REIMBURSEMENT POLICY STATEMENTOhio Marketplace Policy Name & Number Date Effective Unlisted and Miscellaneous Codes-OH MP-PY-1787 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 ………………………….. ………………………….. ………………………….. ……………………. 4 Unlisted and Miscellaneous Codes-OH MP-PY-1787Effective 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. SubjectUnlisted and Miscellaneous Codes B. BackgroundCurrent Procedure Terminology (CPT) codes are used to describe medical procedures and p rovider services. The American Medical Association (AMA) maintains and distributes CPT codes. These code sets were established so providers can use the most specific and appropriate code when submitting claims for reimbursement of services rendered to members. Occasionally, a CP Tcode may not be available for a procedure or service if it is rarelyused, unusual, or new. Only then would providers use an unlisted, unclassified, not otherwise specified (NOS), not otherwise classified (NOC), unlisted, miscellaneous, or generic code for any such procedure, service, or non-provider service.C. Definitions Miscellaneous (Unlisted, Unclassified, Not Otherwise Specified [NOS], or Not Otherwise Classified [NOC]) Codes Submitted by a supplier for an item for which there is no existing or no specific CPT code that adequately describes the item being billed. Unlisted Code A code representing a service, or procedure for which there is no specific CPT code. D. PolicyI. All unlisted or miscellaneous codes require a medical necessity review prior to service. II. Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the service, procedure rendered.III. Reimbursement is based on review of the unlisted or miscellaneous code(s) on an individual claim basis.IV. Providers must submit the unlisted or miscellaneous code(s) along with the relevant information and/or documentation listed below.A. a comparable code for the service or procedure that most closely associates with the service/procedure being requested. The comparable code submitted by the provider will be the basis by which CareSource reimburses the service. The provider will be reimbursed for an approved and covered unlisted service at the rate within their contract/agreement for the comparable service, as applicable. The comparable code must be submitted with the medical necessity review request as well as the claim submission. Fai lure to submit a comparable code will result in a claim denial. B. statement that no other code exists that would be more appropriate Unlisted and Miscellaneous Codes-OH MP-PY-1787Effective 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 C. any other information requested by CareSourceV. Unlisted/non-specific codes used for procedures deemed to be experimental and investigational will be reviewed for medical necessity . VI. In the event that unlisted codes are specified at a fixed rate within the providers agreement, those codes shall be reimbursed at the specific fixed rates specified within the providers contracted with CareSource.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 clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based on 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 a re encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guaran teeclaims payment.All unlisted or miscellaneous codes defined within this policy are subject to medical necessity review. Approved authorization does not a ensure payment.CareSource may verify the use of any code through post-payment audit. If a more appropriate code is discovered, CareSource may request recoupment. F. Related Policies/RulesDME Unlisted and Miscellaneous Codes Claims Reimbursement Hierarchy G. Review/Revision HistoryDATE ACTIONDate Issued 09/25/2024 New policy. Approved at Committee.Date Revised 05/07/2025 09/10/202504/22 /2026Periodic review. Updated references. Approved at Committee. Periodic review. Changed physician to provider where applicable. Approved at Committee. Annual Review. Updated background, definitions Section D., E. , F. and reference s. Approved at Committee. Date Effective 09/01/2026 Unlisted and Miscellaneous Codes-OH MP-PY-1787Effective 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. CPT overview and code approval. American Medical Association. Accessed March 10 , 2026. www.ama-assn.org
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifiers-MP-PY-1392 08/01/2026 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. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Modifiers-MP-PY-1392Effective Dat e: 08/01/20262A. SubjectModifiers B. BackgroundReimbursement modifiers 2-character codes used by providers to indicate that a service or procedure has been altered due to a specific circumstance. Modifiers can be found in the appendices of both Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) manuals. Use of a modifier does not change the code or the codes definition. Examples of modifier use include To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same procedure . To indicate that a procedure was performed on the left side, right side, or bilaterally . To report multiple procedures performed during the same session by the same health care provider . To indicate multiple health care professionals participated in the procedure . To indicate a subsequent procedure due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, use does not guaranteereimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment or post-payment edit or audit . Inappropriate use of a modifier can result in a claim denial or incorrect reimbursement for a product or service . All information regarding the use of these modifiers must be made available upon CareSources request. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure that correct coding standards and guidelines are met. II. Provider claims billed with a modifier may be flagged for either a prepayment or post-payment coding review. