REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Coding Guidelines-MP-PY-1714 11/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsB. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Coding Guidelines-MP-PY-1714Effective Dat e: 11/01/20262A. SubjectCoding Guidelines B. BackgroundCode assignment for claims is based upon the providers (ie, physician or other qualified healthcare practitioner legally accountable for establishing the patients diagnosis) documentation outlining the relationship between the condition and the care or procedure, unless otherwise ins tructed by the classification. There must be a cause-and – effect relationship between the care provided and the condition. ICD-10 guidelines are a set of rules regarding the classification of diagnoses andreasons for health care visits in all settings based on the statistical classification of disease published by the World Health Organization. These guidelines are approved b y the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare and Medicaid Services (CMS), and the National Center for Health Statistics (NCHS). Under the Health Insurance Portability an d Accountability Act (HIPAA), adherence to these guidelines is mandatory. In addition to general coding guidelines outlined by the ICD-10 manual, additionalguidelines are provided within for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings .The Current Procedural Terminology (CPT) is the official code set for compliance mandated by HIPPA for healthcare procedures and services. These codes are developed and maintained by the American Medical Association (AMA). These codes and their guidelines are designed to communicate as a statistical classification ofclinically recognized and generally accepted services provided by healthcare professionals. The use of these codes and guidelines simplifies the reporting and processing of services for advance d analytics of these procedures.CPT includes the use of modifiers to clarify the service that is being reported. Using modifiers increases reimbursement accuracy and coding consistency. In billing, medical necessity is demonstrated by the diagnosis code assigned (ie, ICD-10) and whether thedocumented elements are consistent with the problems addressed (ie, CPT).The Medica re National Correct Coding Initiative (NCCI) aims to reduce improperpayments. It includes edits for Procedure-to-Procedure (PTP ), Medically Unlikely Edits(MUE), and Add-on Code (AOC). Claims denied by NCCI edits are based upon a determination of inappropriate coding and not on the basis of medical necessity. Clinical judgment is not needed to deny a claim based on correct coding. C. Definitions Claim A bill for services, a line item of services, or all services for one recipient within a bill. Claim Adjustment A claim that has b een incorrectly submitted or, as the result of an updated payment policy, payment amount can be changed. Coding Guidelines-MP-PY-1714Effective Dat e: 11/01/20263 Clean Claim A claim received by CareSource for adjudication, in a nationally accepted format in compliance with standard coding guidelines, which requires no further information, adjustment, or alteration by the Provider of the services in order to be processed and paid by CareSource. D. PolicyI. Claims are to be submitted in accordance with NCCI and the coding standards set forth in the following guides: A. the healthcare common procedure coding system B. the current procedural terminology codebook C. the current dental terminology codebook D. the internal classification of diseases handbook II. When adjudicating claims, CareSource utilizes code editing software to help evaluate the accuracy of diagnosis and procedure codes on submitted claims to ensure claims are processed consistently, accurately, and efficiently. The software helps evaluate the accuracy of the procedure code only, not the medical necessity of the procedure.The edits utilized include the following: A. Medicare and/or Medicaid NCCI Policy Manual B. ICD-10 guidelines C. CPT guidelines D. HCPCS guidelines E. CMS published materials, as applicable F. state and federal statutes and regulations G. other recognized industry standards, as applicable III. Per ICD-10 guidelines, there must be a cause-and-effect relationship between the care provided and the condition. As such, the ICD-10 diagnosis and the CPT/HCPCS code demonstrate this through analytics in coding software. Claims may be denied due to an imp roper grouping of codes. E. State-Specific InformationN/A F. Conditions of CoverageN/A G. Related Policies/RulesN/A H. Review/Revision History DATE ACTIONDate Issued 11/05/2025 Approved at Committee.Date Revised 08/12/2026 Approved at Committee. Date Effective 11/01/2026 Date Archived Coding Guidelines-MP-PY-1714Effective Dat e: 11/01/20264I. References1. 202 6 ICD-10-CM Official Guidelines for Coding and Reporting. AAPC; 202 6. 2. CPT Codes. American Medical Association. Accessed July 15, 2026 . www.ama – assn.org 3. Current Procedural Coding Expert. American Medical Association; 202 6. 4. Medicaid NCCI Coding Policy Manual . Centers for Medicare and Medicaid Services; 2025. 5. Medicare NCCI Coding Policy Manual . Centers for Medicare & Medicaid Services ; 2025 . Accessed July 15, 2026 . www.cms.gov
REIMBURSEMENT POLICY STATEMENTOhio Marketplace Policy Name & Number Date Effective Payment to Out of Network Providers-OH MP-PY-1800 09/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Payment to Out of Network Providers-OH MP-PY-1800Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectPayment to Out of Network Providers B. BackgroundEstablishing clear policies for payment to out-of-network (OON) providers is essential to balance member access to care, cost containment, and regulatory compliance. While Marketplace plans generally do not cover services from OON providers without prior authorization, exceptions exist particularly for emergency situations ensuring members receive necessary care when in-network options are not available or appropriate. CareSource outlines a structured reimbursement methodology for OON services that are prea uthorized and medically necessary, using standardized benchmarks like Medicare fee schedules to promote fairness and predictability in payments. This approach helps control healthcare costs while maintaining network adequacy and protecting members from une xpected financial burdens. Additionally, adherence to federal laws, such as the No Surprises Act, safeguards members rights in emergency scenarios, reinforcing the CareSources commitment to consumer protection within the commercial exchange environment. This policy defin es the reimbursement rate for claims received from providers notcontracted (out of network) with CareSource.C. Definitions Out of Network Provider A p rovider not contracted with CareSource . D. PolicyI. Services provided by out-of-network providers are not covered under Marketplace Plans and require prior authorization ; however, exceptions exist. For those situations where CareSource is required to provide out-of-network coverage and the reimbursement methodology is not defined, CareSources standard reimbursement approach to out-of-network (OON) providers is as follows: A. Prior authorization is required for all services rendered by OON providers unless otherwise required by applicable law, regulation, contract, or Plan policy. Exceptions include emergency services and other services for which prior authorization cannot be required under federal or state requirements. B. Requests for service s provided by an OON provider will be reviewed on a case – by-case basis to determine medical necessity, network adequacy, and benefit eligibility. Failure to obtain required prior authorization may result in denial of coverage or reimbursement. C. Preauthorized, medically necessary services rendered to CareSource members by out-of-network providers will be reimbursed at 1. 