REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Evaluation and Management Services and Urinalysis-MP-PY-1609 06/01/2026 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 Reimbursement policies may be superseded by federal and state laws and regulations, as applicable.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 ………………………….. ………………………….. ………………………….. … 2 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 2 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 2 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Evaluation and Management Services and Urinalysis-MP-PY-1609 Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectEvaluation and Management Services and Urinalysis B. BackgroundThis policy provides guidance when billing urinalysis laboratory tests in conjunction with Evaluation and Management (E/M) services, on the same day, for the same member, by the same provider. Urinalysis laboratory tests are used to evaluate health and dia gnose medical conditions using the physical, chemical, and microscopic properties of an individuals urine sample. The urine sample is visually examined for color, clarity, and odor. A dipstick is used to examine the chemical properties of the urine sample for its pH, specific gravity, protein, glucose, ketones, bilirubin, urobilinogen, nitrites, and leukocyte esterase. A microscopic exam of urine measures the presence of red blood cells, white blood cells, epithelial cells, casts, crystals, and bacteria. T he results of a urinalysis can help assess kidney function, monitor diabetes mellitus (DM) status, evaluate liver disease, for routine health screening, or alert the health care provider to the possible presence of a urinary tract infection (UTI), proteinu ria, or hematuria. C. Definitions Routine Procedures Very common procedure (e g, diagnostic test or screen) that is performed in connection with another procedure (e g, collection of a clean-catch urine sample or a throat swab) or is included in a treatment protocol for which a composite payment amount has been established (e g, specific laboratory test performed for an individual receiving dialysis). D. PolicyI. Urinalysis tests (81002, 81003) are considered routine procedures when performed during an office E/M visit. When urinalysis tests are conducted in conjunction with an E/M service on the same day, for the same member, by the same provider, the provider will not be reimbursed for the urinalysis tests. Only the E/M service will be reimbursed. E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 05/07/2025 New policy. Approved at Committee.Date Revised 03/11/2026 Periodic review. Updated definitions, edited to clarify office E/M in section D.I. Approved at Committee. Evaluation and Management Services and Urinalysis-MP-PY-1609 Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Date Effective 06/01/2026Date Archived I. ReferencesNA
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Evaluation and Management (E/M) and Psychotherapy Add-On-MP-PY-1776 06/01/2026 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.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Evaluation and Management (E/M) and Psychotherapy Add-On-MP-PY-1776 Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectEvaluation and Management (E/M) and Psychotherapy Add-On B. BackgroundAn Evaluation and Management (E/M) service is a particular medical service provided by qualified healthcare professionals to evaluate a patient’s health status, assess condition, establish diagnoses, and manage care, which includes guiding treatment plans. The difference between a regular and a high-level E/M code primarily relates to the complexity of care, the extent of the evaluation and the intensity of medical decision – making performed during the encounter. These differences are reflected in the docume ntation requirements and the corresponding CPT codes used for billing. When a provider, based on tax identification number (TIN), performs both E/M andpsychotherapy on the same date of service (DOS) for a member , the 2 services must be coded correctly . Psychotherapy sessions often include some evaluation components . To address the potential overlap, add-on psychotherapy codes are used in addition to E/M services for these visits. Ad d-on psychotherapy services must be documented, requiring start/stop times specific to the service and any therapeutic communication that ameliorate s mental and behavioral symptoms, modif ies behavior and support , and encourage s personal growth as treatment for behavior al disturbance s or mental illness. C. DefinitionsNA D. PolicyI. When psychotherapy add-on codes 90833, 90836 or 90838 are billed concurrently with high-level E/M codes 99204, 99205, 99214 or 99215 on the same date of service for the same member by the same provider based on the provider tax identification number (TIN), the add-on psychotherapy codes will be denied. The E/M portion of the claim will be reimbursed. Due to the complexity and cognitive demands of moderate to high complexity Medical Decision Making (MDM), it is unlikely that the clinical effort required to complete both E /M and psychotherapy services would not overlap. A. Providers are responsible for the appropriate use of add-on codes, billing with modifiers, including use of modifier 25, and interactive complexity. CareSource may request documentation that supports submitted claims. B. Service documentation must ensure that psychotherapy and E/M services are clearly documented, substantial and significant, and independently identifiable. Overlapping time spent in an encounter cannot be counted toward both services. II. The type and level of E/M service is based on MDM. Please see the AmericanMedical Association (AMA) CPT Evaluation and Management (E/M) Services Guidelines for additional instructions .Evaluation and Management (E/M) and Psychotherapy Add-On-MP-PY-1776 Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 A. Time spent on the activities of the E/M service is not included in the time used for reporting the psychotherapy service. E/M documentation must support the level of service based on AMA Medical Decision-Making Guidelines . B. Time may not be used as the basis of E/M code selection and prolonged services may not be reported when psychotherapy with E/M (90833, 90836, 90838) are reported. E. Conditions of CoverageThe following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 90833 Psychotherapy, 30 minutes with patient when performed with an E/M service . 90836 Psychotherapy, 45 minutes with patient when performed with an E/M service . 90838 Psychotherapy, 60 minutes with patient when performed with an E/M service . 99204 Office or other outpatient visit for the E/M of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making . When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. 99205 Office or other outpatient visit for the E/M of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. 99214 Office or other outpatient visit for the E/M of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 99215 Office or other outpatient visit for the E/M of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. F. Related Policies/RulesModifier 25 G. Review/Revision HistoryDATE ACTIONDate Issued 03/11/2026 New policy. Approved at Committee.Date Revised Date Effective 06/01/2026 Date Archived H. References1. CPT Evaluation and Management (E/M) Services Guidelines . American Medical Association. Accessed February 23, 2026. www.ama-assn.org
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407 06/01/2026 IN, OH, WV inactive as of 01/01 /202 7 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 ………………………….. ………………………….. ………………………….. …………………………. 