrosis (CF) is a recessive genetic disorder cause d by mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene . When an individual inherits two abnormal CFTR genes from their parents, they may develop dysregulation of the epithelial lining fluid transport, affecting systemic mucus production . Diagnosis of CF is based upon the finding of genetic and/or functional abnormalities of the CFTR gene (CFTR variants) and is typically as sociated with progressive lung disease, pancreatic insufficiency, and elevated sweat chloride levels. Many individuals with CF demonstrate mild or atypical symptoms and can present later in childhood or as adults, while others may test positive for CF, y et remain asymptomatic(CRMS). Untreated CF in some can lead to early mortality and infertility. This makes early CF diagnosis and identification of carriers of CF important for early intervention to mitigate disease progression as well as to allow for mor e informed health determinations. Advances in CF research has led to steadily evolving tests that can identify abnormal CFTR genes as well as tailored treatments to address the underlying mechanisms leading to disease. More than 10 million Americans are carriers of a defective CFTR gene and show nosymptoms of the disease . Others who do not fit CF diagnostic criteria still go on to develop disease associated with evidence of CFTR dysfunction limited to one organ (CFTR-related disorder) . Carrier testing may pr ovide an early indication as to whether a person might develop a CFTR-related disorder . Potential parents who test positive as carriers for CF will be able to make educated reproductive decisions, bette r prepare for birth, and investigate additional testing for CF-related health conditions. A negative screening result does not completely rule out the possibility that a person is a CF carrier. A negative screening test only rules out the specific CF varia nts that were part of the screen. Diagnosis of CF is a multistage process. Individuals must have clinical symptoms consistent with CF in at least one organ system, have a positive newborn screen, or have a sibling with CF. In addition, there must be evide nce of CFTR dysfunction viaelevated sweat chloride, presence of two disease-causing CFTR mutations (one from each parent), or abnormal nasal potential difference (NPD). Newborn screening involves immunoreactive trypsinogen (IRT), sweat chloride testing, a nd genetic testing. C. Definitions American College of Medical Genetics and Genomics (ACMG) A nationally recognized interdisciplinary organization dedicated to the practice of medical genetics. The ACMG regularly posts technical recommendations for genetic diseases, including cystic fibrosis. Cystic Fibrosis Testing-MP-AD-1219Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 Autosomal Recessive A trait or disorder requiring a deleterious variant in both copies of the gene to express a phenotyp e. Carrier An individual with a gene variant for a disease or disorder who can pass the variant on to offspring but does not have symptoms or features of the disorder . Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Transmembrane protein that functions as a regulated anion channel to maintain a gradient necessary for normal cell function. Mutations that alter the function of the CFTR protein are associated with CF. CFTR-Related Disorder A single pathogenic CFTR variant leading to the development of disease limited to one organ sys tem in a n individual who does not fit the CF diagnosis . CFTR-Related Metabolic Syndrome (CRMS) Infants and children who are asymptomatic but have positive CF screening results. Found in 3-4% of infants with a positive newborn CF screen, CRMS is also known as CF screen positive, inconclusive diagnosis (CFSPID). Immunoreactive Trypsinogen (IRT) A pancreatic enzyme precursor measured in newborns to screen for the presence of CF. D. PolicyI. Genetic testing for CF should only be performed once in a lifetime with member consent and the results documented in the members health record . All genetic testing for CF should use currently recommended ACMG CFTR panels. Prior authorization is only required for CF genomic sequence analysis. II. Diagnostic testing is considered medically necessary when the member meets any of the following criteria: A. clinical presentation of CF B. infertility from oligospermia/azoospermia/congenital bilateral absence of vas deferens (CBAVD) C. infant with meconium ileus or other symptoms indicative of CF but unable to produce adequate amounts of sweat for a sweat chloride test D. infant with an elevated IRT value on newbo rn screening and a sweat chloride of at least 60 mmol/L or intermediate sweat chloride (between 30 mmol/L and 59 mmol/L) III. Carrier screening is indicated whe n the member meets any of the following criteria :A. members who are pregnant or of reproductive age with intent and potential to procreate B. members whose partner test s positive while the member is pregnant or intend ing to become pregnant C. members with a family history of cystic fibrosis D. members where both parents are CF carriers IV. The following are not considered medically necessary and will not be covered:A. repeat testing for the same CFTR panel Cystic Fibrosis Testing-MP-AD-1219Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 B. fetal testingC. gene sequencing of anything other than the CFTR gene E. State-Specific InformationN/A F. Conditions of CoverageCareSource may request documentation for post-payment review of claims submitted for payment of CF testing. If documentation is not provided, CareSource may recoup previously paid claim(s). G. Related Policies/RulesGenetic Testing and Counseling H. Review/Revision HistoryDATE ACTIONDate Issued 07/20/2022Date Revised 07/20 /2022 02/ 14/2024MarketPlace policies were combined into a single policy covering all applicable states. Addition of policy section D, IV and V. Editorial changes. Annual review: c hanges to title, b ackground, and definitions, expanded policy to include diagnostic testing , and u pdated references. Approved at Committee . Date Effective 05/01/2024 Date Archived I. References1. Barben J, Castellani C, Munck A, et al. Updated guidance on the management of children with cystic fibrosis transmembrane conductance regulator-related metabolic syndrome/cystic fibrosis screen positive, inconclusive diagnosis (CRMS/CFSPID). J Cyst Fibros . 