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of the claim. Failure to submit accurate and completeModifiers-MP-PY-1392Effective Dat e: 08/01/20263documentation may result in a denial. If the documentation does not support the claim submission, this will also result in a denial.IV. Providers are expected to use the most accurate and appropriate CPT or HCPCScode(s) for the product or service that is being provided according to the following industry standard guidelines (may not be all-inclusive): A. National Correct Coding Initiative (NCCI) editing guidelines B. American Medical Association (AMA) guidelines C. American Hospital Association (AHA) billing rules D. Current Procedural Terminology (CPT) E. Healthcare Common Procedure Coding System (HCPCS) F. The International Classification of Diseases and Related Health Problems , Tenth Edition (ICD-10-CM and ICD-10-PCS) G. National Drug Codes (NDC) H. Diagnosis Related Group (DRG) guidelines V. The inclusion of a code in a policy does not imply any right to reimbursement or guarantee payment of claims.VI. Other CareSource policies may overlap with this topic. Consult the current catalogue of policies for this market.E. State-Specific InformationNA F. Conditions of CoverageI. 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. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upo n 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. II. Reimbursement is dependent on, but not limited to, submitting approved CPT orHCPCS codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes.III. 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.IV. In the event of a conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.Modifiers-MP-PY-1392Effective Dat e: 08/01/20264G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 10/12/2022 New policyDate Revised 09/27/2023 05/07/2025 04/22/2026Updated references. Approved at Committee.Periodic review. Updated references. Approved at Committee. Annual review. Moved D.I and D.II from Section Bto Section D, updated D.III for clarity, added D.VI, updated references. Approved at Committee. Date Effective 08/01/2026 Date Archived I. References1. 2026 AMA CPT Professional . American Medical Association; 2025. 2. 2026 HCPCS Level II Expert . AAPC; 2025. 3. 2026 ICD-10-CM Official Coding Guidelines for Coding and Reporting . AAPC; 2025. 4. General Correct Coding Policies. Medicare National Correct Coding Initiative Policy Manual . Centers for Medicare and Medicaid Services; 2026. Accessed March 31, 2026. www.cms.gov
REIMBURSEMENT POLICY STATEMENT Ohio Marketplace Policy Name & Number Date Effective Durable Medical Equipment (DME) Codes and DME Unlisted and Miscellaneous Codes-OH MP-PY-1782 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 Contents A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 H. References ………………………….. ………………………….. ………………………….. …………………….. 4 Durable Medical Equipment (DME) Codes and DME Unlisted and Miscellaneous Codes-OH MP-PY-1782 Effective Date: 09/01/2026 The REIMBURSEMENT Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the REIMBURSEMENT Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 2 A. SubjectDurable Medical Equipment (DME) Codes and DME Unlisted and MiscellaneousCodesB. BackgroundThe Centers for Medicare and Medicaid Services (CMS) establishes and maintainsHealth Care Common Procedure Coding System ( HCPCS ) codes. The code sets were established so providers can use the most specific and appropriate code when submitting claims for reimbursement of the item rendered to members.Occasionally, a HCPCS code may not be available for durable medical equipment (DME) if it is rarely used, unusual, or new. Only then would providers use an unlisted, unclassified, not otherwise specified (NOS), not otherwise classified (NOC), miscellaneous, or generic code for any DME item or supply. C. DefinitionsDurable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use.Miscellaneous (Unlisted, Unclassified, Not Otherwise Specified [NOS], or NotOtherwise Classified [NOC]) Codes) Submitted by a supplier for an item for which there is no existing or no specific HCPCS code that adequately describes the item being billed.Provider Acquisition Cost The distributor or manufacturer invoice to the provider(providers cost).o Provider invoice is the amount paid for an item by a DME provider to a distributor or manufacturer after the application of any discounts, rebates, and adjustments that are available to the provider at the time of claim submission.o Documentation of provider cost is subject to approval by CareSource o Suitable documents for substantiating provider cost include, but are not limited to, the following examples:A standard distributor or manufacturer price list that can be independently verified by CareSource.any figure that has been entered, superimposed, modified, obscured, or obliterated by the provider will not be accepted.Relative Value Unit (RVU) A calculator assigned to each code which, when multiplied by the conversion factor (CF) and a Geographic Practice CostIndices (GPCI) adjustment, creates the compensation level for a particular item.D. PolicyI. The reimbursement for all DME codes and DME unlisted and miscellaneous codes is as follows:A. CareSource first applies the rate specified for the item as specifically negotiated in the providers contract. However, If the providers contract does not specify Durable Medical Equipment (DME) Codes and DME Unlisted and Miscellaneous Codes-OH MP-PY-1782 Effective Date: 09/01/2026 The REIMBURSEMENT Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the REIMBURSEMENT Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 3 terms specifically for reimbursement of DME , then CareSource shall reimburse the provider per the methodology listed below: 1. 65% of the Medicare set cost/price for the item2. Codes not covered on Medicare Fee Schedule, but which do have RVUvalues will be reimbursed at the amount calculated by multiplying the RVU(relative value unit assigned to that CPT code) x the conversion factor.3. Essential RVU gap fill fee schedule4. Codes not listed on the Medicare Fee Schedule and which do not have RVUvalues, shall be reimbursed at Providers cost plus 5% after the application of any discounts, rebates, and adjustments available to the Provider and supported by invoice documentation and subject to applicable prior authorization requirements.5. All other DME items not listed in the payment methodology above will be reimbursed at default percent of providers billed charges.II. All unlisted or miscellaneous codes for a DME items require a prior authorization and medical necessity review.A. Prior authorization requests submitted with unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration during review:1. a complete description of the item, including, as applicable, the manufacturer,model or style, and size, a list of all bundled components, and an itemization of all charges, including a provider acquisition cost invoice2. statement that no other more appropriate code exists3. any other information requested by CareSourceIII. Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the item requested .IV. Reimbursement is based on review of the unlisted or miscellaneous code(s) on an individual claim basis.V. Unlisted/non-specific codes used for procedures deemed to be experimental and investigational will be reviewed for medical necessity.VI. CareSource may request warranty information regarding the DME item (s) or supply when an unlisted or miscellaneous code is used. If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the prior authorization.E. Conditions of CoverageI. Reimbursement policies are designed to assist providers when submitting claims toCareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment.Reimbursement for claim s may be subject to limitations and/or qualifications. Durable Medical Equipment (DME) Codes and DME Unlisted and Miscellaneous Codes-OH MP-PY-1782 Effective Date: 09/01/2026 The REIMBURSEMENT Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the REIMBURSEMENT Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 4 Reimbursement will be established based upon a review of the actual item 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 mem ber eligibility. II. It is the responsibility of the submitting provider to submit the most accurate and appropriate HCPCS code(s) for the item that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee payment of clai ms.III. Medical necessity review and authorization does not ensure payment.IV. CareSource may verify the use of any code through post-payment audit. If a more appropriate code is discovered, CareSource may request recoupment.F. Related Policies/RulesDurable Medical Equipment (DME) ModifiersUnlisted and Miscellaneous CodesClaims Reimbursement HierarchyG. Review/Revision HistoryDATE ACTION Date Issued 0 4 / 22 /202 6 New policy. Approved at Committee. Date Revised Date Effective 09/01/2026 Date Archived H. References1 . Durable medical equipment (DME). Accessed March 09, 2026 . www.healthcare.gov2 . Healthcare Common Procedure Coding System (HCPCS). Centers for Medicare &Medicaid Services. Accessed March 09, 2026 . www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Temporary Codes-MP-PY-1413 07/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates 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 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, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject..2 B. Background ………………………………………………………………………………………………………… 2C. 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 Temporary Codes-MP-PY-1413Effective Date: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTemporary Codes B. Background Temporary codes exist in both CPT and HCPCS manuals and are updated throughout the year. Tcodes (ie, Category III codes) are temporary CPT codes for emerging technologies, services, and procedures, which support data collection to substantiate widespread use and/or provide documentation for the Food and Drug Administration (FDA) approval process. Many of these codes have not been proven medically necessary and are considered to be experimental or investigational based on a lack of peer-reviewed scientific literature. A variety of temporary HCPCS codes exist.Temporary HCPCS codes may be established by the Centers for Medicare and Medicaid Services (CMS) to report drugs, biologicals, devices, and procedures, to identify services and procedures under FDA review or address miscellaneous services, procedures, and supplies. Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) may develop temporary HCPCS codes to report supplies and other products for which a national code has not yet been developed. Temporary HCPCS codes may also be developed by commercial payers to report drugs, services, and supplies. Coverage of these services is under the discretion of local carriers.C. Definitions Temporary codes CPT category III alphanumeric codes for new and developing technology, procedures and services. The use of these codes allows physicians and other qualified health care professionals to identify emerging technology, services, procedures, and service paradigms for clinical efficacy, utilization and outcomes. D. Policy I. CareSource considers temporary codes medically necessary when ALL the following criteria are met: A. Documentation in the medical record supports use of the code. B. A more specific code is not available to describe the service/procedure. C. The service provided is within the scope of the members benefit plan. II. CareSource will use current industry standard procedure codes (HCPCS CPT I andCategory II codes) throughout the processing systems. HIPAA Transaction & Code Set Rule requires providers use the procedure code(s) that are valid at the time the service is provided. Temporary Codes-MP-PY-1413Effective Date: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 III. Providers must use industry standard code sets and must use specific HCPCS CPT Iand Category II codes when available unless otherwise directed through the providers contract. IV. If specific codes are not available, all unlisted or miscellaneous codes require a medical necessity review prior to the service. E. State-Specific InformationNA 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 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 being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. G. Related Policies/Rules Unlisted and Miscellaneous Codes H. Review/Revision HistoryDATE ACTIONDate Issued 02/01/2023 New policyDate Revised 01/17/2024 03/26/2025 03/25/2026 Annual review: updated references, approved at Committee. Review: updated references, approved at Committee. Periodic Review. Updated references and DIV. Approved at Committee. Date Effective 07/01/2026 Date Archived I. References1. American Academy of Professional Coders. What is HCPCS? Accessed March 12, 2026. www.aapc.com 2. American Medical Association. CPT Category III Codes. Accessed March 12, 2026. www.ama-assn.org 3. CPT Professional 2026. American Medical Association; 2026. Temporary Codes-MP-PY-1413Effective Date: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 4. HCPCS Codes Temporary Codes for Use with Outpatient Prospective PaymentSystem. Accessed March 12, 2026. www.hcpcs.codes 5. Understanding the HIPAA standard transactions: The HIPAA Transactions and Code Set rule. American Medical Association. Accessed March 12, 2026. www.assets.ama-assn.org