60% of the applicable Medicare fee schedule 2. If a service or procedure is not priced by Medicare , then the service or procedure will be reimbursed at 20% of billed charges. Payment to Out of Network Providers-OH MP-PY-1800Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 NOTE: Approved authorization does not ensure payment.II. In the event of emergency services, CareSource will adhere to the Federal No Surprises Act, January 1, 2022. A. No p rior authorization is required for emergency services. B. Emergency health care services , not otherwise subject to the No Surprises Act , will be reimbursed based on State regulations . III. In the event of any conflict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document.IV. ExclusionsThe following will be reimbursed at 100% of the Medicare rate : A. home health services B. hospice C. private duty nursing (PDN) D. all services in a Federally Qualified Health Center (FQHC), Rural Health Clinics (RHC) and Indian Health Clinics E. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and policy clari fication. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 12/14/2022 New policy. Approved at Committee.Date Revised 07/29 /2026 Period ic review. Policy number changed from PY-1359. Removed Covid testing language. Updated background, D. I,A,B,C for greater clarification and references. Approved at Committee. Date Effective 09/01/2026 Payment to Out of Network Providers-OH MP-PY-1800Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Date ArchivedH. References1. Fuchs B, Hoadley J. Summary of the No Surprises Act . Center on Health Insurance Reform, Georgetown University; 202 1. Accessed July 1, 2026 . www.commonwealthfund.org 2. Managed Care: Out-of-Network Care H-285.904 . American Medical Association. Updated 2025. Accessed July 1, 2026 . www.policysearch.ama-assn.org 3. Reports, Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, 134 Stat. 2859 (2020). Accessed July 1, 2026. www.govinfo.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective E/M – Preventive and Acute Care Visit on Same Date of Service-MP-PY-1388 10/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. …. 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. …… 3 I. References ………………………….. ………………………….. ………………………….. …………………….. 3 E/M – Preventive and Acute Care Visit on Same Date of Service-MP-PY-1388 Effective Date: 10/01/2026 2 A. SubjectE/M Preventive and Acute Care Visit on Same Date of Service B. BackgroundCareSource will reimburse participating providers for medically necessary and preventive screening tests as required by federal statue through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF). C. Definitions Preventive Services Exams and screenings that check for health problems with the intention to prevent any problem discovered from worse ning and may in clude, but are not limited to, physical checkups, hearing, vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider for prev entive services are encouraged at every age but are especially important for children under the age of 18 years. D. PolicyI. When any of the following preventive health service codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse only the preventive service code at 100%. The acute care visit service codes will no t be reimbursed unless billed with the appropriate modifier to identify separately identifiable services that were rendered by the same physician on the same date of service. A. Preventive Health Service Codes 1. 99381-99387 2. 99391-99397 B. Acute Care Visit Codes 1. 9920 2-99205 2. 9921 2-99215 II. CareSource reserves the right to request documentation to support billing both services for all claims received. The provider may need to indicate that in the process of performing a preventive/wellness health service, an abnormality was encountered or a new or existing problem was addressed, and the problem or abnormal finding was significant enough to require additional work t o perform the key components of a problem-focused (acute care) evaluation and management (E/M) service. Documentation must support the following: A. A separately identifiable service significant enough to require additional work to perform the key components of a problem-focused (acute care) E/M service . B. Acute care service may be billed based on time or medical decision making (MDM). 1. If billed based on time, documentation must reflect start/stop or total time spent. If time is used for selection, then the time spent on the preventive service cannot be counted toward the time of the work of the problem assessment, because time spent can not be counted twice. Please see the E/M – Preventive and Acute Care Visit on Same Date of Service-MP-PY-1388 Effective Date: 10/01/2026 3 American Medical Association (AMA) Guidelines for Selecting Level ofService Based on Time. 2. If billed based on MDM, documentation must support the level of service based on AMA Medical Decision-Making Guidelines . 3. A medically appropriate history and physical exam, when performed. E. State-Specific InformationOhio: For the purposes of this policy, physician and provider are defined as a physician or other health care provider of the same group reporting the same federal tax identification number. F. Conditions of CoverageReimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify member eligib ility. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes along with appropria te modifiers. Please refer to the CMS fee schedule for appropriate codes.G. Related Policies/Rules Modifier 25 Reimbursement policy H. Review/Revision HistoryDATE ACTIONDate Issued 09/14/2022Date Revised 01/17/2024 11/5/2025 03/11/26 07/01/26Annual Review; Approved at Committee.Annual Review, Approved at Committee. Added D.II. and criteria under E. Approved at Committee. D.II. removed Other E/M codes . Approved at Committee . Date Effective 10/01/2026 Date Archived I. References1. Coverage of Preventive Health Services, 26 C.F.R. 54.9815-2713 (202 5). 2. CPT Evaluation and Management (E/M) Code and Guideline Changes . American Medical Association; 202 3. Accessed July 1, 2026 . www.ama-assn.org 3. Evaluation and Management Services Guide. Centers for Medicare and Medicaid Services; 2024. MLN4824456. Accessed July 1, 2026 . www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulators-MP-PY-1387 09/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreement, then the plan contract and/or provider agreement will be the controlli ng document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not subject to limits or requirements that are mo re restrictive than those that apply to M/S benefits.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of Contents A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. State-Specific Information ………………………………………………………………………………………. 3 F. Conditions of Coverage …………………………………………………………………………………………. 3 G. Related Policies/Rules …………………………………………………………………………………………… 4 H. Review/Revision History ………………………………………………………………………………………… 4 I. References ………………………………………………………………………………………………………….. 