Overpayment Recovery

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Overpayment Recovery-MP-PY-1393 12/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 ………………………….. ………………………….. ………………………….. … 5 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Overpayment Recovery-MP-PY-1393Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectOverpayment Recovery B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbu rsement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant eeclaims payment.Retrospective review of claims paid to providers assist CareSource with ensuring accuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified.Fraud, waste and abuse investigations are an exception to this policy. In these investigations, the look back period may go beyond 2 years.C. Definitions Claims Adjustment A claim that was previously adjudicated and is being updated for one of the following reasons: o denied as a zero payment o a partial payment o a reduced payment o a penalty applied o an additional payment o a supplemental payment Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the member. Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. Explanation of Payment (EOP) The EOP or contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Forwarding Balance (FB) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past Overpayment Recovery-MP-PY-1393Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 claim has been adjusted to a different dollar amount and that funds are owed to CareSource. Improper Payment A payment that should not have been made or an overpayment was made. Examples include, but are not limited to: o payments made for an ineligible member o ineligible service payments o payments made for a service not received o duplicate payments Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 CFR. o A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Provider Level Balancing (PLB) Adjustments to the total check/remit amount occur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment (BPR, which means total payment within the EOP). Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. D. PolicyI. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider: A. the name and patient account number of the member to whom the service(s) were provided B. the date(s) of services provided C. the amount of overpayment D. the reason for the recoupment E. that the provider has appeal rights II. Overpayment RecoveriesA. Lookback period is 24 months from the claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely fil ing guidelines. III. Coordination of Benefit RecoveriesA. Lookback period is 12 months from claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal Overpayment Recovery-MP-PY-1393Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines.IV. Retro Active Eligibility RecoveriesA. Lookback period is 24 months from claim paid date. B. Advanced notification will occur 30 days in advance of recovery. V. Management of Claim Credit Balances.A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on aproviders record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move aproviders record into a negative balance in which funds would be owed toCareSource. This information will be displayed on the EOP in the PLB section.B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is notconsidered to be an overpayment recovery and does not fall under the terms of this policy.1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 whenadjusted, instead of the $2 difference.b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D. IV.2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelinesoutlines in section D.I D. IV.b. The reduced payment will trigger a 30-day advanced notification with the details related to the claim and overpayment.C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has beenoffset, unless otherwise negotiated.D. Providers are notified of negative balances through EOPs and 835s. Providers are expected to use this information to reconcile and maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances. E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. Providers are expected to maintain their AR to account for the reconciliation of negative balances when they occur. VI. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document. Overpayment Recovery-MP-PY-1393Effective Dat e: 12/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 E. State-Specific Information1. Georgia a. Payment, GA. CODE 33-20A-62 (202 4). 2. Indiana a. Claim Payment Errors, IND . CODE 27-13-36.2-8 (202 4). b. Claim Overpayment Adjustment, IND . CODE 27-13-36.2-9 (202 4). 3. Kentucky a. Resolution of Payment Errors Retroactive Denial of Claims Conditions, KY. REV . STAT . 304.17A-708 (2024). b. Collection of Claim Overpayments Dispute Resolution, KY. REV . STAT . 304.17A-714 (2024). 4. Ohio a. Payments Considered Final Overpayment, OHIO REV . CODE ANN . 3901.388 (2002). 5. West Virginia a. Civil Penalty Imposed by Commissioner, W. VA. CODE R. 33-25A-23a (202 5). b. Definitions, W. VA. CODE R. 33-45-1 (202 5). c. Minimum Fair Business Standards Contract Provisions Required; Processing and Payment of Health Care Services; Provider Claims; Commissioner’s Jurisdiction, W. VA. CODE R. 33-45-2 (202 5). F. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. G. Related Policies/RulesCareSource Marketplace Provider Manual CareSource Provider Agreement, Article V. Claims and Payments H. Review/Revision HistoryDATE ACTIONDate Issued 10/2 6/2022 New policyDate Revised 02/14/2024 09/10/2025Annual review. Removed IV.C. Updated references. Approved at Committee.Periodic review. Updated Eand references. Approved at Committee. Date Effective 12/ 01/2025 Date Archived I. References1. Limitation on Recoupment (935) for Provider, Physicians and Suppliers Overpayments . Center of Medicare & Medicaid Services; May 22, 2025. Accessed August 20, 2025. www.cms.gov

Modifier 26 and TC: Professional and Technical Component

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 12/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 26 and TC: Professional and Technical Component B. BackgroundAccording to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), a modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumst ance but not changed in its definition or code. It may also provide more information about a service, such as the service was performed more than once, unusual events occurred, or it was performed by more than 1 provider and/or in more than 1 location. Current Procedural Terminology (CPT) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increasing accuracy and efficiency, and are also used for administrative manageme nt purposes, such as claims processing and developingguidelines for medical care review. Some procedure coding, described by a single CPT code, is comprised of 2 distinct portions: a professional component (26) and a technical component (TC). When the pro fessional component of 1 such procedure is performed separately, the specific service performed by the provider may be identified by adding CPT modifier 26. In this scenario, the facility provides the technical component of a service/procedure, billing the same procedure code with modifier TC. In this way the components of the service can be separately billed by the provider and facility. C. Definitions0078 Global Procedure /Service 00B1 Represents both the professional and technical component as a complete procedure or service identified by reporting the procedure without modifier 26 or TC. 0078 Modifier 26 ( Professional Component) 00B1 Used to indicate when a p rovider or other qualified health care professional renders the supervision and interpretation portion of a service or procedure and the preparation of a written report. 0078 Modifier TC (Technical Component) 00B1 Used to indicate the technical personnel, equipment, supplies , and institutional charges of a service or procedure . D. PolicyI. Care Source expects providers and facilities to adhere to national coding guidelines and standards when utilizing modifiers . II. Modifier 26A. To claim only the professional portion of a service, CPT instructs professionals (or providers) to append modifier 26 to the appropriate CPT code. B. Modifier 26 is also used t o bill for the professional component portion of a test when the provider utilizes equipment owned by a hospital/facility . Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 III. Modifier TCA. The payment for the technical component portion also includes the practice expense and the malpractice expense. B. To claim only the technical portion of a service, append modifier TC to the appropriate CPT code. C. Fees for the technical component are generally reimbursed to the facility or practice that provides or pays for the supplies, equipment, and/or clinical staff (technicians). D. Hospitals are typically exempt from appending modifier TC , because it is assumed that the hospital is billing for the technical component portion of any onsite service. IV. Global procedure /serviceA. A global service is identified by reporting the eligible code without modifier 26 or TC. In such cases, the provider is reimbursed for the equipment, supplies, and technical support, as well as the interpretation of the results and the report.B. When reporting a global service, modifiers are not necessary to receive payment for both components of the service. V. ExclusionsA. Do not append modifier 26 if there is a dedicated code to describe only the professional component of a given service (eg, 93010 electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). B. Do not append modifier TC if there is a dedicated code to describe the technical component (eg, 93005 electrocardiogram: tracing only, without interpretation and report ). C. Care Source does not allow reimbursement for use of modifier 26 or modifier TC when 1. It is reported with an Evaluation and Management (E&M) code. 2. There is a separate standalone code that describes the professional component only, technical component only or global test only of a selected diagnostic test. VI. Duplicate billingA. W hen 1 provider reports a global procedure and a different provider reports the same procedure with a professional (26) or technical (TC) component modifier for the same patient on the same date of service, the first charge approved by Care Source will be eligible for reimbursement , and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. B. W hen 1 provider reports a procedure with a professional (26) and a different provider reports a global procedure for the same patient on the same date of service, the first charge approved by Care Source will be eligible for Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 2. M-FeC . Centers for Medicare and Medicaid Services. Revised May 9, 2025 . Accessed August 18 , 202 5. www.cms.gov