1 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 A. SubjectDental Services Rendered in a Hospital or Ambulatory Surgery Center Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 B. BackgroundThe decision to perform dental care in a particular place of service is based on a wide variety of factors, including the age and special health care needs (physical, intellectual, and developmental disabilities or chronic medical conditions) of the individual, in addition to the type, number, and complexity of procedures planned. These factors also determine the type of anesthesia used during the procedure. Most dental care can be provided in a dental office setting with local anesthesia or local anesthesia supplemented with non-pharmacological behavior guidance (basic toadvanced techniques) and/or pharmacological options. Basic non-pharmacological behavior guidance includes communication guidance, positive pre-visit imagery, direct observation, tell-show-do, ask-tell-ask, voice control, non-verbal communication, positive reinforcement and descriptive praise, distraction, and desensitization. Pharmacological options may include nitrous oxide, oral conscious sedation and intravenous (IV) sedation (mild, moderate, or deep), or monitored general anesthesia by trained certified individuals in each level of sedation dentistry. As noted by the American Academy of Pe diatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require the use of general anesthesia as medically necessary in a healthcare facility, such as an ambulatory surgica l center, hospital operating room, or short procedure unit (SPU). C. Definitions Ambulatory Surgical Center (ASC) A distinct entity that operates exclusively to furnish outpatient surgical services to patients who do not require hospitalization and are typically discharged less than 24 hours following admission. Hospital An institution primarily engaged in providing, by or under the supervision of physicians, diagnostic and therapeutic services or rehabilitation services. Critical access hospitals are certified under separate standards. Psychiatric hospitals are subject t o additional regulations beyond basic hospital conditions of participation. Monitored Anesthesia Care (MAC) A specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Sedation Continuum When patients undergo procedural sedation/analgesia, a sedation continuum is entered. Several levels have been formally defined along this continuum, as follows: o Minimal Sedation (Anxiolysis) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. o Moderate Sedation (Analgesia) (Conscious Sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 o Deep Sedation (Analgesia) A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require a ssistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. o General Anesthesia A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and p ositive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Note: Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initia lly intended. Individuals administering moderate sedation should be able to rescue patients who enter a state of deep sedation, while those administering deep sedation should be able to rescue patients who enter a state of general anesthesia. Rescue of a p atient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper than intended level of s edation , such as hypoventilation, hypoxia, and hypotension and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation. Short Procedure Unit (SPU ) A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic , or medical services. D. PolicyThis policy is intended to provide guidance on the process for obtaining authorization and reimbursement for dental services performed in a place of service (ASC or hospital OR/SPU) and reimbursement for related facility charges (eg, operating room, anesth esia, medical consults). Dental services are only covered in a hospital setting when the nature of the surgery or the condition of the patient precludes performing the procedure in the dentists office or other non-hospital outpatient setting , and the inpatient or outpatient service is a HealthInsurance Marketplace covered service. As such, it would exclude any diagnostic or preventive dental services delivered in a hospital setting, if these services cannot be performed in office.I. Dental Prior Authorization ProcessA. A review of medical necessity is required for all dental services performed in a hospital inpatient or outpatient facility or ambulatory surgery center facility. Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 B. Dental services authorization for an outpatient/ASC setting1. Requests for dental services should be handled through the members dental plan . Claims submitted for professional dental services should be submitted using the appropriate CDT codes and applicable ADA form. 2. If the member does not have a stand-alone dental plan, the member will be responsible for the costs of the dental services. C. Facility process Facility service claims should be submitted to CareSource using the applicable claim form (eg, CMS-1500, UB-04). E. State-Specific InformationAll states follow any state-specific regulations regarding coverage of dental services. Refer to current state laws, regulations, and administrative code for age restrictions, diagnosis restrictions, and other requirements for coverage of dental services in a hospital or ambula tory surgery center. Georgia: Coverage of general anesthesia and hospital or ambulatory surgical facility charges for certain dental care. GA CODE 33-24-28.4 (2024). Indiana: Dental care provisions required. IN CODE 27-13-7-15 (2024). West Virginia: Required coverage for dental anesthesia services. W EST VIRGINIA CODE 33-15-4j (2009). F. Conditions of CoverageThe fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarantee payment for it. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following information is provided as a reference. This list may not be all inclusive and is subject to updates. Outpatient Hospital Facility (SPU) POS (19, 22); Ambulatory Surgical CenterPOS (24) o Use CPT code G0330 as the facility fee code Paid according to CareSource contract and the Medicare Physician Fee Schedule ( PFS). Dental-related facility charges must be billed on an institutional claim (UB-04 claim form, portal institutional claim, 837I transaction). o Use CPT 00170 for anesthesia for intraoral treatments, including biopsy Paid according to CareSource contract and the Medicare PFS. All associated professional services, such as radiology and anesthesia, as well as ancillary services related to the dental services, must be billed on a professional claim (CMS-1500 claim form or electronic equivalent). Inpatient Hospital Facility POS (21) Dental Services Rendered in a Hospital or Ambulatory Surgery Center-MP-PY-1407Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 o All services as well as any additional Room and Board fees would have to be pre-certified and receive medical necessity review. Services are subject to benefit provisions and criteria for dental hospital admissions for both adult and pediatric members in a ccordance with clinical guidelines. Dental/Oral Surgery Professional Services o The scope of this policy is limited to medical plan coverage of the facility and/or general anesthesia services provided in conjunction with dental treatment, and not the dental or oral surgery services. G. Related Policies/RulesNAH. Review/Revision HistoryDATE ACTIONDate Issued 11/30/2022Date Revised 08/28/2024 09/10/202503/11 /2026Annual review: updated background, reorganized definitions, removed facility PA process and DentaQuest information, updated references. Approved at Committee. Review: updated references, approved at Committee. Review: added state specific regulations. Approved at Committee. Date Effective 06/01/2026 Date Archived I. References1. Ambulatory surgical centers. Centers for Medicare and Medicaid Services. Updated April 22, 2025. Accessed Feburary 5, 2026. www.cms.gov 2. American Academy of Pediatric Dentistry. Management of dental patients with special health care needs. Reference Manual of Pediatr Den t. 2025-2026:364-371 . Accessed Feburary 5, 2026 . www.aapd.org 3. American Academy of Pediatric Dentistry. Policy on hospitalization and operating room access for oral care of infants, children, adolescents, and individuals with special health care needs. Reference Manual of Pediatr Den t. 2025-2026:180-182 . Accessed Feburary 5, 2026 . www.aapd.org 4. American Academy of Pediatric Dentistry. Policy on third-party reimbursement for management of patients with special health care needs. Reference Manual of Pediatr Den t. 2025-2026:193-196 . Accessed Feburary 5, 2026 . www.aapd.org 5. Committee on Quality Management and Departmental Administration. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. October 23, 2024. Accessed Feburary 5, 2026. www.asahq.org 6. Hospitals. Centers for Medicare and Medicaid Services. Updated January 29, 2026 . Accessed Feburary 5, 2026. www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 06/01/2026 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 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 26 and TC: Professional and Technical Component B. BackgroundAccording to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), a modifier is used to report that a service or procedure has been altered by a specific circumstance without changing its definition or code. Modifiers may also convey additional information about a service, such as when the service was performed more tha n once, unusual events occurred, or a service was performed by more than 1 provider and/or in more than 1 location. Current Procedural Terminology (CPT ) codes offer providers a uniform language forreporting medical services and procedures to increase accuracy and efficiency, and for administrative purposes such as claims processing and developing guidelines for medical care review. Certain procedures des cribed by a single CPT code consist of 2distinct components: the professional component and the technical component. When the professional component is performed separately by a provider, it is identified by appending modifie r 26. In this scenario, the facility bills the technical component using the same CPT code with modifier TC. This allows the professional and technical components of the service to be billed separately by the provider and the facility. C. Definitions Global Procedure /Service Represents both the professional and technical component as a complete procedure or service identified by reporting the procedure without modifier 26 or TC. Modifier 26 ( Professional Component) Used to indicate when a p rovider or other qualified health care professional renders the supervision and interpretation portion of a service or procedure and the preparation of a written report. Modifier TC (Technical Component) Used to indicate the technical personnel, equipment, supplies , and institutional charges of a service or procedure . D. PolicyI. Care Source expects providers and facilities to adhere to national coding guidelines and standards when utilizing modifiers . II. Modifier 26A. Modifier 26 is appended to the appropriate CPT code to indicate that only the professional component of a service is being billed. B. Modifier 26 is also used to report the professional component of a test when the provider performs the service while using equipment owned by a hospital or facility. III. Modifier TCA. Modifier TC is appended to the appropriate CPT code to indicate that only the technical component of a service is being billed. Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 B. Reimbursement for the technical component is generally made to the facility or practice that provides the supplies, equipment, and/or clinical staff such as technicians.C. Payment for the technical component includes the practice expense and the malpractice expense associated with the service. D. Hospitals are typically exempt from appending modifier TC because they are presumed to be billing for the technical component of any onsite service. IV. Global procedure /serviceA. A global service is reported by submitting the eligible CPT code without modifier 26 or TC. Reimbursement includes the equipment, supplies, and technical support, as well as interpretation and reporting of test results. B. Modifiers are not necessary to report a global service because payment for both components is included in the reimbursement. V. ExclusionsA. Do not append modifier 26 when there is a dedicated code to report only the professional component of a service (eg, 93010 electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). B. Do not append modifier TC when there is a dedicated code to report only the technical component of a service (eg, 93005 electrocardiogram: tracing only, without interpretation and report ). C. Care Source does not allow reimbursement for use of modifier 26 or modifier TC when 1. it is reported with an Evaluation and Management (E&M) code 2. a dedicated code exists that describes the professional component only, technical component only or global test only of a selected diagnostic test VI. Duplicate billingA. CareSource considers the following scenarios to be duplicate billing when submitted for the same member on the same date of service. Only the first charge approved by CareSource is eligible for reimbursement. All subsequent charges are considered duplicate services and are not eligible for separate reimbursement. 1. when 1 provider reports a global procedure and a different provider reports the same procedure with modifier 26 or modifier TC 2. when 1 provider reports a procedure with modifier 26 and a different provider reports a global procedure 3. when 1 provider reports a procedure with modifier TC and a different provider reports a global procedure VII. Care Source may request documentation for post-payment review of claims submitted with modifier 26 or modifier TC. If documentation is not provided, Care Source may recoup previously paid claim s. Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Dat e: 06/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 E. State-Specific InformationNA F. 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 of claims m ay 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. To ensure HIPAA compliance, please use self-service channels for member eligibility verification. 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 teepayment claims.G. Related Policies/RulesElectrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation H. Review/Revision HistoryDATE ACTIONDate Issued 11/29/2023 New policy. Approved at Committee.Date Revised 09/10/2025 02/25/2026Periodic review. Changed physician to provider where applicable. Updated references. Approved at Committee. Periodic review. Edited for clarity. Updated references. Approved at Committee. Date Effective 06/01/2026 Date Archived I. References1. CPT code set overview . American Medical Association. Updated January 23, 2026 . Accessed January 28, 2026 . www.ama-assn.org 2. Medicare Claims Processing Manual Chapter 23 – Fee Schedule Administration and Coding Requirements . Centers for Medicare and Medicaid Services. Updated December 19, 2025 . Accessed January 28, 2026 . www.cms.gov 3. What are medical coding modifiers? AAPC. Updated August 19, 2022. Accessed January 28, 2026. www.aapc.com
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Interest Payments-MP-PY-1391 04/01/2026 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 ……………………………………………………………………………………………………………. 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 Interest Payments-MP-PY-1391Effective Date: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectInterest Payments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and additional elements, or revisions to data elements, of which the provider has knowledge. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by State and/or Federal regulation defining timeliness and interest requirements. D. PolicyI. CareSource strictly adhere to all regulatory guidelines relating to interest. CareSource follows the guidelines outlined in Prompt Payment regulations. (42 C.F.R. 422.520). II. Payment of interest is made when CareSource fails to pay the claim within the applicable state and federal prompt pay timeframes on clean claims. III. CareSource considers interest payment on claims that were not paid accurately onprior processing attempts. If CareSource had the information to pay the claim correctly on a previous payment but failed to do so, CareSource will pay the claim within the allotted timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe.IV. CareSource only pays interest on claim payments that are occurring under promptpay regulations. A contractual adjustment of a claim is not subject to state andInterest Payments-MP-PY-1391Effective Date: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 federal regulations for interest payment. CareSource performs regular audits to correct claim payment. A. Audits on retroactive eligibility updates, authorization updates, coordination of benefits updates, and fee schedule updates. B. Audits include proactive measures to correct claim payment when it has been determined that a systemic issue has paid claims incorrectly. C. Claims are not subject to interest payment when CareSource takes proactive measures to pay claims correctly. E. State-Specific Information A. Georgia 1. Definitions; Prompt Pay Requirements; Penalties, G A. C ODE ANN . 33-24-59.14 (2024). B. Indiana 1. Payment or Denial of Claims; Interest, I ND . C ODE 27-13-36.2-4 (2024). 2. Required Rules, I ND . C ODE 12-15-21-3 (2024). C. West Virginia 1. Minimum Fair Business Standards Contract Provisions Required; Processing and Payment of Health Care Services; Provider Claims; Commissioner’s Jurisdiction, W. VA. C ODE 33-45-2 (2024). F. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. G. Related Policies/Rules NA H. Review/Revision History DATE ACTIONDate Issued 04/12/2023 New Policy.Date Revised 01/31/2024 01/15/2025 01/14/2026 Updated references. Approved at Committee. Updated references. Approved at Committee. Updated references. Approved at Committee. Date Effective 04/01/2026 Date Archived I. References1. Interest, 41 U.S.C. 7109 (2022). 2. Interest Penalties, 31 U.S.C. 3902 (2023). 3. Interest rates. Bureau of the Fiscal Service. Updated July 1, 2025. Accessed November 21, 2025. www.fiscal.treasury.gov 4. Prompt Payment Interest Rate; Contract Disputes Act, 88 Fed. Reg. 55,501 (2023). Accessed November 21, 2025. www.govinfo.gov Interest Payments-MP-PY-1391Effective Date: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 5. Prompt Payment of Claims, 42 U.S.C. 1395h(c)(2)(B) (2021). 6. Prompt Payment of Claims, 42 U.S.C. 1395u(c)(2)(B) (2021). 7. Prompt Payment by MA Organization, 42 C.F.R. 422.520 (2022).