2021;20(5):810-819. doi:10.1016/j.jcf.2020.11.006 2. Bienvenu T, Lopez M, Girodon E. Molecular diagnosis and genetic counseling of cystic fibrosis and related disorders: new challenges. Genes (Basel) . 2020;11(6):619. doi: 10.3390/genes11060619 3. Carrier. National Human Genome Research Institute. Updated October 15, 2023. Accessed December 8 , 2023. www.genome.gov 4. Carrier testing for cystic fibrosis. Cystic Fibrosis Foundation. Accessed December 8 , 2023. www.cff.o rg 5. Committee on Genetics : c arrier screening for genetic conditions. American College of Obstetricians and Gynecologists. Reviewed 2023. Accessed December 8 , 2023. www.acog.org 6. Cystic fibrosis CFTR gene and mutation panel: A-0597. MCG Health . 27 th ed. Updated September 21, 2023. Accessed December 8 , 2023. www.careweb.careguidelines.com Cystic Fibrosis Testing-MP-AD-1219Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 7. De Boeck K. Cystic fibrosis in the year 2020: a disease with a new face. ActaPaediatr . 2020;109(5):893-899. doi:10.1111/apa.15155 8. Deignan JL, Astbury C, Cutting GR, et al. CFTR variant testing: a technical standard of the American College of Medical Genetics and Genomics (ACMG). Genet Med . 2020;22 (8):1288-1295. doi:10.1038/s41436-020-0822-5 9. Deignan JL, Gregg AR, Grody WW, et al. Updated recommendations for CFTR carrier screening: a position statement of the American College of Medical Genetics and Genomics (ACMG). Genet Med . 2023;25(8):100867. doi:10.1016/j.gim.2023.100867 10. Katkin JP. Cystic fibrosis : clinical manifestations and diagnosis. UpToDate. Updated March 7, 2023. Accessed December 8, 2023. www.uptodate.com 11. Katkin JP. Cystic fibrosis: genetics and pathogenesis. UpToDate. Updated February 8, 2023. Accessed December 8, 2023. www.uptodate.com 12. Langfelder-Schwind E, Karczeski B, Strecker MN, et al. Molecular testing for cystic fibrosis carrier status practice guidelines: recommendations of the National Society for Genetic Counselors . JGenet Couns . 2014;23(1):5-15. doi:10.1007/s10897-013 – 9636-9 13. Marwaha S, Knowles JW, Ashley EA. A guide for the diagnosis of rare and undiagnosed disease: beyond the exome. Genome Med . 2022;14(1):23. doi:10.1186/s13073-022-01026-w 14. Procedure Following Repeat Screening or Diagnostic Testing , OHIO ADMIN . CODE 3701-55-08 (2023). 15. Russo ML. Cystic fibrosis: carrier screening. UpToDate. Updated February 8, 2023. Accessed December 8 , 2023. www.uptodate.com 16. Tests for Diseases Specified by the State Public Health Commissioner , W . VA CODE 16-22-3 (2022) .
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Itemized Billing-MP-AD-1199 01/01/2024 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSo urce 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 guidel ines. 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 p rolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are no t 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 an d 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 mak e 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Itemized Billing-MP-AD-1199Effective Dat e: 01/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectItemized Billing B. BackgroundItemized bill review is the analysis of inpatient facility itemized billing statement against CareSource policies and 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 items, supplies and services. Routine items, supplies, and servi ces 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 to receive inpatient services. Itemized Bill A comprehensive list of all services and goods provided during the inpatient hospital stay which list s the costs and descriptions associated with the service and/or good. D. PolicyI. CareSource follows the CMS Provider Reimbursement Manual guidelines, chapter 22 , section s 2202.6 and 2203 . A. Routine services defined by CMS chapter and section above are services included by the provider in a daily service charge , sometimes referred to as the room and board charge. B. Routine services are composed of two broad components: (1) general routine service s, and (2) special care units (SCU s), including coronary care units ( CCU s) and intensive care units (ICU s). Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and faciliti es for which a separate charge is not customarily made . II. For diagnostic-related group (DRG) high dollar claims exceeding $25,000, an itemized bill is required for review. III. The following supplies, items, and services are typically not separately billable a nd therefore are not reimbursable from the general room and board charge or primary service charge. This list contains examples only and is not an all-inclusive list : A. capital/medical equipment B. fluoroscope C. hydration flushes D. implants and supplies E. inpatient private duty nursing F. oximetry G. rental equipment Itemized Billing-MP-AD-1199Effective Dat e: 01/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 H. routine suppliesIV. If upon review of the itemized bill, charges are determined to exceed state or federal reimbursement guidelines or a CareSource specific policy , then reimbursement will be reduced accordingly. V. Provider exception requests to reimbursement reductions may be submitted viastandard provider appeal process and should include supporting documentation (eg ,medical records or op erative notes to support requested payment exception). E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 05/25/2022 New policyDate Revised 10/11 /2023 Annual Review; Approved at Committee Date Effective 01/01/2024 Date Archived I. References1. Determination of cost of services. The Provider Reimbursement Manual , I. Centers for Medicare and Medicaid Services. Publication 15-1. Accessed October 10 , 2023. www.cms.gov 2. Outlier payments. Centers for Medicare and Medicaid Services. December 1, 2021. Accessed October 10 , 2023. www.cms.gov 3. Payments for Outlier Cases, 42 C.F.R. 412.80 -.84 (2023).
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