Dental Services Rendered in a Hospital or Ambulatory Surgery Center

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407 12/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Dental Services Rendered in a Hospital or Ambulatory SurgeryCenter-MP-PY-1407Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDental Services Rendered in a Hospital or Ambulatory Surgery Center B. BackgroundThe decision to perform dental care in a particular place of service is based on a wide variety of factors, including the age and special health care needs (physical, intellectual, and developmental disabilities or chronic medical conditions) of the individual, in addition to the type, number, and complexity of procedures planned. These factors also determine the type of anesthesia used during the procedure. Most dental care can be provided in a dental office setting with local anesthesia or localanesthesia supplemented with non-pharmacological behavior guidance (basic to advanced techniques) and/or pharmacological options. Basic non-pharmacological behavior guidance includes communication guidance, positive pre-visit imagery, direct observation, tell-show-do, ask-tell-ask, voice control, non-verbal communication, positive reinforcement and descriptive praise, distraction, and desensitization. Pharmacological options may include nitrous oxide, oral conscious sedation and intravenous (IV) sedation (mild, moderate, or deep), or monitored general anesthesia by trained certified individuals in each level of sedation dentistry. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are ce rtain situations where appropriate candidates may require the use of general anesthesia as medically necessary in a healthcare facility, such as an ambulatory surgical center, hospital operating room, or short procedure unit (SPU). C. Definitions Ambulatory Surgical Center (ASC) A distinct entity that operates exclusively to furnish outpatient surgical services to patients who do not require hospitalization and are typically discharged less than 24 hours following admission. Hospital An institution primarily engaged in providing, by or under the supervision of physicians, diagnostic and therapeutic services or rehabilitation services. Critical access hospitals are certified under separate standards. Psychiatric hospitals are subject t o additional regulations beyond basic hospital conditions of participation. Monitored Anesthesia Care (MAC) A specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Sedation Continuum When patients undergo procedural sedation/analgesia, a sedation continuum is entered. Several levels have been formally defined along this continuum, as follows: o Minimal Sedation (Anxiolysis) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. o Moderate Sedation (Analgesia) (Conscious Sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No Dental Services Rendered in a Hospital or Ambulatory SurgeryCenter-MP-PY-1407Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.o Deep Sedation (Analgesia) A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require a ssistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. o General Anesthesia A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and p ositive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Note: Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initia lly intended. Individuals administering moderate sedation should be able to rescue patients who enter a state of deep sedation, while those administering deep sedation should be able to rescue patients who enter a state of general anesthesia. Rescue o f a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper than intended level of sedation , such as hypoventilation, hypoxia, and hypotension and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation. Short Procedure Unit (SPU ) A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic , or medical services. D. PolicyThis policy is intended to provide guidance on the process for obtaining authorization and reimbursement for dental services performed in a place of service (ASC or hospital OR/SPU) and reimbursement for related facility charges (eg, operating room, anesth esia, medical consults). Dental services are only covered in a hospital setting when the nature of the surgery or the condition of the patient precludes performing the procedure in the dentists office or other non-hospital outpatient setting , and the inpatient or outpatient service is a HealthInsurance Marketplace covered service. As such, it would exclude any diagnostic or preventive dental services delivered in a hospital setting, if these services cannot be performed in office.Dental Services Rendered in a Hospital or Ambulatory SurgeryCenter-MP-PY-1407Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 I. Dental Prior Authorization ProcessA. A review of medical necessity is required for all dental services performed in a hospital inpatient or outpatient facility or ambulatory surgery center facility. B. Dental services authorization for an outpatient/ASC setting 1. Requests for dental services should be handled through the members dental plan . Claims submitted for professional dental services should be submitted using the appropriate CDT codes and applicable ADA form. 2. If the member does not have a stand-alone dental plan, the member will be responsible for the costs of the dental services. C. Facility process Facility service claims should be submitted to CareSource using the applicable claim form (eg, CMS-1500, UB-04). E. State-Specific InformationNA F. Conditions of Coverage The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarantee payment for it. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following information is provided as a reference. This list may not be all inclusive and is subject to updates. Outpatient Hospital Facility (SPU) POS (19, 22); Ambulatory Surgical CenterPOS (24) o Use CPT code G0330 as the facility fee code Paid according to CareSource contract and the Medicare Physician Fee Schedule ( PFS). Dental-related facility charges must be billed on an institutional claim (UB-04 claim form, portal institutional claim, 837I transaction). o Use CPT 00170 for anesthesia for intraoral treatments, including biopsy Paid according to CareSource contract and the Medicare PFS. All associated professional services, such as radiology and anesthesia, as well as ancillary services related to the dental services, must be billed on a professional claim (CMS-1500 claim form or electronic equivalent). Inpatient Hospital Facility POS (21) o All services as well as any additional Room and Board fees would have to be pre-certified and receive medical necessity review. Services are subject to benefit provisions and criteria for dental hospital admissions for both adult and pediatric members in accordance with clinical guidelines. Dental Services Rendered in a Hospital or Ambulatory SurgeryCenter-MP-PY-1407Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Dental/Oral Surgery Professional Services o The scope of this policy is limited to medical plan coverage of the facility and/or general anesthesia services provided in conjunction with dental treatment, and not the dental or oral surgery services. G. Related Policies/RulesNAH. Review/Revision HistoryDATE ACTIONDate Issued 11/30/2022Date Revised 08/28/2024 09/10 /2025Annual review: updated background, reorganized definitions, removed facility PA process and DentaQuest information, updated references. Approved at Committee. Review: updated references, approved at Committee. Date Effective 12/01/2025 Date Archived I. References1. Ambulatory surgical centers. Centers for Medicare and Medicaid Services. Updated April 22, 2025. Accessed August 5, 2025. www.cms.gov 2. American Academy of Pediatric Dentistry. Management of dental patients with special health care needs. Reference Manual of Pediatr Den t. 2025-2026:TBD . Accessed August 5, 2025 . www.aapd.org 3. American Academy of Pediatric Dentistry. Policy on hospitalization and operating room access for oral care of infants, children, adolescents, and individuals with special health care needs. Reference Manual of Pediatr Den t. 2024-2025:173-175 . Accessed August 5, 2025 . www.aapd.org 4. American Academy of Pediatric Dentistry. Policy on third-party reimbursement for management of patients with special health care needs. Reference Manual of Pediatr Den t. 2024-2025:186-189 . Accessed August 5, 2025 . www.aapd.org 5. Committee on Quality Management and Departmental Administration. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. October 23, 2024. Accessed August 5, 2025. www.asahq.org 6. Hospitals. Centers for Medicare and Medicaid Services. Updated June 20, 2025 . Accessed August 5, 2025. www.cms.gov