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 03/01/2026 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 A. Subject ………………………………………………………………………………………………………………. 2B. Background ………………………………………………………………………………………………………… 2C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465Effective Date: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectLeft Ventricular Assist Device (LVAD) Supplies B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. A left ventricular assist device (LVAD) is a surgically implanted battery-operated, mechanical pump, which helps the left ventricle (main pumping chamber of the heart) pump blood to the rest of the body. It is a treatment for a weakened heart or end stage heart failure. LVADs can be used as: Bridge-to-transplant therapy: A life-saving therapy for patients awaiting a heart transplant. Patients use the LVAD until a heart becomes available. In some cases, the LVAD is able to restore the failing heart, eliminating the need for a transplant. Destination therapy: Some patients are not candidates for heart transplants. In this case, patients can receive long-term treatment using an LVAD, which can prolong and improve patients’ lives. Since the use of these devices in either therapy is critical, LVAD supplies should be easily accessible. Remote monitoring is NOT bundled and is separately reimbursable.C. Definitions Heart Failure A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently causing symptoms to occur throughout the body. Left-sided heart failure occurs when the heart loses its ability to pump blood preventing organs from receiving enough oxygen. The condition can lead to complications that include right-sided heart failure and organ damage. Ventricular Assist Device (VAD) A surgically attached device to one or both intact ventricles used to assist or augment the ability of a damaged or weakened native heart to pump blood. Improvement in the performance of the native heart may allow the device to be removed. D. PolicyI. Dressings and supplies Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465Effective Date: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 A. CareSource considers reimbursement for LVAD dressings a covered service when all the following criteria are met: 1. The initial dressings supplied under the bundled in-patient benefit at the facility where the LVAD was implanted are expended. 2. Dressings necessary for the effective use of a LVAD must be billed using the appropriate supply code. B. LVAD dressings are a disposable supply and, therefore, a purchase-only item. C. Supplies billed with miscellaneous code E1399 will be denied if a more appropriate code is available. II. The following codes are not all inclusive but provide a general reference of unlisted/miscellaneous codes that are generally used incorrectly. Code Description E1399 Durable medical equipment, miscellaneous Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device III. BatteriesA. CareSource uses CMS guidance for battery replacement, B. Batteries for LVADs should be billed using the following codes: 1. Q0503: Battery for pneumatic ventricular assist device, replacement only, each. 2. Q0506: Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only C. Batteries billed with miscellaneous code E1399 will be denied. D. A rechargeable battery may be approved with a spare for uninterrupted use. E. Battery chargers require periodic inspection and cleaning 1. According to the manufacturer, the hospital contact is responsible for coordinating annual inspection and maintenance of the battery charger after the patient leaves the hospital. 2. Service and maintenance should only be performed by personnel trained by the manufacturer. 3. Battery chargers that are repairable will not be replaced. IV. Warranty CareSource may request warranty information regarding the DME item or supply. If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the claims. V. Prior authorization submitted with unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration during review: Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465Effective Date: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 A. 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 B. current clinic notes listing the amount of dressing changes the member needs per week C. any other information requested by CareSource VI. Non-covered services A. Remote monitoring of LVADs using Q0508 or bundled codes B. multiple battery packs beyond the pair required for continuous use E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Codes in this policy reflect those found in CMS Transmittal 10837 for National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs). A. All unlisted or miscellaneous codes defined within this policy are subject to medical necessity review. B. Prior authorization is not a guarantee of payment. C. Claims must include an invoice. D. CareSource may verify the use of any code through post-payment audit. E. If a more appropriate code is discovered, CareSource may request recoupment. F. Related Policies/Rules Durable Medical Equipment Repairs Unlisted and Miscellaneous Codes G. Review/Revision History DATE ACTIONDate Issued 12/13/2023 New Policy, approved at Committee.Date Revised 12/18/2024 12/03/2025 Added Unlisted and Miscellaneous Codes to section F. Updated references. Approved at Committee. Added non-bundling of remote monitoring to Background. III. A and E. Added V.B to A. Remote monitoring of LVADs using Q0508 or bundled codes. PA requirements. Change VI.A to Added Durable Medical Equipment Repairs to Sec. F. Updated references. Approved at Committee Date Effective 03/01/2026 Date Archived H. References1. Artificial Hearts and Related Devices, Including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy. Medicare Coverage Database; 2020. Decision Memo CAG-00453N. Centers for Medicare & Medicaid Services. Accessed November 04, 2025. www.cms.gov Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465Effective Date: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 2. Heart failure. National Heart, Blood and Lung Institute. Accessed November 04,2025. www.nhlbi.nih.gov 3. Left ventricular assist devices (LVADs). Cleveland Clinic. Accessed November 4, 2025. www.my.clevelandclinic.org 4. NCCI Coding Policy Manual . Centers for Medicare & Medicaid Services; 2025. Accessed November 04, 2025. www.cms.gov 5. NCD-Ventricular Assist Devices (VADs) (20.9.1). Centers for Medicare & Medicaid Services. Accessed November 04, 2025. www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Behavioral Health Rates-MP-PY-1733 03/01/2026 OH and 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 ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Behavioral Health Rates-MP-PY-1733Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectBehavioral Health Rates B. BackgroundState exchanges (or marketplaces) were established by the A ffordable Care Act (ACA) to provide a platform for individuals and small businesses to compare and purchase health insurance plans , in crease access to affordable health insurance, promote competition among insurers and improve the overall quality of care. State marketplaces adhere to consumer protection standards