4Transcutaneous Electrical Nerve Stimulators-MP-PY-1387 Effective Date : 09/01/2026 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d. 2A. SubjectTranscutaneous Electrical Nerve Stimulat ors B. Background Transcutaneous electrical nerve stimulat ion (TENS) devices produce a mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the skin. C. Definitions Supplies Typically disposable items used with a TENS machine, which includes, but is not necessarily limited to, electrodes of any type, lead wires, conductive paste or gel, adhesive, adhesive remover, skin preparation materials, batteries, and battery charger for rechargeable batteries. Transcutaneous Electrical Nerve Stimulation (TENS) The application of mild electrical stimulation to skin electrodes placed over an area of the body experiencing pain, which causes interference with the transmission of pain. TENS requires a stimulator, a type of durable medical equipment (DME). D. Policy I. TENS units may require medical necessity review. II. CareSource reimburses for TENS units and supplies based on the Centers for Medicare & Medicaid Services (CMS) guidelines. III. TENS units are reimbursed on a 13-month rent-to-purchase basis, after a successful 1-month, non-reimbursable trial period. IV. Documentation A. For post-operative pain, an attestation must be available for review upon CareSources request, confirming that treatment lasting no longer than 30 days is needed for acute pain following surgery and includes the date of surgery. B. An attestation that the use of a comparable TENS unit for a trial period of at least 30 days produced substantial relief from pain must be completed and available for review upon CareSources request. C. Regarding a TENS unit that was not originally reimbursed by CareSource, documentation to confirm medical necessity must be available for review upon CareSources request before reimbursement is made for supplies or repair. D. The provider must also provide the member with verbal instruction on the use of the TENS unit and maintain written documentation regarding the instruction in the members medical record. V. Rental of a TENS unit to treat post-operative pain is limited to a single 30-day period and may not be extended. Modifier RR should be used in this case. Transcutaneous Electrical Nerve Stimulators-MP-PY-1387 Effective Date : 09/01/2026 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d. 3VI. Reimbursement for the purchase of a TENS unit may be made if the prescribing provider attests to the medical necessity of continued use of the TENS units (after the successful 1-month, non-reimbursable trial period). VII. Supplies A. Supplies are not reimbursable during the trial period. B. Supplies are not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase, CareSource covers only 1 unit of supplies (A4595) per month for a 2-lead TENS unit (E0720) or 2 units per month for a 4-lead TENS unit (E0730). D. After a TENS unit has been purchased for an individual, regardless of payment source: 1. Separate payment may be made for necessary supplies, which must be dispensed only when they are needed at a frequency not to exceed once per month. 2. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 3. No separate payment is allowed for individual supply items. E. If a submitted claim does not include a modifier or includes an incorrect or inappropriate modifier, the claim may deny.E. State-Specific Information NA F. Conditions of Coverage These proprietary policies are not a guarantee of payment. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. It is the responsibility of the submitting provider to submit the most accurate and appropriate HCPCS /CPT code(s) for the product or service that is being provided. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes are provided as a reference. This list may not be all inclusive and is subject to updates. HCPCS Code Description E0720 TENS unit, 2-lead, localized stimulation (includes supplies during rental ) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation ( includes supplies during rental ) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead ( for a recipient-owned unit ) Modifiers DescriptionRR Rental (use the ‘RR’ modifier when DME is to be rented) NU Purchase of new equipment Transcutaneous Electrical Nerve Stimulators-MP-PY-1387 Effective Date : 09/01/2026 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d. 4G. Related Policies/Rules NA H. Review/Revision History DATE ACTIONDate Issued 10/26/2022Date Revised 12/13/2023 12/18/2024 11/19/2025 06/17/2026Annual review: updated code list and references. Approved at Committee. Review: updated references, approved at Committee. Review: updated references, approved at Committee. Review: removed requirement for CMS 848. Approved at Committee.Date Effective 09/01/2026 Date Archived I. References1. Gibson W, Wand BM, Meads C, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic pain an overview of Cochrane r eviews. Cochrane Database Syst Rev . 2019;4:CD011890. doi:10.1002/14651858.CD011890.pub3 2. Johnson MI, Paley CA, Wittkopf PG, et al. Characterising the features of 381 clinical studies evaluating transcutaneous electrical nerve stimulation (TENS) for pain relief: a secondary analysis of the meta-TENS study to improve future research. Medicina (Kaunas) . 2022;58(6):803. doi:10.3390/medicina58060803 3. Johnson MI, Paley CA, Jones G, et al. Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: a systematic review and meta-analysis of 381 studies (the meta-TENS study). BMJ Open. 2022;12(2):e051073. doi:10.1136/bmjopen-2021-051073 4. Local Coverage Article: Transcutaneous Electrical Nerve Stimulators (TENS). Medicare Coverage Database; 2015. LCA ID A52520. Revised January 1, 2023. Accessed March 30, 2026. www.cms.gov 5. Local Coverage Determination: Transcutaneous Electrical Nerve Stimulators (TENS). Medicare Coverage Database ; 2015. LCD ID L33802. Revised January 1, 2024. Accessed June 2, 2026. www.cms.gov 6. Vance CGT, Dailey DL, Chimenti RL, et al. Using TENS for pain control: update on the state of the evidence. Medicina. 2022;58(10):1332. doi:10.3390/medicina58101332
REIMBURSEMENT POLICY STATEMENTOhio Marketplace Policy Name & Number Date Effective Evaluation and Management (E&M) Codes Billed with Treatment/Specialty Room Revenue Codes-OH MP-PY-1830 09/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlli ng document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not subject to limits or requirements that are mo re restrictive than those that apply to M/S benefits.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Evaluation and Management (E&M) Codes Billed withTreatment/Specialty Room Revenue Codes-OH MP-PY-1830Effective Dat e: 09/01/2026 2A. SubjectEvaluation and Management (E&M) Codes Billed with Treatment /Specialty Room Revenue Codes B. BackgroundThis policy outlines the guidelines for evaluation and management (E&M) codes billed with treatment /specialty room revenue codes. Treatment /specialty room revenue codes characterize services that are procedure-based in a facility setting. These charges are typically billed using a UB-04 institutional /facility claim form. E&M codes characterize eva luation and management services performed in an office-based setting and do not represent a specific procedure performed in a treatment/specialty room. These charges are typically billed using a CMS-1500 practitioner claim form. Billing E &Ms ervices using any revenue code outlined within this policy does not align with t he UB-04 manual and Uniform Billing Editor (2020) and therefore should be avoided. C. Definitions CMS-1500 A standard claim form that professional providers and medical billing professionals use to bill insurance companies for health care services. Evaluation and Management (E&M) Codes Services reported by physician and non-physician practitioners which the provider is either evaluating or managing a patients health. Revenue Code A 4-digit number that is used on hospital bills to inform insurance companies either where the patient was when they received treatment, or what type of item a patient may have received as a patient. Treatment /Specialty Room A room in a facility where a specific procedure