Applied Behavior Analysis for Autism Spectrum Disorder

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 12/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 ………………………….. ………………………….. ………………………….. …… 7 F. State-Specific Information ………………………….. ………………………….. ………………………….. … 8 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 8 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 I. References ………………………….. ………………………….. ………………………….. ……………………. 8 Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectApplied Behavior Analysis for Autism Spectrum Disorder B. BackgroundProvider reimbursement issues for Applied Behavior Analysis (ABA) services for Autism Spectrum Disorder (ASD) can arise from various factors, impacting families, providers, and the accessibility of care. Key issues relating to payment problems include coverage issues, billing and coding challenges, access to services, and legislative and policy issues. Billing an d coding issues are common due to a variety of factors, including the complexity of coding, incorrect coding, insufficient documentation, authoriza tion issues, and billing for supervision and telehealth services. CareSource strives to provide clear practices regarding reimbursement of services and followsfederal and state guidance. Medical criteria for the provision of ABA services is located inCareSources Applied Behavior Analysis for Autism Spectrum Disorders medical policy at www. care source.com under the Provider tab. C. Definitions Medically Unlikely Edit (MUE) Maximum units of service for 1 Current Procedural Terminology (CPT) code a provider can report for 1 member on 1 date of service. D. PolicyI. General Provisions A. Reimbursement Rules 1. Members and providers must adhere to the associated Plans Evidence of Coverage document and schedule of benefits. 2. A review of medical necessity is required prior to any ABA service provision. 3. Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepayment review. 4. Providers cannot submit multiple dates of service on a single claim line. Each claim line must be specific to a single date of service and the units provided on that single date of service. 5. Covered services use fee schedule reimbursement methodology in which reimbursement is made at the lower of the billed charge for the service or the maximum allowable reimbursement for the service. The maximum allowable reimbursement for a service is the sa me for all ABA providers. 6. Preparing a member for services, cleaning or prepping an area before or after services, and/or rest or other break times between service activities is not billable. 7. Time spent on documentation alone is not billable as a service unless otherwise specifically permitted by code definition. B. Documentation Requirements States enact regulations and guidelines for documentation requirements for memberrecords maintained for third party billing. All written, electronic, and other records will be stored and disposed of in such a manner as to ensure confidentiality. All must beApplied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.3 legible. CareSource reserves the right to request supervision documentation,particularly related to telehealth services. 1. Member records should contain the following documentation: a. presenting problem, including referral reason, relevant diagnoses and any recommendations for ABA therapy rendered by an appropriate professional b. service note for each service contact c. any fee information shared with member/family in compliance with applicable laws, regulations and BACB ethical standards d. treatment plan and functional assessment on which the behavior plan is based e. any data collected to ascertain efficacy of services and subsequent modifications of the plan f. notation and results of formal contacts with other providers g. authorizations, if any, by the member/guardian for release of records or information 2. Minimum documentation requirements for all services rendered include a. name of provider organization clearly visible on the record b. members name on each page (ie, legal name) c. date of birth or unique identifier d. any applicable guardianship documents e. date and location of rendered service f. date of note creation if different from date of rendered service g. start and stop times including any pauses in services (must indicate time paused and time resumed) h. type/code of service provided i. rendering providers name, credentials, and dated signature j. dated signature of parent/guardian or member, if applicable , on documents (eg, treatment plan, plan of care, behavior support plans) k. identification of others present in all sessions (eg, individual, group, family), including the relationship with the member and the number of individuals participating in any group sessions l. summary of session activity that directly relates to the POC and member response to intervention m. addendum information, if applicable, including a clear reference of the clinical note it is intended to supplement, date completed and signature with credentials C. Supervision Expectations States require that appropriate supervision of services occur for any provider not acting independently, particularly if the provider is submitting a claim(s) for reimbursement. The BACB provides guidelines and documentation expectations for providers. If there are discrepancies with supervision documentation, the associated claims are subject to recoupment. CareSource expects providers to submit BACB – required documentation for supervision, if requested . II. Covered ServicesCovered services are only reimbursable when delivered in accordance with the members treatment plan or plan of care. Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.4 A. Behavior Assessment (BA)Th is service must be performed by a BCBA. Generally, BAs should not exceed 8 hours every 6 months unless additional justification is provided and authorization is received . The unit of service calculation should only include 1. face-to-face time spent by the BCBA with the member and/or parent/guardian conducting a comprehensive evaluation 2. any non-face-to-face time spent by the BCBA preparing the accompanying comprehensive evaluation report and developing the members initial ITP B. Behavior Identification Supporting Assessment An onsite physician or other qualified health care professional, with assistance from 2 or more technicians, administers a behavior identification supporting assessment of a member with serious destructive behavioral concerns (eg, harming oneself, damaging property, aggression with injury to others ) or behaviors resulting from recurring actions or issues related to communication or social interactions. The technicians spend face – to-face time with the member conducting the assessment, which includes exposure to a number of social and environmental elements associated with the maladaptive behaviors conducted in a structured and safe customized environment. Evaluation targeting certain destructive behaviors includes assessing triggers, events, cues, responses, an d consequences associated with the destructive behavior(s). 1. This service usually includes assessing /analyzing functional behavior and other structured observations, the use of standardized and non-standardized instruments, and procedures that will assist the clinician in establishing the degree of adaptive and maladaptive behaviors or impairments of the member . 2. Report only the time of 1 technician even when 2 or more technicians are present for each 15 minutes of face-to-face time provided by the technician. C. ABA Therapy Treatment Services These services must be performed one-on-one by a BCBA, BCaBA supervised by a BCBA, or an RBT supervised by a BCBA face-to-face with a member. If face-to-face services are provided to 2 or more members but no more than 8, group code(s) should be used . 1. The amount of ABA therapy treatment services performed during a week cannot exceed the prescribed or authorized number of units per week. 2. A week for these purposes is Monday through Sunday. D. Adaptive Behavior Treatment with Protocol Modification Services These services are reimbursed on a per unit basis. During the encounter, the provider solves at least 1 problem with the protocol and may, at the same time, coach a n RBT or BCaBA . The member must be present during the session, including instructions provided to the technician and/or caregiver. 1. This service with use of 2 or more technicians for serious destructive or harmful behaviors by members requires use of a different billable code. 2. The unit of service calculation should only include time spent supervising, observing and interacting in-person with the member and BCaBA or RBT under the BCBAs supervision. 3. Each BCaBA or RBT performing ABA therapy treatment services must be supervised by a BCBA responsible for the quality of the services rendered: Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.5 a. A supervising BCBA must be enrolled with the CareSource plan and meet the following minimum in-person observation thresholds for each BCaBA or RBT under supervision: 01. 5% of total ABA treatment hours performed by the BCaBA or RBT 02. 