established by the ACA and enforced by the Centers for Medicare & Medicaid Services (CMS) . CMS provides guidance and support to state exchanges and issues regulations, guidance document s and technical assistance to help sta tes comply with federal requirements , including operational guidelines that provide instructions on how exchanges should operate (eg, enrollment processes, data reporting, consumer outreach , quality metrics). Payment practices of state healthcare exchanges are governed by federal regulations established under the ACA, specific guidelines from CMS, state regulations, and consumer protection laws that work together to create a framework promoting access toaffordable health insurance . CMS payment guidance helps ensure consistency in the billing and reimburse ment of services across states , simplify ing processes for providers , assuring compliance with federal regulations, improving quality of care and enhancing financial stability. Utilizing CMS guidance can streamline administrative processes for insurers and providers , leading to reduced administrative costs and improved efficiency in claims processing and reimbursement. Adhering to CMS guidelines helps ensure that consumers are protected through fair and transparent payment practices. CareSource is establishing a clear framework for reimbursement rates of behavioral health (BH) services. Rates will reflect Medicare reimbu rsement standards for covered services and utilize the CareSource BH FeeSchedule for services not covered by Medicare.C. DefinitionsN/A D. PolicyI. CareSource will utilize the following for the establishment of rates for BH services: A. If a service is covered by Medicare, rates will reflect Medicare reimbursement standards. A geographic practice cost index (GPCI) is established for every Medicare payment locality for each of the 3 components of a procedures relative value unit (ie, the RVUs for work, practice expense, malpractice). The GPCIs are applied in the calculation of a fee schedule payment amount by multiplying the RVU for each component times the GPCI for that component. B. If a service is not covered by Medicare, rates will follow 1) any specified contract rates, and then 2) utilization of the CareSource BH Fee Schedule located in the Provider Portal on www.caresource.com. Behavioral Health Rates-MP-PY-1733Effective Dat e: 03/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 II. Rate Development ApproachCareSource will employ the f ollowing systematic approach to develop and update rates for the BH Fee Schedule: A. Internal Median Rate Analysi s: Rates will be derived from an analysis of internal median fee schedule rates across various markets. B. Third-Party Data Validation: Where applicable, third-party data sources will be utilized to validate median rates, providing an additional layer of assurance for the established rates. C. Single Case Agreement Rates: In cases where both internal and third-party data are unavailable, single case agreement median rates will be utilized as a last resort to ensure the establishment of a rate. III. Compliance and ReviewA. To ensure compliance with industry standards and mitigate potential risks associated with fee schedule determinations, rates will undergo a comprehensive review at least annually to ensure alignment with industry standards and market benchmarks. B. CareSource will implement a system for ongoing monitoring of rate efficacy and impact on service delivery . E. State-Specific InformationN/A F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 12/03/2025 New policy. Approved at Committee.Date Revised Date Effective 03/01/2026 Date Archived I. References1. Health insurance marketplaces. Centers for Medicare and Medicaid Services. Accessed October 14, 2025. www.cms.gov 2. Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans, 45 C.F.R. Parts 155 and 156 (2025). 3. Treatment of Off –Campus Outpatient Departments of a Provider . Public Law 114-74, Section 603 (2015).
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Venipuncture and Laboratory Testing-MP-PY-1618 02/01/2026 IN, OH, WV inactive as of 01/01/202 7 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Venipuncture and Laboratory Testing-MP-PY-1618Effective Dat e: 02/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectVenipuncture and Laboratory Testing B. BackgroundN/A C. Definitions Venipuncture A needle is used to collect blood from a vein, usually for laboratory testing. D. Policy I. Laboratory Services A. Venipuncture is considered an incidental service when billed on a claim containing laboratory testing with the same place of service for the same member on the same date. Therefore, venipuncture is included in the reimbursement for the laboratory test perf ormed and is not separately reimbursable. B. The following CPT codes are considered venipuncture: 36400, 36405, 36406, 364 10, 36415, 36591, and 36592. C. CareSource may reimburse CPT code (s) 36400, 36405, 36406, and 36410 when billed with modifier 59 , and appropriate documentation and the medical record reflect a distinct service requiring the skill of a qualified health care professional. II. Professional ServicesRoutine venipuncture (36415) is not eligible for reimbursement when reported with office or other outpatient E/M codes (ie, 99202-99205 , 99211-99215). Routine venipuncture is included in the reimbursement for office visit E/M services and not reimbursed separately. III. Outpatient Facility ServicesVenipuncture codes ( ie, 36400, 36405, 36406, 36410, 36415, 36416) are not eligible for reimbursement when reported by an outpatient facility. These codes will be included in the facility payment and not allowed for separate reimbursement. IV. CareSource may conduct a post-payment review on claims with venipuncture and no other laboratory testing to ensure compliance. E. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement 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 a members eligibility. Venipuncture and Laboratory Testing-MP-PY-1618Effective Dat e: 02/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes.Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource polic ies applyto both participating and nonparticipating providers and facilities.F. Related Policies/RulesModifier 59 Overpayment Recovery G. Review/Revision HistoryDATE ACTIONDate Issued 05/21/2025 Approved at Committee.Date Revised 10/22/2025 Periodic review. Updated definition. Removed modifier 22 from D.I.C. Added II. and III. Added reference. Approved at Committee. Date Effective 02/01/2026 Date Archived H. References1. NCI dictionary of cancer terms. National Cancer Institute. Accessed September 8, 2025. www.cancer.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Newborn and Neonatal Intensive Care Unit (NICU) Level of Care – MP-PY-1433 02/01/2026 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 ………………………….. ………………………….. ………………………….. …. 6 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 6 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 6 H. Review/Revision History ………………………….. ………………………….. ………………………….. …… 6 I. References ………………………….. ………………………….. ………………………….. …………………….. 