or treatment is rendered. UB-04 Claim form used by hospitals and other providers to bill for institutional services. A valid procedure code must accompany a revenue code for it to be accepted by the insurance provider. D. PolicyI. CareSource does not reimburse E&M codes when performed and billed using revenue codes associated with a general room, treatment room or other room . II. Billing treatment /specialty room revenue codes is incorrect coding when reported for office-based evaluation and management services. III. Revenue codes not reimbursable when billed with E &M codes Revenue Code Description 0760 General Specialty Services 0761 Treatment Room Specialty Services 0769 Other Specialty Services IV. CPT/HCPCS codes not reimbursable when billed with revenue codes listed aboveEvaluation and Management (E&M) Codes Billed withTreatment/Specialty Room Revenue Codes-OH MP-PY-1830Effective Dat e: 09/01/2026 3CPT/HCPCS Code Description99202-99499 Evaluation and Management Services G0463 Hospital outpatient clinic visit for assessment and management of a patient E. Conditions of CoverageClaims submitted with revenue codes in conjunction with an evaluation and management cod es (CPT/HCPCS) codes listed within this policy will be denied . Reimbursement policies are designed to assist providers when submitting claims to CareSource. These policies are routinely updated to promote accurate coding and policy clarification. Reimbursement will be established based upon a review of the actual serv ices provided to a member and will be determined when the claim is received forprocessing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. Reimbursement i s dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers, if applicable. Codes referenced in this payment policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 06/17/2026 New policy. Approved at Committee.Date Revised Date Effective 09/01/2026 Date Archived H. References1. CPT. Accessed June 04, 2026. www.ama-assn.org 2. Evaluation and Management (E &M) Coding. Accessed June 04, 2026. www.ama – assn.org 3. Facility fees and how they affect health care prices. Health Care Cost Institute. Accessed June 04, 2026. www.healthcostinstitute.org 4. Healthcare Common Procedure Coding System (HCPCS). Accessed June 04, 2026. www.cms.gov 5. Professional paper claim form (CMS-1500). Centers for Medicare & Medicaid Services. Modified September 10, 2024. Accessed June 04, 2026. www.cms.gov 6. Revenue Codes. Medicare Claims Processing Manual Chapter 25 – Completing and Processing the Form CMS-1450 Data Set. Centers for Medicare & Medicaid Services; 2023. Accessed June 04, 2026. www.cms.gov Evaluation and Management (E&M) Codes Billed withTreatment/Specialty Room Revenue Codes-OH MP-PY-1830Effective Dat e: 09/01/2026 47. Uniform Billing with Form CMS-1450. Medicare Claims Processing Manual Chapter25 – Completing and Processing the Form CMS-1450 Data Set. Centers for Medicare & Medicaid Services; 2023. Accessed June 04, 2026. www.cms.gov 8. What are E &M Codes? Accessed June 04, 2026 . www.aapc.com 9. What is outpatient facility coding and reimbursement. AAPC. Reviewed April 29, 2026. Accessed June 04, 2026. www.aapc.com
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Diagnostic Colonoscopy and/or Sigmoidoscopy – MP-PY-1594 09/01/2026 IN, OH, WV inactive as of 01/01/2027 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Diagnostic Colonoscopy and/or Sigmoidoscopy-MP-PY-1594Effective Dat e: 09/01/20262A. SubjectDiagnostic Colonoscopy and/or Sigmoidos copy B. BackgroundColo no scopies and sigmoidoscopies pertain to procedures that involve direct visual examination of the lower gastrointestinal tract using a flexible tube fitted with a camera. The procedures identify polyps, tumors, and other intestinal irregularities or health i ssues and are performed by medical professionals, typically gastroenterologists or colorectal surgeons. Both procedures are valuable tools in diagnosing and monitoring gastrointestinal conditions. Specific clinical indications and area of examination deter mine w hich procedure will be utilized. There are different billing procedures for screening versus diagnostic colonoscopies andsigmoidoscopies. Screening procedures are typically performed as part of preventive services for cancer or other health issues. Diagnostic procedures may be performed in the presence of symptoms, abnormal findings, prior abnormal screening results, or other clinical indications supporting diagnostic evaluation. Some screening procedures can become diagnostic procedures when abnorma l findings are identified requiring intervention, biopsy, polypectomy, or additional evaluation. Both screening and diagnostic procedures utilize the same equipment, so providers must maintain thorough documentation in the members medical record to substantiate medical necessity of these tests and differentiate between screening and diagnostic tests . This policy exclusively pertains to diagnostic colonoscopies and does not apply topreventive screenings that follow US Preventive Services Task Force (USPSTF) or other preventive guidelines. Refer to the appropriate Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes for screenings (ie, G0104, G0105, G0121). Providers are encouraged to use modifiers when procedures meet modifier criteria. C. Definitions Colonoscopy A procedure in which a provider inserts a flexible tube fitted with a camera through the anus into the rectum to examine the entire length of the colon from the rectum to the cecum and may include the terminal ileum allowing for screening and diagnosis of health issues. Sigmoidoscopy A procedure similar to a colonoscopy that examines the lower third of the large intestine , the rectum, sigmoid colon and possibly a portion of the descending colon, for screening and diagnosing health conditions. D. PolicyI. CareSource requires appropriate documentation of medical necessity and valid diagnosis codes for reimbursement of diagnostic colonoscopies and sigmoidoscopies. Claims submitted without supporting medical necessity or correct coding will be denied. Documentation requirements include A. an assessment of the member by the ordering provider as related to the complaint for that visit B. relevant medical history Diagnostic Colonoscopy and/or Sigmoidoscopy-MP-PY-1594Effective Dat e: 09/01/20263C. results of pertinent tests/procedures , if known , or if results are normal or did not provide a diagnosis during a diagnostic colonoscopy, the symptom(s) for which the endoscopy was performed D. signed and dated office visit record/operative report E. precise areas scoped and depth reached during the procedure II. CareSource follow s Centers for Medicaid and Medicare Services (CMS) guidelines regarding billing for diagnostic colonoscopies and sigmoidoscopies . A. Reimbursement requests must include a procedure code with a diagnosis code that best describes the condition for which the service was performed. B. If the service begins as a screening procedure but results in a diagnostic or therapeutic procedure at the same operative session, health care providers should report an appropriate screening I nternational Classification of Diseases (ICD) diagnosis code as the primary diagnosis and the diagnostic or abnormal finding ICD diagnosis code as the secondary or subsequent diagnosis. C. If the member is symptomatic or the claim for these services indicates a primary diagnosis of something other than preventive or wellness, colonoscopy examinations will be covered under a diagnostic benefit, not a Preventive Health Care Services benefit. E. Conditions of CoverageI. ICD-10 codes must be coded to the highest level of specificity. CareSource develops reimbursement policy