1 hour of ABA delivery performed by BCaBA or RBT every 30 days b. When not directly observing an ABA session, supervising BCBA must be on – call and immediately available to advise and assist throughout the entirety of any ABA session performed by a BCaBA or RBT. Availability by telecommunication is sufficient to meet this requirement. c. Supervising BCBA must review and approve the data collection and progress notes completed by a BCaBA or RBT under supervision prior to submitting a claim for any ABA therapy treatment services delivered. d. A BCBA delivering direct one-on-one treatment services to a member (ie, not supervising a BCaBA or RBT perform an ABA therapy treatment session) is not considered an adaptive behavior treatment with protocol modification service and must be billed as an ABA therapy treatment service. e. Adjusting and updating an existing ITP as required is considered an adaptive behavior treatment with protocol modification service. E. Family Adaptive Behavior Treatment Service Services must include the participation of a single members parent , guardian or other appropriate caregiver and must be performed by a BCBA. The member may or may not be present. During the session, the provider assists and documents helping parent(s)/caregiver(s) learn to identify behavioral problems and implement treatment strategies to minimize behavioral concerns while maximizing target behaviors. 1. Services are reimbursed on a per unit basis and should only include time spent collaborating face-to-face with the parent or guardian. 2. If the session involves multiple sets of parents/caregivers with the member s present, group family code(s) should be billed. F. Telemedicine Services Telemedicine services are reimbursed in the same manner and subject to the same limits as in-person, face-to-face service delivery. III. Codes of ConductCodes of conduct protect members by establishing, disseminating, and managing professional standards , and states mandate that these standards are followed. CareSource supports professional standards established by licensing and credentialing bodies and encourages professional compliance to any and all standards across disciplines for the protection of members and families. The ethics code written by the BACB should be maintained at all times. IV. Special Provisions Related to RBTsA. Current Standards for RBTs1. RBT services must be supervised by a qualified RBT supervisor. Services delivered by an RBT must be supervised by a BCBA, BCBA-D, or a licensed psychologist who tested in ABA and is certified by the American Board of Professional Psychology in Behavioral a nd Cognitive Psychology. Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.6 2. An RBT certified by the BACB may provide ABA under the supervision of an independent practitioner if affiliated with the organization under which the provider is employed or contracted. If the independent practitioner leaves the affiliated organization and no longer provides supervision, the RBT may not continue to provide services under that independent practitioner. Additionally, if the RBT leaves the affiliated organization and no longer receives mandated supervision, the RBT may not continue to provide services to the member. 3. RBTs must use appropriate modifiers that indicate qualifications of staff delivering services, if applicable. 4. CareSource will allow providers 60 days from the date of hire for RBTs to complete the RBT credentialing process with the BACB. B. Upcoming RBT Changes from the Behavior Analyst Certification Board 1. Effective January 1, 2026 , the BACB approved a recommendation that RBT supervisors must hold BCBA or BCaBA certification. During this transition, RBT Requirements Coordinators who currently attest to the qualifications of non – certified supervisors should prepare to ensure continuity of care . 2. Effective January 1, 2026 , the BACB adopted n ew rules regarding eligibility for and maintenance of certification for RBTs and can be located in the BACB Newsletter: December 2023 at www.bacb.com. V. ExclusionsReimbursement for the following services or activities is not permitted:A. reimbursement for the following services or activities is not permitted: 1. any services not documented in the treatment plan 2. behavioral methods or modes considered experimental /investigational 3. education-related services or activities described under Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. 1400 (IDEA), amended through Public Law 114-95, Every Student Succeeds Act 4. vocational services in nature or those available through programs funded under Section 110 of the Rehabilitation Act of 1973 5. components of adult day care programs B. treatment solely for the benefit of the family, caregiver or therapist or for symptoms/behaviors not part of core symptoms of ASD C. treatment that worsens symptoms, prompt s member regression or is unexpected to cause improvement D. services provided by family or household members or custodial care not re quiring trained ABA staff E. shadowing, para-professional, or companion services in any setting F. services more costly than an alternative service(s) likely to produce equivalent diagnostic or therapeutic result G. any program or service performed in nonconventional settings, even if performed by a licensed provider (eg, spas/resorts, vocational or recreational settings, Outward Bound, wilderness, camp or ranch programs ). Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.7 E. Conditi ons of CoverageI. CareSource complies with the Centers for Medicare and Medicaid Services (CMS) Medicaid Medically Unlikely Edit (MUE) table. If CMS updates the MUE list, the update will take precedence over this policy. II. Treatment codes are based on daily total units of service in 15-minute increments. A unit of time is attained when the mid-point is passed. The following are time interval examples: Unit(s) Number of Minutes 1 unit >8-22 minutes 2 units >23 – 37 minutes 3 units >38 – 52 minutes 4 units >53 – 67 minutes 5 units >68 – 82 minutes 6 units >83 – 97 minutes 7 units >98 – 112 minutes 8 units >113 – 127 minutes III. The following code set has been provided for informational purposes only. These codes may be used to identify a service as part of ABA treatment. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code i n this policy does not imply any right to reimbursement or guarantee claim payment. Please refer to the applicable fee schedule s and plan information for appropriate codes. CPT Codes Code Description97151 Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physicians or other qualified health care professionals time face-to-face with member and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan 97152 Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to- face with the member , each 15 minutes 97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one member , each 15 minutes 97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more member s, each 15 minutes 97155 Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one member , each 15 minutes Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.8 97156 Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the member present), face-to-facewith guardian(s)/caregiver(s), each 15 minutes97157 Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the member present), face-to-face with multiple sets of guardians /caregivers , each 15 minutes 97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple member s, each 15 minutes 0362T Behavior identification supporting assessment, each 15 minutes of technicians time face-to-face with a member , requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of 2 or more technicians; for a member who exhibits destructive behavior; completion in an environment that is customized to the member s behavior. 0373T Adaptive b ehavior treatment with protocol modification , each 15 minutes of technicians time face-to-face with a member , requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of 2 or more technicians; for a member who exhibits destructive behavior; completion in an environment that is customized to the member s behavior. F. State-Specific InformationNA G. Related Policies/RulesApplied Behavior Analysis for Autism Spectrum Disorder Medical policy H. Review/Revision HistoryDATE ACTIONDate Issued 08/27/2025 New policy. Approved at Committee.Date Revised Date Effective 12/01/2025 Date Archived I. References1. BACB Newsletter. Behavior Analyst Certification Board; 2023. Accessed August 19 , 2025. www.bacb.com 2. BACB Newsletter: Introducing the 2026 RBT Examination and Certification Requirements. Behavior Analyst Certification Board; 2023. Accessed April 3, 2025. www.bacb.com 3. Board Certified Behavior Analyst Handbook . Behavior Analyst Certification Board. Accessed August 19, 2025 . www.bacb.com 4. Board Certified Assistant Behavior Analyst Handbook . Behavior Analyst Certification Board. Accessed August 19, 2025 . www.bacb.com 5. Contents of a Request for a Waiver, 42 C.F.R. 441.301 (2024). Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.9 6. Ethics Code for Behavior Analysts . Behavior Analyst Certification Board . Accessed August19, 2025 . www.bacb .com 7. Georgia Marketplace Evidence of Coverage. CareSource; 2025. www.caresource.com 8. Indiana Marketplace Evidence of Coverage. CareSource; 2025. www.caresource.com 9. NCCI MUE Edits-Practitioner Services . Centers for Medicare and Medicaid Services. Updated April 1, 2025. Accessed August 19, 2025 . www.cms.gov 10. Ohio Marketplace Evidence of Coverage. CareSource; 2025. www.caresource.com 11. Registered Behavior Technician Handbook . Behavior Analyst Certification Board. Accessed August 19, 2025 . www.bacb.com 12. West Virginia Marketplace Evidence of Coverage. CareSource; 2025. www.caresource.com

