Overpayment Recovery

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

Applied Behavior Analysis for Autism Spectrum Disorder

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 12/01/2025 IN, OH, WV inactive as of 01/01/2027 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditi ons of Coverage ………………………….. ………………………….. ………………………….. …… 7 F. State-Specific Information ………………………….. ………………………….. ………………………….. … 8 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 8 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 I. References ………………………….. ………………………….. ………………………….. ……………………. 8 Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectApplied Behavior Analysis for Autism Spectrum Disorder B. BackgroundProvider reimbursement issues for Applied Behavior Analysis (ABA) services for Autism Spectrum Disorder (ASD) can arise from various factors, impacting families, providers, and the accessibility of care. Key issues relating to payment problems include coverage issues, billing and coding challenges, access to services, and legislative and policy issues. Billing an d coding issues are common due to a variety of factors, including the complexity of coding, incorrect coding, insufficient documentation, authorization issues, and billing for supervision and telehealth services. CareSource strives to provide clear practices regarding reimbursement of services and followsfederal and state guidance. Medical criteria for the provision of ABA services is located inCareSources Applied Behavior Analysis for Autism Spectrum Disorders medical policy at www. care source.com under the Provider tab. C. Definitions Medically Unlikely Edit (MUE) Maximum units of service for 1 Current Procedural Terminology (CPT) code a provider can report for 1 member on 1 date of service. D. PolicyI. General Provisions A. Reimbursement Rules 1. Members and providers must adhere to the associated Plans Evidence of Coverage document and schedule of benefits. 2. A review of medical necessity is required prior to any ABA service provision. 3. Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepayment review. 4. Providers cannot submit multiple dates of service on a single claim line. Each claim line must be specific to a single date of service and the units provided on that single date of service. 5. Covered services use fee schedule reimbursement methodology in which reimbursement is made at the lower of the billed charge for the service or the maximum allowable reimbursement for the service. The maximum allowable reimbursement for a service is the sa me for all ABA providers. 6. Preparing a member for services, cleaning or prepping an area before or after services, and/or rest or other break times between service activities is not billable. 7. Time spent on documentation alone is not billable as a service unless otherwise specifically permitted by code definition. B. Documentation Requirements States enact regulations and guidelines for documentation requirements for memberrecords maintained for third party billing. All written, electronic, and other records will be stored and disposed of in such a manner as to ensure confidentiality. All must beApplied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.3 legible. CareSource reserves the right to request supervision documentation,particularly related to telehealth services. 1. Member records should contain the following documentation: a. presenting problem, including referral reason, relevant diagnoses and any recommendations for ABA therapy rendered by an appropriate professional b. service note for each service contact c. any fee information shared with member/family in compliance with applicable laws, regulations and BACB ethical standards d. treatment plan and functional assessment on which the behavior plan is based e. any data collected to ascertain efficacy of services and subsequent modifications of the plan f. notation and results of formal contacts with other providers g. authorizations, if any, by the member/guardian for release of records or information 2. Minimum documentation requirements for all services rendered include a. name of provider organization clearly visible on the record b. members name on each page (ie, legal name) c. date of birth or unique identifier d. any applicable guardianship documents e. date and location of rendered service f. date of note creation if different from date of rendered service g. start and stop times including any pauses in services (must indicate time paused and time resumed) h. type/code of service provided i. rendering providers name, credentials, and dated signature j. dated signature of parent/guardian or member, if applicable , on documents (eg, treatment plan, plan of care, behavior support plans) k. identification of others present in all sessions (eg, individual, group, family), including the relationship with the member and the number of individuals participating in any group sessions l. summary of session activity that directly relates to the POC and member response to intervention m. addendum information, if applicable, including a clear reference of the clinical note it is intended to supplement, date completed and signature with credentials C. Supervision Expectations States require that appropriate supervision of services occur for any provider not acting independently, particularly if the provider is submitting a claim(s) for reimbursement. The BACB provides guidelines and documentation expectations for providers. If there are discrepancies with supervision documentation, the associated claims are subject to recoupment. CareSource expects providers to submit BACB – required documentation for supervision, if requested . II. Covered ServicesCovered services are only reimbursable when delivered in accordance with the members treatment plan or plan of care. Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.4 A. Behavior Assessment (BA)Th is service must be performed by a BCBA. Generally, BAs should not exceed 8 hours every 6 months unless additional justification is provided and authorization is received . The unit of service calculation should only include 1. face-to-face time spent by the BCBA with the member and/or parent/guardian conducting a comprehensive evaluation 2. any non-face-to-face time spent by the BCBA preparing the accompanying comprehensive evaluation report and developing the members initial ITP B. Behavior Identification Supporting Assessment An onsite physician or other qualified health care professional, with assistance from 2 or more technicians, administers a behavior identification supporting assessment of a member with serious destructive behavioral concerns (eg, harming oneself, damaging property, aggression with injury to others ) or behaviors resulting from recurring actions or issues related to communication or social interactions. The technicians spend face – to-face time with the member conducting the assessment, which includes exposure to a number of social and environmental elements associated with the maladaptive beha viors conducted in a structured and safe customized environment. Evaluation targeting certain destructive behaviors includes assessing triggers, events, cues, responses, and consequences associated with the destructive behavior(s). 1. This service usually includes assessing /analyzing functional behavior and other structured observations, the use of standardized and non-standardized instruments, and procedures that will assist the clinician in establishing the degree of adaptive and maladaptive behaviors or impairments of the member . 2. Report only the time of 1 technician even when 2 or more technicians are present for each 15 minutes of face-to-face time provided by the technician. C. ABA Therapy Treatment Services These services must be performed one-on-one by a BCBA, BCaBA supervised by a BCBA, or an RBT supervised by a BCBA face-to-face with a member. If face-to-face services are provided to 2 or more members but no more than 8, group code(s) should be used . 1. The amount of ABA therapy treatment services performed during a week cannot exceed the prescribed or authorized number of units per week. 2. A week for these purposes is Monday through Sunday. D. Adaptive Behavior Treatment with Protocol Modification Services These services are reimbursed on a per unit basis. During the encounter, the provider solves at least 1 problem with the protocol and may, at the same time, coach a n RBT or BCaBA . The member must be present during the session, including instructions provided to the technician and/or caregiver. 1. This service with use of 2 or more technicians for serious destructive or harmful behaviors by members requires use of a different billable code. 2. The unit of service calculation should only include time spent supervising, observing and interacting in-person with the member and BCaBA or RBT under the BCBAs supervision. 3. Each BCaBA or RBT performing ABA therapy treatment services must be supervised by a BCBA responsible for the quality of the services rendered: Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.5 a. A supervising BCBA must be enrolled with the CareSource plan and meet the following minimum in-person observation thresholds for each BCaBA or RBT under supervision: 01. 5% of total ABA treatment hours performed by the BCaBA or RBT 02. 1 hour of ABA delivery performed by BCaBA or RBT every 30 days b. When not directly observing an ABA session, supervising BCBA must be on – call and immediately available to advise and assist throughout the entirety of any ABA session performed by a BCaBA or RBT. Availability by telecommunication is sufficient to meet this requirement. c. Supervising BCBA must review and approve the data collection and progress notes completed by a BCaBA or RBT under supervision prior to submitting a claim for any ABA therapy treatment services delivered. d. A BCBA delivering direct one-on-one treatment services to a member (ie, not supervising a BCaBA or RBT perform an ABA therapy treatment session) is not considered an adaptive behavior treatment with protocol modification service and must be billed as an ABA therapy treatment service. e. Adjusting and updating an existing ITP as required is considered an adaptive behavior treatment with protocol modification service. E. Family Adaptive Behavior Treatment Service Services must include the participation of a single members parent , guardian or other appropriate caregiver and must be performed by a BCBA. The member may or may not be present. During the session, the provider assists and documents helping parent(s)/caregiver(s) learn to identify behavioral problems and implement treatment strategies to minimize behavioral concerns while maximizing target behaviors. 1. Services are reimbursed on a per unit basis and should only include time spent collaborating face-to-face with the parent or guardian. 2. If the session involves multiple sets of parents/caregivers with the member s present, group family code(s) should be billed. F. Telemedicine Services Telemedicine services are reimbursed in the same manner and subject to the same limits as in-person, face-to-face service delivery. III. Codes of ConductCodes of conduct protect members by establishing, disseminating, and managing professional standards , and states mandate that these standards are followed. CareSource supports professional standards established by licensing and credentialing bodies and encourages professional compliance to any and all standards across disciplines for the protection of members and families. The ethics code written by the BACB should be maintained at all times. IV. Special Provisions Related to RBTsA. Current Standards for RBTs1. RBT services must be supervised by a qualified RBT supervisor. Services delivered by an RBT must be supervised by a BCBA, BCBA-D, or a licensed psychologist who tested in ABA and is certified by the American Board of Professional Psychology in Behavioral a nd Cognitive Psychology. Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.6 2. An RBT certified by the BACB may provide ABA under the supervision of an independent practitioner if affiliated with the organization under which the provider is employed or contracted. If the independent practitioner leaves the affiliated organization and no longer provides supervision, the RBT may not continue to provide services under that independent practitioner. Additionally, if the RBT leaves the affiliated organization and no longer receives mandated supervision, the RBT may not continue to provide services to the member. 3. RBTs must use appropriate modifiers that indicate qualifications of staff delivering services, if applicable. 4. CareSource will allow providers 60 days from the date of hire for RBTs to complete the RBT credentialing process with the BACB. B. Upcoming RBT Changes from the Behavior Analyst Certification Board 1. Effective January 1, 2026 , the BACB approved a recommendation that RBT supervisors must hold BCBA or BCaBA certification. During this transition, RBT Requirements Coordinators who currently attest to the qualifications of non – certified supervisors should prepare to ensure continuity of care . 2. Effective January 1, 2026 , the BACB adopted n ew rules regarding eligibility for and maintenance of certification for RBTs and can be located in the BACB Newsletter: December 2023 at www.bacb.com. V. ExclusionsReimbursement for the following services or activities is not permitted:A. reimbursement for the following services or activities is not permitted: 1. any services not documented in the treatment plan 2. behavioral methods or modes considered experimental /investigational 3. education-related services or activities described under Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. 1400 (IDEA), amended through Public Law 114-95, Every Student Succeeds Act 4. vocational services in nature or those available through programs funded under Section 110 of the Rehabilitation Act of 1973 5. components of adult day care programs B. treatment solely for the benefit of the family, caregiver or therapist or for symptoms/behaviors not part of core symptoms of ASD C. treatment that worsens symptoms, prompt s member regression or is unexpected to cause improvement D. services provided by family or household members or custodial care not re quiring trained ABA staff E. shadowing, para-professional, or companion services in any setting F. services more costly than an alternative service(s) likely to produce equivalent diagnostic or therapeutic result G. any program or service performed in nonconventional settings, even if performed by a licensed provider (eg, spas/resorts, vocational or recreational settings, Outward Bound, wilderness, camp or ranch programs ). Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.7 E. Conditi ons of CoverageI. CareSource complies with the Centers for Medicare and Medicaid Services (CMS) Medicaid Medically Unlikely Edit (MUE) table. If CMS updates the MUE list, the update will take precedence over this policy. II. Treatment codes are based on daily total units of service in 15-minute increments. A unit of time is attained when the mid-point is passed. The following are time interval examples: Unit(s) Number of Minutes 1 unit >8-22 minutes 2 units >23 – 37 minutes 3 units >38 – 52 minutes 4 units >53 – 67 minutes 5 units >68 – 82 minutes 6 units >83 – 97 minutes 7 units >98 – 112 minutes 8 units >113 – 127 minutes III. The following code set has been provided for informational purposes only. These codes may be used to identify a service as part of ABA treatment. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code i n this policy does not imply any right to reimbursement or guarantee claim payment. Please refer to the applicable fee schedule s and plan information for appropriate codes. CPT Codes Code Description97151 Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physicians or other qualified health care professionals time face-to-face with member and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan 97152 Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to- face with the member , each 15 minutes 97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one member , each 15 minutes 97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more member s, each 15 minutes 97155 Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one member , each 15 minutes Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.8 97156 Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the member present), face-to-facewith guardian(s)/caregiver(s), each 15 minutes97157 Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the member present), face-to-face with multiple sets of guardians /caregivers , each 15 minutes 97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple member s, each 15 minutes 0362T Behavior identification supporting assessment, each 15 minutes of technicians time face-to-face with a member , requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of 2 or more technicians; for a member who exhibits destructive behavior; completion in an environment that is customized to the member s behavior. 