7 Newborn and Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Dat e: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectNewborn and Neonatal Intensive Care Unit (NICU) Level of Care B. BackgroundThis policy aligns with guidance from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) regarding NICU levels of care. This policy provides guidelines for determining the medically appropriate level of care for reimbursement based on available documentation. NICU admissions are reviewed to ensure that services are of an appropriate duration and level of care to promote optimal health outcomes in the most efficient manner. Clinical documentation of an ongoing NICU hospitalization will be reviewed concurrently to substantiate level of care with continued authorization based on the documentation submitted. Reimbursement for the NICU stay will be based on the authorized level of care and determined by the concurrent review process. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have defined and specified the capabilities for each of 4 facility levels of care (ie, a specific unit located in the hospital). These facilities ra ngefrom a Level I Newborn Observation Unit to a Level IV Regional Neonatal Intensive Care Unit. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification.The Neonatal Intensive Care Unit (NICU) is a critical care area in a facility for newborn babies who need specialized care. The NICU designation requires a combination ofadvanced technology and a NICU team of licensed professionals.Newborn and NICU levels of care are based on the complexity of care that a newbornwith specified diagnoses and symptoms requires. All four levels of care are represented by a unique revenue code . Any inpatient revenue codes not billed as levels 2-4 will be recognized as a level 1. Newborn nursery=0170 Level 1=0171 Level 2=0172 Level 3=0173 Level 4=0174 While most infants admitted to the NICU are premature, others are born at term but suffer from medical conditions , such as infections or birth defects. A newborn also couldbe admitted to the NICU for associated maternal risk factors or complicated deliveries.Although the list of criteria used to determine the NICU levels of care in this policy is not all inclusive, it does provide an overview of the guidelines that are used. C. Definitions Intensity of Care (IOC) The complexity of care that a newborn with specified diagnoses and symptoms require s. Newborn and Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Dat e: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Newborn CareServices Services performed from birth to 4 weeks. Neonatal Intensive Care Services (NICU) Critical care services for a newborn. Well Baby Care Services A basic level of care to neonates who are low risk. D. PolicyI. Per federal mandate, newborn members are covered at an inpatient facility for a 2 – day stay for vaginal deliveries and a 4-day stay for cesarean sections. These stays will be covered without clinical review (notification may be required) if they are submitted with a normal newborn DRG. II. For any newborn diagnoses/revenue codes/procedures that may be associated with care/treatment outside of routine newborn care (any revenue code 0172, 0173, 0174) , authorization is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to provide documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. When a newborn require s a NICU admission or a higher IOC service, anauthorization is required.IV. If a complication develops with the mother or baby that necessitates additionalhospital days, NICU admission, or non-well-baby service, an authorization should be submitted along with clinical information to support the stay. V. If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to newborn nursery or pediatric level of care,NICU intensity of care will not be assigned regardless of interventions completed during transitional time. VI. Clinical review will determine appropriate IOC utilizing MCG standards. Care Sourcewill adjust IOC reimbursement if clinical documentation does not support the IOCbilled. VII. Inpatient admissions may be reviewed to ensure that all services are of an appropriate duration and intensity of care to promote optimal health outcomes.Clinical documentation of an ongoing neonatal hospitalization will be reviewed concurrently to substantiate the level of care and length of stay. A continued authorization will be based on the documentation subm itted and alignment with MCGNeonatal Facility Levels of Care and Neonatal Intensity of Care Criteria , as well as CareSource policy. VIII. In order to avoid reimbursement delay or adjustments, providers are encouraged to reference MCG guidelines as well as the clarifications and specific details below .Newborn and Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Dat e: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Note: Newborn nursery babies that do not require advance levels of care are billed using revenue code 0170. NICU LevelRevenue Code Description MCG NICU Intensity of Care Level 1 0171: Newborn Level I Intensity of Care Criteria 1 Routine Care (LOC-010 )Neonatal care may be indicated for the physiologically stable infant (eg, no apnea, bradycardia, or unstable temperature) requiring care consisting of 1 or more of the following: Routine newborn care Evaluation and care of neonates with conditions that require inpatient services available at Level I Continued inpatient care during convalescence from condition(s) treated in Level II, Ill or IV while awaiting resolution of specific issues (eg , sustained weight gain, poor PO feeding ), or establishment of safe discharge destination and plan Uncomplicated jaundice treated only with phototherapy and requiring infrequent bilirubin checks Absence of parenteral medications Evaluation and management of glucose levels without IV fluids , d iagnostic work – up/surveillance, on an otherwise stable neonate where no therapy is initiated Level 2 0172: Newborn Level II Intensity of Care Criteria 2 Continuing Care (LOC-011 )Neonatal care may be indicated for 1 or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen, ( 2L/min), with other co – morbidities stable Administration of intravenous (IV) medications IV Therapy; peripheral or PICC o IV fluids inclusive of hyperalimentation ( 2 L/min of blended oxygen , continuous positive airway pressure (CPAP), NIPPV o conventional ventilation (via endotracheal tube, nasotracheal tube or tracheostomy tube) o high-frequency ventilation long-term (> one week) Presence of chest tubes Umbilical arterial catheter (UAC) for blood draws Active apnea/bradycardic episodes requiring PPV Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia requiring > 5 mg/kg/min or hypoglycemia not responsive to 1 IV dextrose bolus (200 mg/kg or 2 ml/kg of D10W ) Total parenteral nutrition or IV fluids to supplement inadequate oral intake (NG or PO) > 50% total nutrition NAS requiring initiation/escalation of medication or inability to wean Hyperbilirubinemia with evidence of hemolysis requiring IVIG or blood transfusion Acute encephalopathy that is moderate to severe and under active investigation or has been investigated and does not meet criteria for therapeutic hypothermia Surgical conditions requiring general anesthesia up to 2 