guidelines following evaluation and validation of provider billing in accordance with various methodologies (eg, CPT publications, AMA publications, Medicare ). CareSource uses clinical editing software to evaluate the accuracy of diagnosis and procedure codes on submitted claims to ensure that claims are processed consistently, accurately and efficiently and strives to follow the prevailing National Correct Coding Initiative (NCCI) edits as maintained by CMS . Coding industry standards, such as the CPT Manual , CCI and input from medical specialty societies , are used to review multiple aspects of a claim for coding reasonableness , including diagnosis to procedure matching , currently valid CPT/HCPCS codes, modifier usage or bundling issues . Any specific claim is subject to current CareSource claim logic and other established coding benchmarks. Any consideration of a providers claim payment concern regarding clinical edit logic will be based upon review of generally accepted coding standards and the clinical information particular to the specific claim in question. II. CareSource reserves the right to request medical record documentation from providers.F. Related Policies/RulesMedical Necessity Determinations Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 03/26/2025 New policy. Approved at Committee.Diagnostic Colonoscopy and/or Sigmoidoscopy-MP-PY-1594Effective Dat e: 09/01/20264Date Revised 06/17 /2026 Review: updated background and references. Approved atCommittee. Date Effective 09/01/2026 Date Archived H. References1. American Society for Gastrointestinal Endoscopy Standards of Practice Committee; Early DS, Ben-Menachem T, Decker G, et al . Appropriate use of GI endoscopy. Gastrointest Endosc . 2012;75(6):1127-1131. doi:10.1016/j.gie.2012.01.1 2. Colonoscopy ACG: A-0129. MCG. 30 th ed. Updated January 25, 2026 . Accessed June 12, 2026 . www.careguidelines.com 3. Colonoscopy. American Cancer Society. Updated February 3, 2026. Accessed April 30, 2026 . www.cancer.org 4. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions. 42 CFR 410.32 (202 5). 5. Flexible sigmoidoscopy. Mayo Clinic. Updated July 9, 2024. Accessed April 30, 2026. www.mayoclinic.org 6. Georgia Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 30, 2026 . www.caresource.com 7. Georgia Marketplace Provider Manual . CareSource; 202 6. Accessed April 30, 2026. www.caresource.com 8. Indiana Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 30, 2026 . www.caresource.com 9. Indiana , Kentucky and West Virginia Marketplace Provider Manual . CareSource; 202 6. Accessed April 30, 2026 . www.caresource.com 10. Kentucky Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 30, 2026 . www.caresource.com 11. LCD Reference Article: Billing and Coding: Colonoscopy and Sigmoidoscopy – Diagnostic. Medicare Coverage Database; 2019. LC DID A56394. Updated January 1, 2025 . Accessed April 30, 2026 . www.cms.gov 12. LCD Reference Article: Billing and Coding: Colonoscopy and Sigmoidoscopy – Diagnostic. Medicare Coverage Database; 2019. LC DID A56456. Updated February 20, 2026 . Accessed April 30, 2026 . www.cms.gov 13. LCD Reference Article: Billing and Coding: Colonoscopy/Sigmoidoscopy/ Proctosigmoidoscopy. Medicare Coverage Database; 2019. LC DID A56632. Updated August 14 , 2025. Accessed April 30, 2026 . www.cms.gov 14. Local Coverage Determination: Colonoscopy and Sigmoidoscopy-Diagnostic. Medicare Coverage Database; 2015. LCD ID L34614. Updated August 2 1, 2024. Accessed April 30, 2026 . www.cms.gov 15. Local Coverage Determination: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy. Medicare Coverage Database; 2015. LCD ID L34005. Updated February 20, 2026 . Accessed April 30, 2026 . www.cms.gov 16. Local Coverage Determination: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy. Medicare Coverage Database; 2015. LCD ID L34454. Updated December 1 3, 2024. Accessed April 30, 2026 . www.cms.gov 17. Ohio Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 30, 2026 . www.caresource.com Diagnostic Colonoscopy and/or Sigmoidoscopy-MP-PY-1594Effective Dat e: 09/01/2026518. Ohio Marketplace Provider Manual . CareSource; 202 6. Accessed April 30, 2026 .www.caresource.com 19. Sigmoidoscopy ACG: A-0128. MCG. 30 th ed. Updated January 25, 2026 . Accessed June 12, 2026 . www.careguidelines.com 20. West Virginia Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 30, 2026 . www.caresource.com
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Partial Hospitalization Program-Behavioral Health – MP-PY-1480 09/01/2026 IN, OH, WV inactive as of 01/01/2027 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Partial Hospitalization Program-Behavioral Health-MP-PY-1480 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectPartial Hospitalization Program Behavioral Health B. BackgroundPartial hospitalization programs (PHPs) provide intensive psychiatric or substance use disorder (SUD) care through active, structured treatment combining clinically recognized services under 1861(ff) of the Social Security Act. Programs resemble short-ter m inpatient hospital programs but are less intensive than inpatient care. PHPs use individualized treatment plans with multidisciplinary coordination led by a qualified provider. Treatment goals must be measurable, time-bound, medicallynecessary, and related to the admission reason. A qualified provider must certify that member s require at least 20 hours per week of therapeutic services for comprehensive,medically supervised treatment due to a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis that severely impairs daily functioning. Members must cognitively and emotionally participate and tolerate PHP intensity. Programs usually best benefit members discharged from inpatient care to avoid rehospitalization or at risk of inpatient admission. When PHPs shorten inpatient stays, documentation must support necessity. Recertification should confirm ongoing serious psych iatric needs, and discharge planning must align with best practices to ensurecoordinated follow-up and promote recovery in the least restrictive setting.C. Definitions Inpatient Services Behavioral health (BH) services provided during an inpatient admission or confinement for acute inpatient services in a hospital or treatment setting on a 24-hour basis under the direct care of a qualified provider , including psychiatric hospitalization, inpatient detoxification, and emergency evaluation and stabilization. Intensive Outpatient Level of Care (LOC) 2.1 9 or more hours of SUD treatment services a week (adults) or 6 or more hours (adolescents) to treat multidimensional instability, particularly services meeting complex needs of members with addiction and co-occurring conditions. Intensive Outpatient Program (IOP) Services addressing BH needs provided by facilities, group practices or clinics at least 3 hours a day, 2 to 3 days a week and usually as a step down from acute inpatient care, partial hospitalization care or residential care but a step up from tradition al outpatient services. Partial Hospitalization Structured, multimodal, active treatment for BH needs with a treatment period of less than 24 hours, including individual, group and/or family psychotherapy, member education and training, and diagnostic services focusing on member reintegration into society. Residential Treatment Services for BH needs that can include individual, family and group therapy, nursing services, medication assisted treatment, detoxification (ambulatory or subacute), and pharmacological therapy in a congregate living community with 24-hour support. Partial Hospitalization Program-Behavioral Health-MP-PY-1480 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. Policy I. Prior authorization