0373T Adaptive b ehavior treatment with protocol modification , each 15 minutes of technicians time face-to-face with a member , requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of 2 or more technicians; for a member who exhibits destructive behavior; completion in an environment that is customized to the member s behavior. F. State-Specific InformationNA G. Related Policies/RulesApplied Behavior Analysis for Autism Spectrum Disorder Medical policy H. Review/Revision HistoryDATE ACTIONDate Issued 08/27/2025 New policy. Approved at Committee.Date Revised Date Effective 12/01/2025 Date Archived I. References1. BACB Newsletter. Behavior Analyst Certification Board; 2023. Accessed August 19 , 2025. www.bacb.com 2. BACB Newsletter: Introducing the 2026 RBT Examination and Certification Requirements. Behavior Analyst Certification Board; 2023. Accessed April 3, 2025. www.bacb.com 3. Board Certified Behavior Analyst Handbook . Behavior Analyst Certification Board. Accessed August 19, 2025 . www.bacb.com 4. Board Certified Assistant Behavior Analyst Handbook . Behavior Analyst Certification Board. Accessed August 19, 2025 . www.bacb.com 5. Contents of a Request for a Waiver, 42 C.F.R. 441.301 (2024). Applied Behavior Analysis for Autism Spectrum Disorder-MP-PY-1636 Effective Dat e: 12/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.9 6. Ethics Code for Behavior Analysts . Behavior Analyst Certification Board . Accessed August19, 2025 . www.bacb .com 7. Georgia Marketplace Evidence of Coverage. CareSource; 2025. www.caresource.com 8. Indiana Marketplace Evidence of Coverage. CareSource; 2025. www.caresource.com 9. NCCI MUE Edits-Practitioner Services . Centers for Medicare and Medicaid Services. Updated April 1, 2025. Accessed August 19, 2025 . www.cms.gov 10. Ohio Marketplace Evidence of Coverage. CareSource; 2025. www.caresource.com 11. Registered Behavior Technician Handbook . Behavior Analyst Certification Board. Accessed August 19, 2025 . www.bacb.com 12. West Virginia Marketplace Evidence of Coverage. CareSource; 2025. www.caresource.com

Reimbursement of Advanced Practice Nonphysician Practitioners

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Reimbursement of Advanced Practice Nonphysician Practitioners-MP-1662 09/01/2025 IN, OH, WV inactive as of 01/01/2027 Kentucky Inactive 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design, and other factors are consider ed in developing Reimbursement Policies. Reimbursement Policies do not guarantee authorization or payment for services. Coverage and payment determinations are subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreements, and applicable referral, authorization, notification, and utilization management guidelines. Please refer to the plan contract (e.g., Evidence of Coverage, Member Handbook) for the service(s) referenced herein. Except as otherwise required by law, if there is a conflict between the Reimbursement Policy and the plan contract and/or provider agreeme nt, then the plan contract and/or provider agreement will be the controlling document used to make the determination. Reasonable discretion may be used in interpreting and applying this policy to services provided in a particular case and the policy may be modified at any time. Reimbursement policies may be superseded by federal and state laws and regulations, as applicable. In the case of a discrepancy between the Policy Statements effective date and any applicable legal or regulatory requirement, the law or regulation will govern. Coverage for mental health and substance use disorder (MH/SUD) benefits are provided at the same level as coverage for medical and surgical (M/S) benefits, as required by the Mental Health Parity and Addiction Equity Act (MHPAEA). MH/SUD benefits are not s ubject to limits or requirements that are more restrictive than those that apply to M/S benefits.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Reimbursement of Advanced Practice Nonphysician Practitioners-MP-1662 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectReimbursement of Advanced Practice Nonphysician Practitioners B. BackgroundCenters for Medicare and Medicaid Services (CMS) established guidelines regarding reimbursement of advanced practice providers, initially categorized under non-physician practitioner s (NPP), i ncluding , but not limited to , physician assis tants (PA), nurse practitioners (NP) , clinical nurse specialists (CNS) , licensed social workers ( LSW), mental health counselors (MHC) and marriage family therapists (MFT). NPP s are health care providers who assess, diagnose, and treat patients but do notpossess the education or certification as a physician. NPP s work in both the medical/surgical realm and within behavioral health (BH) models that deliver psychotherapy, counseling and other substance use disorder services. Billing varies according to the level of the practitioner and field of practice. The scope of practice for each type of NPP will vary by state and is defined by state laws and regulations. Medical billing falls under 2 categories: direct billing and incident-to billing. Direct billinginvolves a claim that is submitted under the NPP s National Provider Identification (NPI)number with a reduced payment that is typically a percentage of the contracted fee schedule. Incident-to billing involves claim s submitted under the supervising physicians NPI that are paid at a higher percentage of the physicians fee schedule. CMS billing protocols ensure that healthcare providers deliver services efficiently whilecomplying with regulatory standards. Understanding guidelines is crucial to navigate the billing process successfully, optimize reimbursement, and maintain compliance with regula tions. This policy applies to services provided by NPP s within a medical or other healthcare practice and to both in-and out-of-network providers. CareSource recognizes licensed NPP s as a separate provider type when working under the supervision o f a participating physician or doctorate-level provider . C. Definitions Consolidated Billing All claims for the entire package of care received by residents or inpatient members must be billed by the facility. D. PolicyI. General Reimbursement Guidelines A. If a practitioner or provider has a contract with CareSource that contract supersedes this policy direction and is the governing document. B. Providers are required and responsible for use of any applicable modifiers on claims, as necessary. C. Patients cannot be charged more than amounts permitted under federal law. If a member pays more for a service than the assign ed payment limits, the excess amount must be refunded. Reimbursement of Advanced Practice Nonphysician Practitioners-MP-1662 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. All providers must follow applicable CMS qualifications and criteria for direct and incident to billing , service requirements, coverage and documentation guidelines, and billing guidelines. 