days post-op , if indicated Surgical/Therapies for retinopathy of prematurity (ROP) Seizure activity requiring initiation, supplementation or changing of seizure medications Transfusion of blood products in absence of severe acute etiology or manifestations (eg, transfusion needed for anemia of prematurity, iatrogenic anemia) Hypotension requiring IV fluid bolus Level 4 0174: Newborn Level IV Intensity of Care Criteria 4 Intensive Care (LOC-013 )Includes Level 3 requirements and 1 or more of the following clinical interventions: Perioperative care following surgical repair of severe neonatal conditions, for example: o bowel resection for necrotizing enterocolitis (NEC) o tracheoesophageal fistula or esophageal atresia repair o cardiac surgery excluding PDA ligation o myelomeningocele closure (up to 48 hours post-op) o organ transplant Medically necessary inhaled nitric oxide (iNO) Extracorporeal membrane oxygenation (ECMO) High frequency oscillatory or jet ventilation (initial week) Therapeutic cooling Exchange transfusion (day of procedure) Uncontrolled active seizures despite medications Newborn and Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Dat e: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 Ongoing cardiovascular support (inotropes, chronotropes, antiarrhythmics) Severe hemodynamic instability requiring ongoing intravenous fluid/medication support o dialysis o IV sedation that includes paralysis o prostaglandin infusion CPR in the last 24 hours (not inclusive of delivery room resuscitation) Transfusion of blood products in setting of severe acute etiology or manifestation (eg, hemolytic anemia, disseminated intravascular coagulation, hemorrhage) E. State-Specific InformationNA F. Conditions of CoverageI. Reimbursement is independent of the location of care and corresponds to the medical treatment provided and level of service the neonate requires. To ensure accurate reimbursement, submitted claims will be reviewed to align with authorized levels of care and/or clinically validate diagnoses, procedures , and other claim information that impact payment. Based on review, the following may occur: Down-code revenue codes to authorized levels of care . Issue a base DRG payment . Adjust claim diagnoses/procedures that are not substantiated in the medical information provided and apply DRG regrouping . Request for complete medical records and/or itemized statements to support the services on the claim may be made . II. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document.G. Related Policies/Rules NA H. Review/Revision HistoryDATE ACTIONDate Issued 09/27/2023 New policy. Approved at Committee.Date Revised 03/12/2025 10/22/2025Annual review, References updated. Approved at Committee.Periodic review. Added Newborn to title and newborn nursery revenue code information . Updated references . Approved at Committee. Date Effective 02/01/2026 Date Archived Newborn and Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Dat e: 02/01/2026 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 I. References 1. About preterm labor and birth. National Institutes of Health. Reviewed May 9, 2023. Accessed October 10, 2025 . www.nichd.nih.gov 2. Admission to NICU. Specification Manual for Joint Commission National Quality Measures . The Joint Commission; 202 5. Version 202 5A 1. Accessed October 10, 2025 . www.manual.jointcommission.org 3. Intensity of Care Criteria 1 – Routine Care: LOC-010 (ISC GRG). MCG Health. 29th ed. Accessed October 10, 2025. www.careweb.careguidelines.com 4. Intensity of Care Criteria 2 – Continuing Care: LOC-011 (ISC GRG). MCG Health. 29th ed. Accessed October 10, 2025. www.careweb.careguidelines.com 5. Intensity of Care Criteria 3 – Intermediate Care: LOC-012 (ISC GRG). MCG Health. 29th ed. Accessed October 10, 2025. www.careweb.careguidelines.com 6. Intensity of Care Criteria 4 – Intensive Care: LOC-013 (ISC GRG). MCG Health. 29th ed. Accessed October 10, 2025. www.careweb.careguidelines.com 7. Stark AR, Pursley DM, Papile L, et al. Standards for levels of neonatal care: II, III, and IV. Pediatr . 2023;151(6):e2023061957. doi:10.1542/peds.2023-061957
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana 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 ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450Effective Dat e: 01/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectPre-Exposure Prophylaxis (PrEP) Preventive Services B. BackgroundAn estimated 1.2 million individuals in the United States are human immunodeficiency virus positive (HIV +), with a n estimated 30,635 new infections in 2020 . Though treatable, HIV infection is incurable and associated with s ignificant health complications. Effective strategies to prevent HIV infection remain a key public health priority. To prevent the spread of HIV, t he Centers for Disease Control and Prevention (CDC) recommends the use of antiretroviral pre-exposure prophylaxis (PrEP) in sexually active individuals who are at high risk of HIV exposure as well as individuals who use drugs intravenously. Studies have shown that PrEP significantly reduce s the transmission of HIV to persons who are currently HIV -. The Federal Patient Protection and Preventive Care Act of 2010 requires insurance plans cover preventive medicine services with a recommendation of A or Bby the U.S. Preventive Services Task Force (USPSTF). The USPSTF assigns one of five letter grades (A, B, C, D, or I) which describes the strength of a recommendation andcommunicates its importance to providers. Grade A The USPSTF recommends the service; there is high certainty that the net benefit is substantial. Grade B The USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Grade C The USPSTF recommends selectively offering or providing the service to individual patients based on professional judgement and patient preferences. There is at least moderate certainty that the net benefit is small. Grade D The USPSTF recommends against the service; there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Grade I The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of the service. The USPSTF recommends clinicians prescribe PrEP with effective antiretroviral therapy to individuals who are at increased risk of HIV acquisition to decrease the risk ofacquiring HIV infection (Grade A). To achieve the benefit of PrEP, it is important for individuals to receive counseling about antiretroviral medication adherence, safer sex practices, and regular testing for HIV and other related infections. Prior to receiving a prescription for PrEP, individuals may require counseling and laboratory testi ng to evaluate the need for PrEP as well as establish a baseline health status. As PrEP is only effective with medication adherence, follow-up appointments with or without laboratory testing are often necessary. As of October 1, 2023, ICD-10 code Z29.81 (encounter for HIV pre-exposure prophylaxis) is available for providers to use on medical claims. Insurance plans are not required to provide coverage for these preventive services when delivered by out-of-network providers. Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450Effective Dat e: 01/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. Definitions Pre-Exposure Prophyaxis (PrEP) Antiretroviral medication that helps prevent individuals from acquiring HIV. USPSTF An independent, volunteer panel of national experts that makes evidence-based recommendations about clinical preventive services. D. PolicyI. CareSource will provide PrEP and related services to members who qualify as high risk, follow ing USPSTF guidelines for the prevention of HIV . These services are classified as preventive with no cost share . Please refer to the most recently published USPSTF guideline for clarification of high risk and current coverage recommendations. II. CareSource covers the following without cost-sharing when associated with PreP:A. FDA-approved PrEP antiretroviral medications B. baseline and monitoring services, including 1. HIV testing 2. hepatitis Band Ctesting 3. creatinine testing and calculated estimated creatine clearance (eCrCI) or glomerular filtration rate (eGFR) 4. pregnancy testing (as appropriate) 5. sexually transmitted infection (STI) screening and counseling 6. adherence counseling C. office visits associated with PrEP III. The following code set has been provided for informational purposes only . These codes may be used to identify a service as part of PrEP preventive services. In order for a service in Section II to be identified as part of PrEP preventive services and cost sharing to be waived, providers need to follow the below coding steps: A. Use ICD-10 code Z29.81 on the claim, or B. Use ICD-10 code Z20.6 or Z11.4, and at least one of the other below codes on the claim. ICD-10Code Code Description Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z11.4 Encounter for screening for human immunodeficiency virus [HIV] Z11.59 Encounter for screening for other viral diseases Z11.8 Encounter for screening for other infectious and parasitic diseases Z11.9 Encounter for screening for infectious and parasitic diseases, unspecified Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV] Z20.828 Contact with and (suspected) exposure to other viral communicable diseases Z20.89 Contact with and (suspected) exposure to other communicable diseases Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450Effective Dat e: 01/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Z20.9 Contact with and (suspected) exposure to unspecified communicable diseaseZ29.89 Encounter for other specified prophylactic measuresZ32.00 Encounter for pregnancy test, result unknown Z32.01 Encounter for pregnancy test, result positive Z32.02 Encounter for pregnancy test, result negative Z51.81 Encounter for therapeutic drug level monitoring Z70.0 Counseling related to sexual attitude Z70.1 Counseling related to patients sexual behavior and orientation Z70.3 Counseling related to combined concerns regarding sexual attitude, behavior and orientation Z71.7 Human immunodeficiency virus [HIV] counseling Z72.51 High risk heterosexual behavior Z72.52 High risk homosexual behavior Z72.53 High risk bisexual behavior Z72.89 Other problems related to lifestyle Z77.21 Contact with and (suspected) exposure to potentially hazardous body fluids Z77.9 Other contact with and (suspected) exposures hazardous to health Z79.899 Other long term (current) drug therapy W46.0XXA Contact with hypodermic needle, initial encounter W46.0XXD Contact with hypodermic needle, subsequent encounter W46.1XXA Contact with contaminated hypodermic needle, initial encounter W46.1XXD Contact with contaminated hypodermic needle, subsequent encounter IV. ExclusionsClaims received from the emergency department would not generally qualify as PrEP preventive services. E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 09/27/2023 New Policy. Approved at Committee.Date Revised 10/09 /2024 10/08 /2025 Review: updated references. Approved at Committee. Review: updated references, approved at Committee. Date Effective 01/01/2026 Date Archived Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450Effective Dat e: 01/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 I. References1. Agency for Healthcare Research and Quality. Effectiveness of Pre-Exposure Prophylaxis to Prevent HIV Infection: Findings of a Systematic Review. Updated October 2023. Accessed September 12, 2025. www.ahrq.gov 2. Assistant Secretary for Public Affairs. About the Affordable Care Act. United States Dept of Health and Human Services. Reviewed March 17, 2022. Accessed September 1 2, 202 5. www.hhs.gov 3. Billing Coding Guide for HIV Prevention . National Alliance of State & Territorial AIDS Directors; 2016. Accessed September 1 2, 202 5. www.nastad.org 4. Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas, 2021. Accessed September 12, 2025 . www.cdc.gov 5. Centers for Medicare and Medicaid Services. FAQs about Affordable Care Act implementation part 54. July 28, 2022. Accessed September 12, 2025 . www.cms.gov 6. Coverage of Preventive Health Services, 29 C.F.R. 2590.715-2713 (2023). 7. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention. About HIV. Centers for Disease Control and Prevention. Reviewed January 14, 2025 . Accessed September 12, 2025 . www.cdc.gov 8. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention. Preventing HIV with PrEP . Centers for Disease Control and Prevention. Reviewed January 18, 2024 . Accessed September 1 2, 2025 . www.cdc.gov 9. Krakower D, Mayer KH. HIV pre-exposure prophylaxis. UpToDate. Updated September 3, 2025 . Accessed September 12, 2025 . www.uptodate.com 10. Mayer KH, Molina JM, Thompson MA, et al. Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER): primary results from a randomised, double-blind, multicentre, active – controlled , phase 3, non-inferiority trial. Lancet . 2020;396(10246):239-254. doi:10.1016/S0140-6736(20)31065-5 11. Patient Protection and Affordable Care Act, 42 U.S.C. 18001-18122 (202 4). 12. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2021 Update: Clinical Providers Supplement. Centers for Disease Control and Prevention; 2021. Accessed September 12, 2025 . www.cdc.gov 13. Pre-Exposure Prophylaxis for the Prevention of HIV Infection: A Systematic Review for the U.S. Preventive Services Task Force. August 2023 . Accessed September 1 2, 202 5. www.uspreventiveservicestaskforce.org 14. Task force at a glance. United States Preventive Services Task Force. Accessed September 12, 2025 . www.uspreventiveservicestaskforce.org 15. U.S. Preventive Services Task Force. Preexposure prophylaxis to prevent acquisition of HIV: US Preventive Services Task Force recommendation statement. JAMA . 2023;330(8):736-745. doi:1 0.1001/jama.2023.14461 16. U.S. Preventive Services Task Force. Grade Definitions. June 2018. Accessed September 12, 2025 . www.uspreventiveservicestaskforce.org 17. US Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2021 Update: A Clinical Practice Guideline . US Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450Effective Dat e: 01/01/2026The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 Centers for Disease Control and Prevention; 2021. Accessed September 12, 2025 .www.cdc.gov 18. What does FDA regulate ? United States Food and Drug Administration. Reviewed March 29, 2024 . Accessed September 12, 2025 . www.fda.gov
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