is required after 5 days per calendar year. CareSource follows MCG criteria for reviews of medical necessity for mental health requests and American Society of Addiction Medicine (ASAM) criteria for review of SUD requests. II. BillingA. Some professional services are separately covered and unbundled . See Chapter 4 of the Medicare Claims Processing Manual for additional instructions. B. Under component billing, p roviders must include the following for service claims: 1. PHP ambulatory payment classifications (APCs) for each provider type a. days with 3 or fewer services a day b. days with 4 or more services a day 2. Type of bills (TOB) for institutional billing include the following: a. TOB 13X outpatient hospital b. TOB 85X critical access hospital (CAH) c. TOB 76X community mental health center (CMHC) 3. Claims must be submitted in sequence for a continuing course of treatment. Consistency editing will be enforced for interim billing of PHP claims. Definition TOB SettingAdmit through discharge 131 13X 851 85X 761 76X Interim First 132 13X 852 85X 762 76X Interim – Continuing 133 13X 853 85X 763 76X Interim Last 134 13X 854 85X 764 76X 4. Hospitals other than CAHs are required to report line item dates of service per revenue code line for claims and the charge for each individual covered service furnished, including required Healthcare Common Procedure Coding System (HCPCS) or CPT codes. Rev enue codes can be found in Chapter 4of the Medicare Claims Processing Manual, 100-04 . 5. PHP services are identified using condition code 41 on claims. 6. Providers must report service units for billed codes. Patient status must be reported. Discharge status codes can located in the Medicare Claims Processing Manual, 100-04. 7. When applicable, add on codes may be used following an appropriate initial code. Partial Hospitalization Program-Behavioral Health-MP-PY-1480 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 8. Modifiers, including the following, must be reported:Modifier DescriptionPN Services provided in non-excepted , off-campus , provider-based departments of a hospital . Use will trigger a payment rate under the Medicare Physician Fee Schedule. PN should be reported with each non-excepted item and service, including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services . PO Services provided in excepted , off-campus , provider-based departments of a hospital (services, procedures and surgeries provided at off-campus provider-based outpatient departments for all excepted items and services furnished ). III. The following activities and/or programs are considered not medically necessary:A. day care programs, providing primarily social, recreational, or diversionary activities, custodial or respite care B. programs that maintain psychiatric wellness with no risk of relapse o r hospitalization of member C. services for members otherwise psychiatrically stable or requiring medication management only D. services to inpatient members at a hospital, including meals, self-administration of medication, transportation, and/or vocational training E. members who cannot or refuse to participate with treatment (eg, low cognitive status, volatile behavioral issues) or cannot tolerate the intensity of a PHP F. treatment of chronic conditions without acute exacerbation of symptoms that place the member at risk of relapse or hospitalization E. State-Specific InformationNA F. Conditions of CoverageI. In the event of any conflict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document. II. The inclusion of codes in this policy does not guarantee coverage, authorization or reimbursement. This list may not be all-inclusive:Partial Hospitalization ProgramsCode Code Description H0035 Mental health partial hospitalization, treatment, less than 24 hours G. Related Policies/RulesBehavioral Health Rates Behavioral Health Service Record Documentation Standards Partial Hospitalization Program-Behavioral Health-MP-PY-1480 Effective Dat e: 09/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 H. Review/Revision HistoryDATE ACTIONDate Issued 05/22/2024 Merged AD-1264 & AD-1263. Converted to a PY policy.Date Revised 05/20 /202 6 Annual review. Simplified background. Added F.II. Updated references. Approved at Committee. Date Effective 09/01/2026 Date Archived I. References1. About the ASAM criteria. American Society of Addiction Medicine. Accessed April 27, 2026 . www.asam.org 2. Centers for Medicare and Medicaid Services. CY 2024 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule . Centers for Medicare and Medicaid Services; 2023. CMS Fact Sheet CMS 1786-FC. Accessed April 27, 2026 . www.cms.gov 3. Conditions for Fee Schedule Payment for Physician Services to Beneficiaries in Providers . 42 C.F.R. 415.102 (2023). 4. Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, 136 Stat. 4459. 5. Definitions. 42 U.S.C. 1395 (2011). 6. Diagnostic and Statistical Manual of Mental Disorders (5th ed, Text Revised) . American Psychiatric Association; 2022. Accessed April 27, 2026 . doi:10.1176/appi.books.9780890425787 7. Further Additional Continuing Appropriations and Other Extensions Act, 2024, Pub. L. No. 118-35, 138 Stat. 3. 8. Georgia Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 27, 2026 . www.caresource.com 9. Indiana Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 27, 2026 . www.caresource.com 10. Medical Insurance (SMI) Benefits, 42 C.F.R. 410.42, 410.71, 410.73 to 76, and 410.78 (2023). 11. Medicare Benefit Policy Manual Chapter 6 . Centers for Medicare and Medicaid Services. Accessed April 27, 2026 . www.cms.gov 12. Medicare Claims Processing Manual, Chapter 4 , 100-04 . Centers for Medicare and Medicaid Services . Accessed April 27, 2026 . www.cms.gov 13. Ohio Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 27, 2026 . www.caresource.com 14. Partial Hospitalization Services: Conditions and Exclusions , 42 C.F.R. 410.43 (2023). 15. Requirements for Medical and Other Health Services Furnished by Providers under Medicare Part B , 42 C.F.R. 424.24 (2023). 16. West Virginia Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 27, 2026 . www.caresource.com
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Intensive Outpatient Program-Behavioral Health – MP-PY-1477 09/01/2026 IN, OH, WV inactive as of 01/01/2027 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Intensive Outpatient Program-Behavioral Health-MP-PY-1477Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectIntensive Outpatient Program Behavioral Health B. BackgroundThe Consolidated Appropriations Act of 2023 (CAA, 2023) established Medicare coverage and payment for I ntensive Outpatient Program (IOP) services provided on or after January 1, 2024 for individuals with mental health conditions and/or substance use disorder (SUD) needs provided in hospital outpatient departments (HOPD), critical access hospital (CAH) outpatient departments, community mental health centers (CMHC), rural health clinics (RHCs) and federally qualified health centers (FQHCs). IOP services m ay also be furnished in opioid treatment programs (OTPs) for the treatment of opioid use disorder (OUD). Per federal guidelines, IOPs incorporate active treatment prescribed by a qualifiedprovider for an individual determined, not less frequently than once every other month, to need services for a minimum of 9 hours per week. Services are provided under the supervision of a qualified staff based on an individualized treatment plan established and periodically reviewed by a multidisciplinary team with goals that are measurable, time – framed, directly related to an admission reason and medically necessary. IOPs for SUDs serve members seeking primary treatment, step-down care from higherlevels of