REIMBURSEMENT POLICY STATEMENTOhio Marketplace Policy Name & Number Date Effective Multiple Procedure Payment Reduction for Therapies-OH MP-PY-1742 08/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Multiple Procedure Payment Reduction for Therapies-OH MP-PY-1742Effective Dat e: 08/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectMultiple Procedure Payment Reduction for Therapies B. BackgroundMany therapy services, such as occupational, physical, or speech-language pathology, are time-based CPT/HCPCS codes, where multiple units may be billed for a single service. In addition to multiple units, multiple therapy services may be reported together on the same date of service by the same practitioner or group of practitioners. Some elements that comprise these services, referred to as Practice Expense (PE) by the Centers for Medicare and Medicaid Services (CMS), are duplicative. When multiple procedures are performed on the same day by the same p ractitioner orgroup of practitioners , reduction in reimbursement for secondary and subsequent procedures can occur when they feature overlapping services or clinical labor . This may include (but is not limited to) greeting the member, obtaining measurements, counseling and home care coordination, education and instruction, and post-therapy assistance. When the same practitioner or group of practitioners performs multiple ther apeutic servic es or multiple units of a therapeutic service for the same patient on the same day, the PE procedures are not repeated. The CMS National Physician Fee Schedule Relative Value File identifies procedures that are subject to multiple procedure reductions. CareSource supports the CMS guidelines of multiple procedure payment reduction (MPPR) when multiple services are performed on a member by the same practitioner or group of practitioners on the same day. This policy describes how the MPPR methodology will be a pplied to therapy services billed to CareSource. C. Definitions Occupational Therapy A form of therapy for members recuperating from physical or mental illness that encourages rehabilitation through the performance of activities of daily living (ADLs). Physical Therapy Therapy for the preservation, enhancement, or restoration of movement and physical function threatened by disease, injury, or disability. Practitioners within the Same Group Practice All health care practitioners of the same group reporting the same Federal Tax Identification number. Practice Expense Relative Value Units (PE RVU) The portion of the total relative value units assigned to a particular CPT or HCPCS code for maintaining a practice, including rent, equipment, supplies, and nonphysician staff costs. Speech Therapy the therapeutic treatment of impairments and disorders of speech, voice, language, communication, and swallowing. Total Relative Value Units (Total RVU) The assigned unit value of a particular CPT or HCPCS code that consists of the sum of the Work Relative Value Units, the PE RVU, and the Malpractice Relative Value Units. Multiple Procedure Payment Reduction for Therapies-OH MP-PY-1742Effective Dat e: 08/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. PolicyA. Consistent with CMS, CareSource ranks all reimbursable procedures from the Multiple Therapy Reducible Codes list (procedures with indicator 5 in the MPPR field on the CMS National Physician Fee Schedule) that are provided on a single date of service. When multiple procedures and/or units are billed, reimbursement is as follows for Ohio Marketplace : 1. The procedure or unit with the highest valued paid amount is reimbursed without reduction at 100%. 2. All subsequent procedures/units are reimbursed at 80% of the paid amount allowance. II. This reduction applies to always therapy services provided on the same day to the same member by the same practitioner or practitioners within the same group practice, regardless of whether the services were provided in one therapy discipline or multiple disciplines ( e.g. , physical therapy, occupational therapy, speech-language pathology). The reduction also applies to multiple units of the same always therapy service provided on the same day to the same member by the same practitioner or practitioners within the same group practice. III. Always therapy services may include the following (not an all-inclusive list): treatment of speech, language, voice, communication, and/or auditory processing disorder in an individual or group setting evaluation of speech fluency evaluation of speech sound production behavioral and qualitative analysis of voice and resonance treatment of swallowing dysfunction and/or oral function for feeding evaluation for use of voice prosthesis, speech-augmenting, or speech-generating device cognitive performance testing physical therapy evaluations occupational therapy evaluations therapeutic modality applications therapeutic procedures wheelchair management physical performance test or management assistive technology assessment orthotic management and training prosthetic training E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifier, if applicable. Please refer to the individual fee schedule for appropriate codes. Multiple Procedure Payment Reduction for Therapies-OH MP-PY-1742Effective Dat e: 08/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Providers must follow proper billing guidelines and industry standards, and utilize state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within this policy, this policy applies to both participating and nonparticipating providers and facilities. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/25/2026 New policy. Approved at Committee.Date Revised Date Effective 08/01/2026 Date Archived H. References1. PFS Relative Value Files. Centers for Medicare and Medicaid Services. Updated February 25, 2026 . Accessed March 18, 2026 . www.cms.gov 2. Therapy Services. Centers for Medicare and Medicaid Services. Updated March 10, 2026 . Accessed March 18, 2026 . www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-MP-PY-1367 07/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates 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 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, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 3 D. Policy …………………………………………………………………………………………………………………. 3 E. State-Specific Information ……………………………………………………………………………………… 4 F. Conditions of Coverage ………………………………………………………………………………………… 4 G. Related Policies/Rules ………………………………………………………………………………………….. 5 H. Review/Revision History ……………………………………………………………………………………….. 5 I. References …………………………………………………………………………………………………………. 5 Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Date: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 59, XE, XP, XS, XU B. Background Reimbursement modifiers are 2-character codes used by physicians and other qualified health care professionals to indicate that a service or procedure has been altered due to a specific circumstance. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when 2 Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together but are appropriate under the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because 2 different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the 2 procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established four HCPCS modifiers to define specific subsets of modifier 59 XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59.Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Date: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) and provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. Policy I. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a pre- payment or post-payment coding review. A. For pre-payment review, once the claim line has been validated , it is either processed for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim line is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation tosubstantiate the coding of the claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claim submission, this will also result in a denial. IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59. VI. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that adistinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available. Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed at different anatomic sites 2. are not ordinarily performed or encountered on the same day Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Date: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 3. cannot be described by 1 of the more specific anatomic NCCI Procedure toProcedure (PTP)-associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI) B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed during different patient encounters 2. cannot be described by 1 of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91) C. Modifier XE (or 59, when applicable) may also be used when 2 timed procedures are performed during the same encounter but occur 1 after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are either: 1. performed at separate anatomic sites 2. performed at separate patient encounters on the same date of service E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when all the following apply: 1. diagnostic procedure is the basis for performing the therapeutic procedure 2. occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires 3. provides clearly the information needed to decide whether to proceed with the therapeutic procedure 4. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately.) F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when all the following apply: 1. diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure 2. occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires 3. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the post-procedure diagnostic procedure is an inherent component or otherwise included (eg, not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately.) E. State-Specific InformationNA F. Conditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, when applicable. In the absence of state Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Date: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 specific instructions, the CMS guidelines on Modifier 59, XE, XP, XS, XU will apply.Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy applies to both participating and nonparticipating providers and facilities. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. G. Related Policies/Rules Modifiers H. Review/Revision History DATE ACTIONDate Issued 08/17/2022Date Revised 08/02/2023 07/17/2024 07/16/2025 04/08/2026 Annual review: updated references, approved at Committee Review: updated references, approved at Committee Review: updated references, approved at Committee Annual Review. Updated reference. Approved at Committee. Date Effective 07/01/2026 Date Archived I. References1. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services . US Centers for Medicare and Medicaid Services; 2025. Accessed March 13, 2026. www.cms.gov 2. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners. US Centers for Medicare & Medicaid Services; Accessed . March 13, 2026. www.cms.gov 3. Mechanized Claims Processing and Information Retrieval Systems; Operational, etc., Requirements, 42. U.S.C. 1396b(r) (2026). 4. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicare and Medicaid Services. Updated January 1, 2026. Accessed March 13, 2026. www.cms.gov 5. MLN1783722-Proper Use of Modifiers 59 & -X{EPSU}. US Centers for Medicare and Medicaid Services; 2025. Accessed March 13, 2026. www.cms.gov 6. Transmittal R1422OTN-Publication 100-20-MM8863-Specific Modifiers for Distinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Accessed March 13, 2026. www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Digital EEG Spike Analysis-MP-PY-1681 07/01/2026 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 ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Digital EEG Spike Analysis-MP-PY-1681Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDigital EEG Spike Analysis B. BackgroundEpilepsy is a chronic brain disorder that affects approximately 1.2% of the US population or 3,700,000 people. Epileptic seizures are associated with a loss of awareness, fatigue, drowsiness, physical weakness, and confusion. Epilepsy seizures can be trigg ered by stress, dehydration, alcohol, toxic exposure, hormonal changes, sleep deprivation, and visual stimulation. Epilepsy and seizures are diagnosed with a detailed medical history, blood tests, developmental, neurological, and behavioral tests, and scan s and imaging techniques ( eg , electroencephalography, computerized tomography, magnetic resonance imaging). Electroencephalography (EEG) is a diagnostic test that measures electrical activity in the brain. EEG is a non-invasive procedure where small electrodes are attached to thepatients scalp and the patient remains still or is instructed to perform specific tasks while brain wave patterns are recorded. Specific wave patterns are then used to help diagnose medical conditions such as epilepsy . Advances in digital technology have led to software and hardware applications that expand the capability to record brain wave forms, graph out brain wave patterns, and automatically detect brain wave spikes that are indicative of abnormal brain activity. Abnormal EEG findings are often associated with epileptiform activity, such as epileptiform discharge. An epileptiform discharge represents disrupt ion in brain functionand is typically associated with spikes and sharp waves. Analy zing spikes and sharps with the accompanying slow waves helps localize seizure onset. When combined with clinical observation, prolonged monitoring via ambulatory EEG, and the recorded clinical behavior provided by video EEG, spike analysis helps to diagnose e pilepsy and other health conditions. Digital EEG spike analysis requires substantial additional work by the technician to process data from the digital EEG as well as the physicians time to review the technicians work, review the data produced, and form a careful analysis of clinical observ ation with any changes in the EEG occurring before, during, and after the seizure. C. Definitions Ambulatory EEG (aEEG) Monitoring Portable recording of EEG outside of the hospital or clinic setting. Can be done with simultaneous video recording. Often uses computer software to detect seizures and interictal epileptiform discharges (IED) to aid in interpretation. Digital EEG Systems that allow for the recording, analysis, and storage of EEG data. These systems often include software tools that can detect spikes and other abnormal brain patterns and can help visualize, quantify, and interpret the data. Dipole Analysis Localization and quantification of the sources of electrical activity in the brain, which helps understand the origins of conditions such as epilepsy. Epileptiform Activity Indicates cortical hyperexcitability, which is associated with an increased risk of seizures and the presence of an epileptic network in the brain. Digital EEG Spike Analysis-MP-PY-1681Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Sharp Waves Single epileptiform discharge defined by its duration and disruption of the EEG background. Spikes Sharp, transient waveforms that are clearly distinguished from background activity and indicate abnormal electrical activity in the brain. Spikes are often associated with seizures. Video-EEG Monitoring Synchronous recording and display of EEG patterns and video-recorded behavior. Procedure can be done in the outpatient EEG laboratory, in the home, or in a hospital inpatient setting. D. PolicyI. CareSource considers digital EEG spike analysis (CPT code 95957) medically necessary and therefore reimbursable when performed in conjunction with EEG for topographic voltage and/or dipole analysis. This applies specifically for pre-surgical evaluation with video-EEG long-term monitoring in members with intractable epilepsy, intracranial injuries, and concussions. II. CareSource does not consider digital EEG spike analysis to be medically necessary for other indications. III. The submitting provider is responsible for submitting accurate documentation to substantiate the coding of claims. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, th is will also result in a claims denial.E. State-Specific Information NA F. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 06/18/2025 New policy. Approved at Committee.Date Revised 04/08 /2026 Periodic review. Updated background, definitions , and references. Approved at Committee. Date Effective 07/01/2026 Date Archived Digital EEG Spike Analysis-MP-PY-1681Effective Dat e: 07/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 I. References 1. Baumgartner C, Pirker S. Video-EEG. Hanb Clin Neurol . 2019;160:171-183. doi:10.1016/B978-0-444-64032-1.00011-4 2. EEG, noninvasive. MCG Health, 29th edition . Updated June 13, 2025 . Accessed February 24, 2026 . www.careweb.careguidelines.com 3. EEG, video monitoring. MCG Health, 29 th edition. Updated June 13, 2025 . Accessed February 24, 2026 . www.careweb.careguidelines.com 4. Eom TH. Electroencephalography source localization. Clin Exp Pediatr . 2022;66(5):201-209. doi:10.3345/cep.2022.00962 5. Epilepsy and seizures. National Institute of Neurological Disorders and Stroke. Updated April 7, 2025. Accessed February 24, 2026 . www.ninds.nih.gov 6. Feyissa AM, Tatum WO. Adult EEG. Handb Clin Neurol . 2019;160:103-124. doi:10.1016/B978-0-444-64032-1.00007-2 7. Guideline Twelve: Guidelines for long-term monitoring for epilepsy. JClin Neurophysiol . 2008; 25(3): 170-80. doi: 10.1097/WNP.0b013e318175d472 8. Haider HA, Hirsch LJ, Sutherland HW. Electroencephalography (EEG) in the diagnosis of seizures and epilepsy. UpToDate. Updated April 29, 2025. Accessed February 24, 2026 . www.uptodate.com 9. Halford JJ, Sabau D, Drislane FW, et al. American Clinical Neurophysiology Society Guideline 4: Clinical EEG on digital media. JClin Neurophysiol . 2016; 33(4):317-9. doi: 10.1097/WNP.0000000000000318 10. Hirsch LJ, Fong MWWK, Leitinger M, et al. American Clinical Neurophysiology Societys standardized critical care EEG terminology: 2021 version. JClin Neurophysiol . 2021; 38:1-29. doi: 10.1097/WNP.0000000000000806 11. Kobau R, Luncheon C, Greenlund K. Active epilepsy prevalence among U.S. adults is 1.1% and differs by educational level National Health Interview Survey, United States, 2021. Epilepsy Behav . 2023;142:109180. doi:10.1016/j.yebeh.2023.109180 12. Moeller J, Haider HA, Hirsch LJ. Video and ambulatory EEG monitoring in the diagnosis of seizures and epilepsy. UpToDate. Updated May 6, 2025. Accessed February 24, 2026 . www.uptodate.com 13. Tatum WO, Halford JJ, Olejniczak P, et al. Minimum technical requirements for performing ambulatory EEG. JClin Neurophysiol . 2022;39(6):435-440. doi:10.1097/WNP.0000000000000950