Modifier 59, XE, XP, XS, XU

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-MP-PY-1367 10/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 59 , XE, XP, XS, XU B. BackgroundReimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Reimbursement modifiers are 2-character code s that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, their use does not guarantee reimburs ement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Usin g a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when 2 Healthcare Common Procedure Coding System(HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and ma nagement (E/M) services, that are not usually reported together, but are appropriate under the patients specific circumstance. NCCI guidelines s tate that providers should not use modifier 59 solely because 2 different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the 2 procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established four HCPCSmodifiers to define specific subsets of modifier 59 XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note tha t the Xmodifiers are more selective versions of modifier 59. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding review.A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims s ubmission, this will also result in a claims denial.IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59.VI. Modifier X {EPSU} (or 59 , when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available . Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 A. Modifier XS (or 59, when applicable) is for sur gical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed at different anatomic sites 2. are not ordinarily performed or encountered on the same day 3. cannot be described by 1 of the more specific anatomic NCCI Procedure to Procedure (PTP) -associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1 – T9, LC, LD, RC, LM, RI) B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed during different patient encounters 2. cannot be described by 1 of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91) C. Modifier XE (or 59, when applicable) may also be used when 2 timed procedures are performed during the same encounter but occur 1 after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are either: 1. performed at separate anatomic sites 2. performed at separate patient encounters on the same date of service E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when all the following apply: 1. diagnostic procedure is the basis for performing the therapeutic procedure 2. occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires 3. provides clearly the information needed to decide whether to proceed with the therapeutic procedure 4. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately. ) F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when all the following apply: 1. diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure 2. occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires 3. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the post-procedure diagnostic procedure is an inherent component or otherwise included (eg, not separately payable) post – procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately. ) E. State-Specific InformationNA Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 F. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.G. Related Policies/Rules Modifiers H. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised 08/02/2023 07/17 /2024 07/16/2025 Annual review: updated references, approved at Committee Review: updated references, approved at Committee Review: updated references, approved at Committee Date Effective 10/01/2025 Date Archived I. References1. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 202 5. Accessed J une 27, 2025 . www.cms.gov 2. Mechanized Claims Processing and Information Retrieval Systems; Operational, etc., Requirements, 42. U.S.C. 1396b(r) (2024). 3. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services; 2024. Accessed J une 27, 2025 . www.cms.gov 4. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicare and Medicaid Services. Updated April 11, 2025. Accessed J une 27, 2025 . www.cms.gov 5. MLN1783722 – Proper Use of Modifiers 59 & -X{EPSU}. US Centers for Medicare & Medicaid Services; 2024. Accessed J une 27, 2025 . www.cms.gov 6. Transmittal R1422OTN – Publication 100-20 – MM8863 – Specific Modifiers for Distinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Accessed J une 27, 2025 . www.cms.gov

Modifier 25

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 25-MP-PY-1363 10/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 25-MP-PY-1363Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 25 B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a 2-character code that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifier 25 is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association (AMA) Current Procedural Terminology (CPT ) book defines modifier 25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of mo difier 25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a medically necessary,significant, and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by documentation that satisfies th e relevant criteria for the respective E/M service to be reported (see E/M Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. This modifier is not used to report an E/M service tha t resulted in a decision to perform surgery. See modifier 57 for a surgical decision . For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier throu gh prepayment and post-payment edit or audit. Using a modifierinappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon Care Sources request. CareSource uses published guidelines fromModifier 25-MP-PY-1363Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 CPT and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.C. Definitions American Medical Association (AMA) A professional association of physicians and medical students that maintains the Current Procedural Terminology coding system. Current Procedural Terminology (CPT ) Codes that are issued, updated, and maintained by the AMA that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 25 may be flagged for either a prepayment clinical validation or prepayment medical record coding review .A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims s ubmission, this will also result in a claims denial.IV. Standard appeal rights apply for both pre-and post-payment findings and outco me s of the review. V. Modifier 25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of mo difier 25, the code may be denied.VI. Appending modifier 25 to an E/M service is considered inappropriate in the following circumstances: Modifier 25-MP-PY-1363Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period.B. The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure. C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. H. The preventative E/M service is performed at the same time as a preventative care visit (eg, a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preve ntative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation. J. CareSource will not reimburse CPT 99211 when billed with modifier 25. K. HCPCS G2211 will only be reimbursed when billed with modifier 25 for the following services: 1. preventive services 2. immunization administrations 3. annual wellness visits E. State-Specific InformationNA F. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.Modifier 25-MP-PY-1363Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 G. Related Policies/RulesModifiers H. Review/Revision HistoryDATE ACTIONDate Issued 07/20/2022 New PolicyDate Revised 08/02/2023 07/17/2024 07/16/2025 Annual Review: updated references. Approved at Committee Review: updated references, approved at Committee Review: added D.VI.J and K, updated references. Approved at Committee Date Effective 10/01/2025 Date Archived I. References1. American Medical Association. Reporting CPT modifier 25. CPT Assistant (Online). 2023;33(11):1-12. Accessed June 19, 2025. www.ama-assn.org 2. Appropriate use of modifier 25. American College of Cardiology. Accessed June 19, 2025. www.acc.org 3. Chaplain S. Are you using modifier 25 correctly. American Academy of Professional Coders. March 25, 2022. Accessed June 19, 2025. www.aapc.com 4. Chapter 1 General Correct Coding Policies for Medicare National Correct Coding Initiative Policy Manual . Centers for Medicare and Medicaid Services ; 2025 . Accessed June 19, 2025. www.cms.gov 5. Evaluation and Management Services Guide. Centers for Medicare and Medicaid Services; 2024. MLN006764. Accessed June 19, 2025. www.cms.gov 6. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag . 2004;11(9):21-22. Accessed June 19, 2025. www.aafp.org 7. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services ; 2024. Accessed June 19, 2025. www.cms.go v 8. Transmittal 13015 Publication 100-20 Allow Payment for Healthcare Common Procedure Coding System (HCPCS) Code G2211 when Certain Part BPreventive Services are Provided on the Same Day. US Centers for Medicare and Medicaid Services; 2024. Accessed July 10, 2025 . www.cms.gov