care, or step-up treatment from outpatient services , which may include in-house therapies, peer support, mutual-help group participation, and collaboration with community providers to address needs such as medication-assisted treatment, psychological assessments, vocational rehab, and trauma-specific care. C. Definitions Intensive Outpatient Level of Care (LOC ) 2.1 9 or more hours of SUD treatment services a week (adults) or 6 or more hours (adolescents) to treat multidimensional instability, particularly services meeting complex needs of members with addiction and co-occurring conditions. Intensive Outpatient Program (IOP) Behavioral health (BH) services provided by facilities, group practices or clinics at least 3 hours a day, 2 to 3 days a week and usually as a step down from acute inpatient care, partial hospitalization care or residential care but a step up from traditional outpatient services. Partial Hospitalization Structured, multimodal, active treatment for BH needs with a treatment period of less than 24 hours, including individual, group and/or family psychotherapy, member education and training, and diagnostic services focusing on member reintegration into society. Residential Treatment Services for BH needs that can include individual, family and group therapy, nursing services, medication assisted treatment, detoxification (ambulatory or subacute), and pharmacological therapy in a congregate living community with 24-hour support. Intensive Outpatient Program-Behavioral Health-MP-PY-1477Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. PolicyI. Prior authorization is required after 5 days per calendar year. CareSource follows MCG criteria for reviews of medical necessity for mental health requests and American Society of Addiction Medicine (ASAM) criteria for review of SUD requests. II. BillingA. Some professional services are separately covered and unbundled. See Chapter 4 of the Medicare Claims Processing Manual for additional instructions. B. Under component billing for IOP services, p roviders must include the following components for service claims: 1. IOP ambulatory payment classifications (APCs) for each provider type a. days with 3 services a day b. days with 4 or more services a day 2. Type of bills (TOB) for institutional billing a. TOB 13X outpatient hospital b. TOB 85X critical access hospital (CAH) c. TOB 76X community mental health center (CMHC) 3. Claims must be submitted in sequence for a continuing course of treatment. Consistency editing will be enforced for interim billing of IOP claims. Definition TOB SettingAdmit through discharge 131 13X 851 85X 761 76X Interim First 132 13X 852 85X 762 76X Interim – Continuing 133 13X 853 85X 763 76X Interim Last 134 13X 854 85X 764 76X 4. Hospitals are required to report a revenue code and the charge for each individual covered service furnished under an IOP, including required Healthcare Common Procedure Coding System (HCPCS) or CPT codes. Revenue codes can be found in Chapter 4 of the Medicare ClaimsProcessing Manual, 100-04. 5. IOP services are identified on claims using condition code 92. 6. When applicable, add on codes may be used following an appropriate initial code. 7. Providers must report service units, dates of service, and patient status. Discharge status codes can located in the Medicare Claims Processing Manual, 100-04 . Intensive Outpatient Program-Behavioral Health-MP-PY-1477Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 8. Modifiers, including the following, must be reported:Modifier Description PN Services provided in non-excepted , off-campus , provider-based departments of a hospital . Use will trigger a payment rate under the Medicare Physician Fee Schedule. PN should be reported with each non-excepted item and service, including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services . PO Services provided in excepted , off-campus , provider-based departments of a hospital (services, procedures and surgeries provided at off-campus provider – based outpatient departments for all excepted items and services furnished ). III. The following activities and/or programs are considered not medically necessary:A. day care programs providing primarily social, recreational, or diversionary activities, custodial or respite care B. programs that maintain psychiatric wellness, in which there is no risk of relapse or hospitalization of member C. services for members otherwise psychiatrically stable or requir ing medication management only D. services to inpatient members at a hospital, including meals, self-administration of medication, transportation, and/or vocational training E. members who cannot or refuse to participate in treatment (eg , low cognitive status, volatile behavioral issues) or cannot tolerate the intensity of an IOP F. treatment of chronic conditions without acute exacerbation of symptoms that place the member at risk of relapse or hospitalization E. State-Specific InformationNA F. Conditions of CoverageI. In the event of any conflict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document. II. The inclusion of codes in this policy does not guarantee coverage, authorization or reimbursement. This may not be an all-inclusive list:Intensive Outpatient ProgramCode Code Description H0015 Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapi es or education S9480 Intensive outpatient psychiatric services, per diem G. Related Policies/RulesBehavioral Health Rates Behavioral Health Service Record Documentation Standards Intensive Outpatient Program-Behavioral Health-MP-PY-1477Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 H. Review/Revision HistoryDATE ACTIONDate Issued 05/22/2024 Merged AD-1262 and AD-1261. Converted to PY policy.Date Revised 05/20/2026 Annual review. Simplified background. Removed PA information for WV in E. Added F.II. Updated references. Approved at Committee. Date Effective 09/01/2026 Date Archived I. References1. About the ASAM criteria. American Society of Addiction Medicine. Accessed April 27, 2026 . www.asam.org 2. Centers for Medicare and Medicaid Services. CY 2024 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule. Centers for Medicare and Medicaid Services; 2023. CMS Fact Sheet CMS 1786-FC. Accessed April 27, 2026 . www.cms.gov 3. Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, 136 Stat. 4459. 4. Definitions. 42 U.S.C. 1395 (2011). 5. Diagnostic and Statistical Manual of Mental Disorders (5th ed, Text Revised) . American Psychiatric Association; 2022. Accessed April 27, 2026 . doi:10.1176/appi.books.9780890425787 6. Further Additional Continuing Appropriations and Other Extensions Act, 2024, Pub. L. No. 118-35, 138 Stat. 3. 7. Georgia Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 27, 2026 . www.caresource.com 8. Indiana Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 27, 2026 . www.caresource.com 9. Medical Insurance (SMI) Benefits, 42 C.F.R. 410.42, 410.71, 410.73 to 76, and 410.78 (2023). 10. Medicare Claims Processing Manual, 100-04 . Centers for Medicare and Medicaid Services. Accessed April 27, 2026 . www.cms.gov 11. Medicare Learning Network. Billing Requirements for Intensive Outpatient Program Services with New Condition Code 92 . Centers for Medicaid and Medicare Services; 2023. MLN Matters Number MM13496. Accessed April 27, 2026 . www.cms.gov 12. Ohio Marketplace Evidence of Coverage . CareSource; 202 6. Accessed April 27, 2026 . www.caresource.com 13. Substance Abuse and Mental Health Services Administration. Clinical Issues in Intensive Outpatient Treatment for Substance Use Disorders: Advisory . U.S. Dept. of Health and Human Services; 2021. Publication # PEP20-02-01-021 . Accessed April 27, 2026 . www.samhsa.gov 14. Substance Abuse and Mental Health Services Administration. TIP 47: Clinical Issues in Intensive Outpatient Treatment for Substance Use Disorders. US Dept of Health and Human Services; 2013. Publication # SMA-13-4182. Accessed April 27, 2026. www.samhsa.