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 25-MP-PY-1363 06/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 25-MP-PY-1363Effective Dat e: 06/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 25 B. BackgroundReimbursement modifiers are 2-character code s used by physicians and other qualified health care professionals to indicate that a primary service or procedure has been altered due to a specific circumstance. Modifier 25 is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association ( AMA) Current Procedural Terminology (CPT) book defines modifier 25 as a significant, separately identifiable evaluation and m anagement service by the same physician or other qualified health care professional on the same day of the primary procedure or other service. There must be documentation that substantiates the use of modifier 25 included in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a medically necessary,significant, and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see E/M Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. This modifier is not used to report an E/M service that resulted in a decision to perform surgery ; see modifier 57 for service that resulted in a surgical decision . For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier throu gh prepayment and post-payment edit or audit. Using a modifierinappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon Care Sources request. CareSource uses published guidelines from CPTand the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly. C. Definitions American Medical Association (AMA) A professional association of physicians and medical students that maintains the Current Procedural Terminology coding system. Modifier 25-MP-PY-1363Effective Dat e: 06/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Current Procedural Terminology (CPT ) Codes that are issued, updated, and maintained by the AMA , provid ing a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by CMS, provid ing a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 25 may be flagged for either a prepayment or post-payment medical record coding review.A. For prepayment review, once the claim line has been validated , it is either proces sed for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim line is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims s ubmission, this will also result in a claims denial.IV. Standard appeal rights apply for both pre-and post-payment findings and outco me s of the review. V. Modifier 25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of mo difier 25, the code may be denied.VI. Other CareSource policies may overlap with this topic. Refer to the PreventiveEvaluation and Management Services and Acute Care Visit on Same Date of Service policy for specific information on reimbursement practices for E/M and acute care regarding modifier 25. VII. Appending modifier 25 to an E/M service is considered inappropriate in the following circumstances:A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. Modifier 25-MP-PY-1363Effective Dat e: 06/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 B. The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure.C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. H. The preventative E/M service is performed at the same time as a preventative care visit (eg, a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preve ntative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation. J. CareSource will not reimburse CPT 99211 when billed with modifier 25. E. State-Specific InformationNA F. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, when applicable. In the absence of state specific instructions, CMS guidelines on modifier 25 will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.G. Related Policies/Rules Modifiers Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service H. Review/Revision HistoryDATE ACTIONDate Issued 07/20/2022 New PolicyDate Revised 08/02/2023 Annual Review: updated references. Approved at Committee Modifier 25-MP-PY-1363Effective Dat e: 06/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 07/17/202407/16/2025 03/11 /2026Review: updated references, approved at CommitteeReview: added D.VI.J and K, updated references. Approved at Committee Review: removed G2211, clarified review process in D.II, added related policies section D.VI , removed first Background paragraph . Approved at Committee. Date Effective 06/01/2026 Date Archived I. References1. American Medical Association. Reporting CPT modifier 25. CPT Assistant (Online). 2023;33(11):1-12. Accessed February 26, 2026 . www.ama-assn.org 2. Appropriate use of modifier 25. American College of Cardiology. Accessed February 26, 2026 . www.acc.org 3. Chaplain S. Are you using modifier 25 correctly. American Academy of Professional Coders. March 25, 2022. Accessed February 26, 2026 . www.aapc.com 4. Chapter 1 General Correct Coding Policies for Medicare National Correct Coding Initiative Policy Manual . Centers for Medicare and Medicaid Services ; 202 6. Accessed February 26, 2026 . www.cms.gov 5. Evaluation and Management Services Guide. Centers for Medicare and Medicaid Services; 2024. MLN006764. Accessed February 26, 2026 . www.cms.gov 6. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag . 2004;11(9):21-22. Accessed February 26, 2026 . www.aafp.org 7. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services ; 202 5. Accessed February 26, 2026 . www.cms.go v