Digital EEG Spike Analysis

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Digital EEG Spike Analysis-MP-PY-1681 10/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Digital EEG Spike Analysis-MP-PY-1681Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDigital EEG Spike Analysis B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Epilepsy is a chronic brain disorder that affects approximately 1.2% of the US population or 3,700,000 people. Epileptic seizures are associated with a loss of awareness, fatigue, drowsiness, physical weakness, and confusion. Epilepsy seizures can be trigg ered bystress, dehydration, alcohol, toxic exposure, hormonal changes, sleep deprivation, and visual stimulation. Epilepsy and seizures are diagnosed with a detailed medical history, blood tests, developmental, neurological, and behavioral tests, and scan s and imaging techniques (eg, electroencephalography, computerized tomography, magnetic resonance imaging). Electroencephalography (EEG) is a diagnostic test that measures electrical activity in the brain. EEG is a non-invasive procedure where small electrodes are attached to thepatients scalp and the patient remains still or is instructed to perform specific tasks while brain wave patterns are recorded. Specific wave patterns are then used to help diagnose medical conditions (eg, epilepsy), sleep disorders, evaluate brain function, and monitor brain activity. Advances in digital technology have led to software and hardware applications that expand the capability to record brain wave forms, graph out brain wave patterns, and automatically detect brain wave spikes that are indicative of abnormal brain activity. There are several approaches to EEG monitoring, with short-term and long-term optionsthat can be either inpatient or outpatient. Long-term EEG with video (video-EEG) is often used to assess patients with difficult diagnostic/management after clinical evaluation and routine EEG. This is generally an inpatient procedure through an epilepsy monitoring unit or as continuous EEG (cEEG) monitoring in the hospital or in special care units. Another option is ambulatory EEG (aEEG) which can provide EEG recordings outside of the hospital or clinic. Long-term EEG helps to detect brain disturbances as they happen and can provide more information to adjust treatment. Abnormal EEG findings are often associated with epileptiform activity, such as epileptiform discharge. An epileptiform discharge represents disrupt ion in brain functionand is typically associated with spikes and sharp waves. Analy zing spikes and sharps with the accompanying slow waves helps localize seizure onset. When combined with clinical observation, prolonged monitoring via ambulatory EEG, and the recorded clinical Digital EEG Spike Analysis-MP-PY-1681Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 behavior provided by video EEG, spike analysis helps to diagnose epilepsy and other health conditions.C. Definitions Ambulatory EEG (aEEG) Monitoring Portable recording of EEG outside of the hospital or clinic setting. Can be done with simultaneous video recording. Often uses computer software to detect seizures and interictal epileptiform discharges (IED) to aid in interpretation. Digital EEG Systems that allow for the recording, analysis, and storage of EEG data. These systems often include software tools that can detect spikes and other abnormal brain patterns and can help visualize, quantify, and interpret the data. Dipole Analysis Localization and quantification of the sources of electrical activity in the brain, which helps understand the origins of conditions such as epilepsy. Epileptiform Activity Indicates cortical hyperexcitability, which is associated with an increased risk of seizures and the presence of an epileptic network in the brain. Sharp Waves Single epileptiform discharge defined by its duration and disruption of the EEG background. Spikes Sharp, transient waveforms that are clearly distinguished from background activity and indicate abnormal electrical activity in the brain. Spikes are often associated with seizures. o Simple Spikes Short, sharp waveforms. o Spike-and-Wave Patterns A combination of spikes followed by a slower wave that are often seen in certain types of epilepsy. Video-EEG Monitoring Synchronous recording and display of EEG patterns and video-recorded behavior. Procedure can be done in the outpatient EEG laboratory, in the home, or in a hospital inpatient setting. D. PolicyI. CareSource considers digital EEG spike analysis (CPT code 95957) medically necessary and therefore reimbursable when performed in conjunction with EEG for topographic voltage and/or dipole analysis. This applies specifically for pre-surgical evaluation with video-EEG long-term monitoring in members with intractable epilepsy, intracranial injuries, and concussions. II. All other indications for digital EEG spike analysis are not covered nor are reimbursable.III. The submitting provider is responsible for submitting accurate documentation to substantiate the coding of claims. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, th is will also result in a claims denial.E. State-Specific Information NA Digital EEG Spike Analysis-MP-PY-1681Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 06/18/2025 New policy. Approved at Committee.Date Revised Date Effective 10/01/2025 Date Archived I. References1. Baumgartner C, Pirker S. Video-EEG. Hanb Clin Neurol . 2019;160:171-183. doi:10.1016/B978-0-444-64032-1.00011-4 2. EEG, noninvasive. MCG Health, 28 th ed. Updated June 9, 2025. Accessed May 23, 2025. www.careweb.careguidelines.com 3. EEG, video monitoring. MCG Health, 28 th ed. Updated June 9, 2025. Accessed May 23, 2025. www.careweb.careguidelines.com 4. Eom TH. Electroencephalography source localization. Clin Exp Pediatr . 2022;66(5):201-209. doi:10.3345/cep.2022.00962 5. Epilepsy and seizures. National Institute of Neurological Disorders and Stroke. Accessed June 9, 2025. www.ninds.nih.gov 6. Feyissa AM, Tatum WO. Adult EEG. Handb Clin Neurol . 2019;160:103-124. doi:10.1016/B978-0-444-64032-1.00007-2 7. Guideline 8: guidelines for recording clinical EEG on digital media. American Clinical Neurophysiology Society. Accessed June 9, 2025. www.acns.org 8. Guideline 12: guidelines for long-term monitoring for epilepsy. American Clinical Neurophysiology Society. Accessed June 9, 2025. www.acns.org 9. Haider HA, Hirsch LJ, Sutherland HW. Electroencephalography (EEG) in the diagnosis of seizures and epilepsy. UpToDate. Updated April 29, 2025. Accessed June 9, 2025. www.uptodate.com 10. Hirsch LJ, Fong MWWK, Leitinger M, et al. American Clinical Neurophysiology Societys standardized critical care EEG terminology: 2021 version. JClin Neurophysiol . 2021; 38:1-29. doi: 10.1097/WNP.0000000000000806 11. Kobau R, Luncheon C, Greenlund K. Active epilepsy prevalence among U.S. adults is 1.1% and differs by educational level National Health Interview Survey, United States, 2021. Epilepsy Behav . 2023;142:109180. doi:10.1016/j.yebeh.2023.109180 12. Moeller J, Haider HA, Hirsch LJ. Video and ambulatory EEG monitoring in the diagnosis of seizures and epilepsy. UpToDate. Updated May 6, 2025. Accessed May 23, 2025. www.uptodate.com 13. Tatum WO, Halford JJ, Olejniczak P, et al. Minimum technical requirements for performing ambulatory EEG. JClin Neurophysiol . 2022;39(6):435-440. doi:10.1097/WNP.0000000000000950