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Electrocardiogram (EKG/ECG) Interpretations – MP-PY-1807 09/01/2026 IN, OH, WV inactive as of 01/01/2027 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.This policy applies to the following Marketplace(s): Georgia Indiana 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 ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Electrocardiogram (EKG/ECG) Interpretations-MP-PY-1807Effective Dat e: 09/01/20262A. SubjectElectrocardiogram (EKG/ECG) Interpretations B. BackgroundAn electrocardiogram (EKG/ECG) is a non-invasive test that records the electrical activity of the heart and is often used when a possible cardiac issue occurs. The recording is reviewed by a provider who renders an interpretation and written report. An EKG /ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspects together as one service. For the purpose of this policy, EKG will be used to represent both EKG and ECG. A second EKG interpretation may be warranted only under unusual circumstances asmedically necessary .C. DefinitionsNA D. PolicyI. CareSource will reimburse the first EKG interpretation claim that is received for the member on the date of service. A. If another claim for the same EKG interpretation is received for reimbursement , CareSource will only reimburse the first claim received for the same member on the same date of service . B. CareSource will not reimburse for duplicate claims for the same service on the same member on the same date of service without the appropriate modifier. II. If a second EKG interpretation is medically necessary on the same date of service before the member is discharged, modifier 76 or modifier 77 must be appended to the second EKG interpretation for reimbursement.III. CareSource expects providers to work with other departments within the provider organization to determine which department will submit the claim to prevent duplicate claim submissions.E. Conditions of Coverage I. CareSource expects providers to use appropriate standard billing guidelines. Modifiers are listed below as a reference only . Modifier Description 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional II. Reimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Electrocardiogram (EKG/ECG) Interpretations-MP-PY-1807Effective Dat e: 09/01/20263Reimbursement of claims may be subject to limitations and/or qualifications. Reimbursement will be established based on a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care provi ders and office staff are encouraged to use self-service channels to verify a members eligibility. III. Reimbursement is dependent on, but not limited to, submitting approved CPT or HCPCS codes along with appropriate modifiers if applicable. Please refer to individual fee schedule for appropriate codes.IV. 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.V. In the event of any conflict between this policy and the providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/Rules Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 05/20/2026 New policy created. Previous Administrative policy AD-1237converted to Reimbursement policy PY-180 7. Removed imaging language to improve clarity. Approved at Committee. Date Revised Date Effective 09/01/2026 Date Archived H. References1. Prutkin JM. ECG tutorial: Basic principles of electrocardiography analysis. UpToDate. Updated March 9, 2026. Accessed April 23, 2026. www.uptodate.com 3. Sattar Y, Chhabra L. Electrocardiogram. In: StatPearls . Updated June 5, 2023. Accessed April 23, 2026. www.ncbi.nlm.nih.gov
REIMBURSEMENT POLICY STATEMENTOhio Marketplace Policy Name & Number Date Effective Claim Reimbursement Hierarchy-OH MP-PY-1794 09/01/2026 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 no t limited to, those health care services or suppli es that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or si gnificant 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 inc lude 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 Rei mbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan c ontract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may mod ify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Claim Reimbursement Hierarchy-OH MP-PY-1794Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectClaim Reimbursement Hierarchy B. BackgroundCareSource utilizes Medicare reimbursement methodology for Marketplace covered services. This excludes any incentive add-ons or risk adjustments aka sequestration. Marketplace reimbursement methodology may vary for services not covered by Medicare. Reimbursement 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. Payments for claims may be su bject to limitations and/or qualifications. Payment will be determinedbased upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Providers and their office staff are encouraged to use self-service channels to verify member eligibility. This policy is intended to provide general payment hierarchy information. Where a specific reimbursement policy exists for a particular product or service, that policy shall apply and supersede this policy. In the absence of a more specific service-level p olicy,the provisions of this policy govern reimbursement.C. DefinitionsNA D. PolicyI. CareSource will reimburse claims based on the general guidelines and decision hierarchies set forth in this policy Payment Hierarchy A. Providers contracted rate/reimbursement method. B. If the contract doesnt specify terms for reimbursement for a covered service, then CareSource pays using the Medicare maximum allowable for the specific procedure or service. C. Codes not covered on Medicare Fee Schedules, but have RVU values, will be reimbursed utilizing the RVU values and/or the Optum Medicare rate gap module. In the absence of Medicare guidance, State guidelines will be consulted. D. For provider administered medical drugs, provided through the medical benefit, not addressed above, shall be reimbursed at AWP minus 15 %. NOTE : When there is not a rate on the Medicare or Medicaid Fee Schedule, CareSource will develop a custom rate based on industry standards.II. Reimbursement for authorized medically necessary services: A. Approved authorization does not ensure payment. Claim Reimbursement Hierarchy-OH MP-PY-1794Effective Dat e: 09/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 B. Where applicable, DME services that do not have Medicare rates, an invoice will need to be submitted for reimbursement. C. Specific reimbursement for products and services can be found in individual policies per market. NOTE : Additional guidance for reimbursement may be found in our AdministrativePolicies. III. Guidelines for out of network reimbursementOut of network reimbursement will align with CareSource contracts and policies. IV. Other Regulatory ReimbursementCareSource will adhere to any additional reimbursement methodology for Marketplace as outlined in the state or federal requirements. In the event of any conflict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document. Pre-authorization does not guarantee payment. E. Conditions of CoverageNA F. Related Policies/RulesDurable Medical Equipment (DME) Unlisted and Miscellaneous Codes Unlisted and Miscellaneous Codes Payment to Out of Network Providers G. Review/Revision HistoryDATE ACTIONDate Issued 05/06 /2026 New policy. Approved at Committee.Date Revised Date Effective 09/01/2026 Date Archived H. ReferencesNA
© Copyright CareSource 2026. All rights reserved.
System Details