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Infusion & Injection Administration-MP-PY-1770 06/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana 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 ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Infusion & Injection Administration-MP-PY-1770Effective Dat e: 06/01/20262A. SubjectInjection & Infusion Administration B. BackgroundAll health care providers are expected to utilize the same standard coding sets and rules to codify the services provided during encounters with patients. This ensures appropriate reimbursement is made for the services rendered. C. Definitions Administration Fee A fee charged for the professional services related to the administration of infusion or injection therapies, which may include preparation, monitoring, and follow-up care. Current Procedural Terminology (CPT) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated and maintained by the AMA that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Infusion Injection The administration of medication through a needle or catheter into the bloodstream, typically requiring specialized equipment and monitoring. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered . D. PolicyI. Providers must utilize the appropriate CPT codes to describe the specific infusion and injection services performed. Codes must align with (1) the substance administered, (2) the route of administration, and (3) the total duration of the procedure. It is the responsibility of the submitting provider to submit accurate documentation of services performed. Providers are expected to use the most accurate and appropriate CPT/HCPCS code(s) for the product or service th at is being provided according to the follow ing industry standard guidelines (may not be all-inclusive): A. National Correct Coding Initiative (NCCI) editing guidelines B. AMA guidelines C. American Hospital Association (AHA) billing rules D. HCPCS E. ICD-10 CM and PCS F. National Drug Codes (NDC) G. Diagnosis Related Group (DRG) guidelines H. CCI table edits NOTE : The inclusion of a code in a policy does not imply any right toreimbursement or guarantee claims payment.Infusion & Injection Administration-MP-PY-1770Effective Dat e: 06/01/20263II. Administration Service CareSource covers administration fees for infusions and injections, provided the services are medically necessary. A. An injection or infusion has 2 components: the administration of a fluid medium and, except in the case of hydration, the pharmaceutical itself. No separate payment is made for the administration service if an injection or infusion is given during the course of an office visit or in con junction with another medical service that includes an evaluation and management element . B. Administration services associated with an infusion or injection are separately reimbursed when the infusion/injection is the primary reason or service performed during the facility visit . C. Certain high-cost medications and complex infusion therapies may require prior authorization (PA). Please use Procedure Code Lookup Tool on CareSource website to verify if prior authorization is needed . III. ExclusionsA. Chemotherapy and hydration B. Home health visits E. State-Specific InformationN/A F. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource. The se are routinely updated to promote accurate coding and policy clarification and are not a guarantee of payment. Reimbursement 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 providers and office staff are encouraged to use self-service channels to verify member eligibility. It is the responsibilit y of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will rei mburse participating providers for medically necessary services . Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, whileothers do not affect the reimbursement rate. CareSource may verify the use of any modifier through post-payment audit. Inappropriate use of a modifier can result in a claim denial or incorre ct reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request . G. Related Policies/RulesModifiers , CareSource Reimbursement policy Infusion & Injection Administration-MP-PY-1770Effective Dat e: 06/01/20264H. Review/Revision HistoryDATE ACTIONDate Issued 03/11/2026 Approved at CommitteeDate Revised Date Effective 06/01/2026 Date Archived I. ReferencesN/A
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective G2211 Reimbursement-MP-PY-1779 IN, WV: 06/01/2026 OH: 07/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 2 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 G2211 Reimbursement-MP-PY-1779Effective Dat e: IN, WV: 06/01/2026OH: 07/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectG2211 Reimbursement B. BackgroundEvaluation and Management (E/M) services are a category of healthcare services which involve assessing a members health and managing their care, and can include office and outpatient visits, hospital visits, home services, and preventive medicine services . E/M coding utilizes current procedural terminology (CPT) codes in the 99202 to 99499 range. There are more than 2 dozen categories of E/M codes, which are further divided to distinguish new patients from established patients. As an add-on code, HCPCS code G2211 seeks to capture the complexity of ongoingmedical care and the longitudinal nature of the member-provider relationship as it pertains to a members single, serious condition or complex condition during an associated off ice or outpatient E/M visit. G2211 is a Medicare-covered code, however, per this CareSource policy, visit complexity is already included in the associated office or outpatient E/M visit for Marketplace. C. Definitions G2211 Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient s single, serious condition or a complex condition. (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established). D. PolicyCareSource considers G2211 not eligible for reimbursement regardless of E/M code billed and/or modifier used. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/11/2026 New policy. Approved at Committee.Date Revised Date Effective IN, WV: 06/01/2026 OH: 07/01/2026 Date ArchivedG2211 Reimbursement-MP-PY-1779Effective Dat e: IN, WV: 06/01/2026OH: 07/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 H. References 1. 2026 HCPCS Level II Expert . AAPC; 2025. 2. What are E/M Codes? AAPC. Accessed February 26 , 2026. www.aapc.com
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