Venipuncture and Laboratory Testing

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Venipuncture and Laboratory Testing-MP-PY-1618 09/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Venipuncture and Laboratory Testing-MP-PY-1618Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectVenipuncture and Laboratory Testing B. BackgroundN/A C. Definitions Venipuncture The insertion of a needle for a blood sample collection. D. PolicyI. Venipuncture is considered an incidental service when billed on a claim containing laboratory testing with the same place of service, for the same member, on the same date. Therefore, venipuncture is included in the reimbursement for the laboratory test performed and is not separately reimbursable. II. The following CPT codes are considered venipuncture: 36400, 36405, 36 406,34610, 36415, 36591, and 36592. III. CareSource may reimburse CPT code 36400, 36405, 36406, and 36410 when billed with Modifier 59 and/or 22, and appropriate documentation and the medical record reflect a distinct service requiring the skill of a qualified health care professional.IV. CareSource may conduct a post-payment review on claims with venipuncture and no other laboratory testing to ensure compliance. E. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and offic e staff are encouraged to use self-service channels to verify a members eligibility. Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes.Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource polic ies apply to both participating and nonparticipating providers and facilities. F. Related Policies/RulesModifier 59 Venipuncture and Laboratory Testing-MP-PY-1618Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Overpayment RecoveryG. Review/Revision HistoryDATE ACTIONDate Issued 05/21/2025 Approved at Committee.Date Revised Date Effective 09/01/2025 Date Archived H. ReferencesN/A

Reimbursement of Advanced Practice Nonphysician Practitioners

REIMBURSEMENT POLICY STATEMENT Marketplace Policy Name & Number Date Effective Reimbursement of Advanced Practice Nonphysician Practitioners-M P-PY-1662 09/01/2025 Kentucky Inactive 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Reimbursement of Advanced Practice Nonphysician Practitioners-MP-1662 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectReimbursement of Advanced Practice Nonphysician Practitioners B. BackgroundCenters for Medicare and Medicaid Services (CMS) established guidelines regarding reimbursement of advanced practice providers, initially categorized under non-physician practitioner s (NPP), i ncluding , but not limited to , physician assis tants (PA), nurse practitioners (NP) , clinical nurse specialists (CNS) , licensed social workers ( LSW), mental health counselors (MHC) and marriage family therapists (MFT). NPP s are health care providers who assess, diagnose, and treat patients but do notpossess the education or certification as a physician. NPP s work in both the medical/surgical realm and within behavioral health (BH) models that deliver psychotherapy, counseling and other substance use disorder services. Billing varies according to the level of the practitioner and field of practice. The scope of practice for each type of NPP will vary by state and is defined by state laws and regulations. Medical billing falls under 2 categories: direct billing and incident-to billing. Direct billinginvolves a claim that is submitted under the NPP s National Provider Identification (NPI)number with a reduced payment that is typically a percentage of the contracted fee schedule. Incident-to billing involves claim s submitted under the supervising physicians NPI that are paid at a higher percentage of the physicians fee schedule. CMS billing protocols ensure that healthcare providers deliver services efficiently whilecomplying with regulatory standards. Understanding guidelines is crucial to navigate the billing process successfully, optimize reimbursement, and maintain compliance with regula tions. This policy applies to services provided by NPP s within a medical or other healthcare practice and to both in-and out-of-network providers. CareSource recognizes licensed NPP s as a separate provider type when working under the supervisi on of a participating physician or doctorate-level provider . C. Definitions Consolidated Billing All claims for the entire package of care received by residents or inpatient members must be billed by the facility. D. PolicyI. General Reimbursement Guidelines A. If a practitioner or provider has a contract with CareSource that contract supersedes this policy direction and is the governing document. B. Providers are required and responsible for use of any applicable modifiers on claims, as necessary. C. Patients cannot be charged more than amounts permitted under federal law. If a member pays more for a service than the assign ed payment limits, the excess amount must be refunded. Reimbursement of Advanced Practice Nonphysician Practitioners-MP-1662 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. All providers must follow applicable CMS qualifications and criteria for direct and incident to billing , service requirements, coverage and documentation guidelines, and billing guidelines. 1. Direct billing criteria include the following: a. The service(s) provided is considered a physicians service and is a covered service under the members benefit plan. b. The service(s) provided is within the NPPs scope of practice for the applicable license/certification and state. c. Claims include assigned individual NPP NPI number. d. NPPs must be credentialed. 2. Incident to services criteria include the following: a. Services must be an integral (incidental) part of the members normal treatment when the physician performed an initial service and remains actively involved in the members care. b. Services are those commonly rendered without charge or included in the physicians bill. c. Billed services occurred in an office or clinic setting, not hospital inpatient or outpatient setting. d. Services must be provided under direct physician supervision (ie, supervising physician and NPP must be associated with the same practice and the supervising physician must be present in the location of service and immediately available to provide assistan ce and direction throughout the time the NPP is performing services). e. Physician involvement must be documented in the medical record. II. Physical Health or Medical/SurgicalCareSource reimburses the following physical health NPPs at the following rates: A. Certified Registered Nurse Anesthetists (CRNAs) are exempt from mid-level reductions in payment and paid at 100% of the Physician Fee Schedule (PFS). B. Anesthesiologist Assistants (A As) 1. Services are paid at 100% under the PFS or in accordance with the level of supervision provided. 2. Units are paid u nder the Anesthesia Fee Schedule and based on applicable locality adjusted anesthesia conversion factor multiplied by the sum of allowable base and time units (ie, 1 anesthesia time unit = 15 minutes anesthesia time ). C. Physician Assistants (PAs) 1. Incident to and incident to a PA services provided outside a hospital or SNF setting are paid at 85% of the amount a physician receives under the PFS. 2. Assistant-at-surgery services are paid 85% of 16% of the physician rate under the PFS. 3. When services are provided in the hospital setting (inpatient and outpatient), payment is unbundled and made directly to the PA under the PFS. D. Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs) Reimbursement of Advanced Practice Nonphysician Practitioners-MP-1662 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 1. Direct billing is paid at 80% of the lesser of the actual charge or 85% of the amount a physician receives under the PFS when furnished outside a hospital or skilled nursing facility (SNF) setting . 2. Assistant-at-surgery services are paid 85% of 16% of the amount a physician receives under the PFS. 3. Incident to services provided by auxiliary personnel outside a hospital or SNF setting are paid at 85% of the physician rate under the PFS. E. Certified Nurse Midwives (CNMs) 1. Direct billing is paid at 80% of the lesser of the actual charge or 100% of the amount a physician receives under the PFS. When billing directly for services in a hospital setting (inpatient and outpatient), payments are unbundled and paid under the PFS. 2. Covered drugs and biologicals provided incident to CNM services are paid according to Part Bdrug and biological payment methodology. 3. Incident to services provided outside a hospital or SNF setting are paid at 100% of the physician rate under the PFS. 4. Covered clinical diagnostic laboratory services are paid according to the Clinical Laboratory Fee Schedule. 5. When most of a global service is provided and a physician is called in to provide a portion of care or when the physician provides most of the service and calls in a CNM , payment will be based on the portion of the global fee that would be paid to the billing practitioner. Service modifiers would be used to report that not all covered global allowance services were provided. F. Other NPPs of physical health services NPPs not listed above will be paid at 8 5% of the physician rate under the PFS. III. Behavioral HealthCareSource reimburses NP Ps (eg, marriage and family therapist s, mental health counselors , licensed social worker s, substance abuse counselors ) at 75% of the clinical psychologist rate under the PFS . Clinical psychologists are paid 100% of the rate paid to physicians under the PFS. A. MFT and MHC services furnished to skilled nursing facility residents on or after January 1, 2024 are excluded from consolidated billing. B. There may be other billing exclusions related to BH billing by certain groups of NP Ps (eg, MFT/MHC services to inpatient of Medicare-participating hospitals, MFT/MHC services to client under partial hospitalization or intensive outpatient programs by hospital outpatient departments or community mental health centers). Providers are responsible for submitting claims appropriately. IV. Commodity ServicesThese services will not be subject to reductions when submitted on the same claim as an applicable service and will be reimbursed at 100% of the fee schedule allowance if covered under the members benefit plan, but not limited to, A. laboratory services B. after-hours services C. supplies Reimbursement of Advanced Practice Nonphysician Practitioners-MP-1662 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 D. injected or infused drugsE. diagnostic tests E. State-Specific InformationNA F. Conditions of CoverageI. Proper documentation is crucial to demonstrate compliance with supervision requirements , including maintaining clear records of services provided, the nature of the supervisory relationship, and any collaboration with the supervising physician or BH professional . CareSource reserves the right to request supervision documents or medical records that establish the validity of billed services. II. Additional criteria may exist for billing some services (eg, assistant-at-surgery ) that include the use of modifiers or other guidelines. Providers are responsible for billing these services according to federal and/or state guidelines. III. Paid claims submitted in violation of state and/or federal guidelines or filed incorrectly by providers , including a lack of modifier use, may be subject to recoupment.G. Related Policies/Rules NA H. Review/Revision HistoryDATE ACTIONDate Issued 06/04/2025 New policy. Approved at Committee.Date Revised Date Effective 09/01/2025 Date Archived I. References1. Advanced practice nonphysician practitioners. Centers for Medicare and Medicaid Services. Updated December 5, 2024. Accessed June 3 , 2025. www.cms.gov 2. Consolidated Appropriations Act, Sections 4113 and 4121(FF) (2023). 3. Incident to services and supplies. Centers for Medicare and Medicaid Services. Updated April 9, 2025 . Accessed June 3 , 2025. www.cms.gov 4. Marriage and family therapists. Centers for Medicare and Medicaid Services. Updated April 11, 2025. Accessed June 3 , 2025. www.cms.gov 5. Marriage and Family Therapist Services, 42 C.F.R. 410.53 (2023). 6. Medicare and Medicaid Programs. 42 CFR Parts 401, 405, 410, 411, 414, 423-425, 427, 428, and 491 (2024). 7. Medicare and Mental Health Coverage. Centers for Medicare and Medicaid Services; 2024. MLN1986542. Accessed May 3, 2025. www.cms.gov 8. Mental Health Counselor Services, 42 C.F.R. 410.54 (2023). 9. Payment for Physicians Services, 42 U.S.C. 1395, section 1848(g)(4)(A) (2018).

Urinalysis and Evaluation and Management Services

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Urinalysis and Evaluation and Management Services – MP-PY-1609 08/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Urinalysis and Evaluation and Management Services-MP-PY-1609 Effective Dat e: 08/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectUrinalysis with Evaluation and Management Services B. BackgroundThis policy provides guidance when billing urinalysis laboratory tests in conjunction with Evaluation and Management (E/M) services, on the same day, for the same member, by the same provider. Urinalysis laboratory tests are used to evaluate health and diagnose medical conditions using the physical, chemical, and microscopic properties of an individuals urine sample. The urin e sample is visually examined for color, clarity, and odor. A dipstick is used to examine the chemical properties of the urine sample for its pH, specific gravity, protein, glucose, ketones, bilirubin, urobilinogen, nitrites, and leukocyte esterase. A micr oscopic exam of urine measures the presence of red blood cells, white blood cells, epithelial cells, casts, crystals, and bacteria. The results of a urinalysis can help assess kidney function, monitor diabetes mellitus (DM) status, evaluate liver disease, for routine health screening, or alert the health care provider to the possible presence of a urinary tract infection (UTI), proteinuria, or hematuria. C. Definitions Evaluation and Management ( E/M) Service An interaction with a patient that involves a health care professional evaluating or managing a patients health, which may include office and other outpatient services, hospital inpatient services, consultations, ER visits, nursing facility services, a nd home care services. Outpatient Visit Physicians private office or group practice where members can be evaluated and treated by their provider. Routine Procedures Very common procedure (eg, diagnostic test or screen) that is performed in connection with another procedure (eg, collection of a clean-catch urine sample or a throat swab) or is included in a treatment protocol for which a composite payment amount has been established (eg, specific laboratory test performed for an individual receiving dialysis). D. PolicyI. Urinalysis tests (81002, 81003) are considered routine procedures when performed during an E/M visit in the outpatient setting. When urinalysis tests are conducted in conjunction with an E/M service on the same day, for the same member, by the same provider, the provider will not be reimbursed for the urinalysis tests. Only the E/M service wi ll be reimbursed. E. State-Specific InformationA. Georgia B. Indiana C. Kentucky D. Ohio E. West Virginia Urinalysis and Evaluation and Management Services-MP-PY-1609 Effective Dat e: 08/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 05/07/2025 New policy. Approved at Committee.Date Revised Date Effective 08/01/2025 Date Archived I. ReferencesNA

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