1. Direct billing criteria include the following: a. The service(s) provided is considered a physicians service and is a covered service under the members benefit plan. b. The service(s) provided is within the NPPs scope of practice for the applicable license/certification and state. c. Claims include assigned individual NPP NPI number. d. NPPs must be credentialed. 2. Incident to services criteria include the following: a. Services must be an integral (incidental) part of the members normal treatment when the physician performed an initial service and remains actively involved in the members care. b. Services are those commonly rendered without charge or included in the physicians bill. c. Billed services occurred in an office or clinic setting, not hospital inpatient or outpatient setting. d. Services must be provided under direct physician supervision (ie, supervising physician and NPP must be associated with the same practice and the supervising physician must be present in the location of service and immediately available to provide assistan ce and direction throughout the time the NPP is performing services). e. Physician involvement must be documented in the medical record. II. Physical Health or Medical/SurgicalCareSource reimburses the following physical health NPPs at the following rates: A. Certified Registered Nurse Anesthetists (CRNAs) are exempt from mid-level reductions in payment and paid at 100% of the Physician Fee Schedule (PFS). B. Anesthesiologist Assistants (A As) 1. Services are paid at 100% under the PFS or in accordance with the level of supervision provided. 2. Units are paid u nder the Anesthesia Fee Schedule and based on applicable locality adjusted anesthesia conversion factor multiplied by the sum of allowable base and time units (ie, 1 anesthesia time unit = 15 minutes anesthesia time ). C. Physician Assistants (PAs) 1. Incident to and incident to a PA services provided outside a hospital or SNF setting are paid at 85% of the amount a physician receives under the PFS. 2. Assistant-at-surgery services are paid 85% of 16% of the physician rate under the PFS. 3. When services are provided in the hospital setting (inpatient and outpatient), payment is unbundled and made directly to the PA under the PFS. D. Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs) Reimbursement of Advanced Practice Nonphysician Practitioners-MP-1662 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 1. Direct billing is paid at 80% of the lesser of the actual charge or 85% of the amount a physician receives under the PFS when furnished outside a hospital or skilled nursing facility (SNF) setting . 2. Assistant-at-surgery services are paid 85% of 16% of the amount a physician receives under the PFS. 3. Incident to services provided by auxiliary personnel outside a hospital or SNF setting are paid at 85% of the physician rate under the PFS. E. Certified Nurse Midwives (CNMs) 1. Direct billing is paid at 80% of the lesser of the actual charge or 100% of the amount a physician receives under the PFS. When billing directly for services in a hospital setting (inpatient and outpatient), payments are unbundled and paid under the PFS. 2. Covered drugs and biologicals provided incident to CNM services are paid according to Part Bdrug and biological payment methodology. 3. Incident to services provided outside a hospital or SNF setting are paid at 100% of the physician rate under the PFS. 4. Covered clinical diagnostic laboratory services are paid according to the Clinical Laboratory Fee Schedule. 5. When most of a global service is provided and a physician is called in to provide a portion of care or when the physician provides most of the service and calls in a CNM , payment will be based on the portion of the global fee that would be paid to the billing practitioner. Service modifiers would be used to report that not all covered global allowance services were provided. F. Other NPPs of physical health services NPPs not listed above will be paid at 8 5% of the physician rate under the PFS. III. Behavioral HealthCareSource reimburses NP Ps (eg, marriage and family therapist s, mental health counselors , licensed social worker s, substance abuse counselors ) at 75% of the clinical psychologist rate under the PFS . Clinical psychologists are paid 100% of the rate paid to physicians under the PFS. A. MFT and MHC services furnished to skilled nursing facility residents on or after January 1, 2024 are excluded from consolidated billing. B. There may be other billing exclusions related to BH billing by certain groups of NP Ps (eg, MFT/MHC services to inpatient of Medicare-participating hospitals, MFT/MHC services to client under partial hospitalization or intensive outpatient programs by hospital outpatient departments or community mental health centers). Providers are responsible for submitting claims appropriately. IV. Commodity ServicesThese services will not be subject to reductions when submitted on the same claim as an applicable service and will be reimbursed at 100% of the fee schedule allowance if covered under the members benefit plan, but not limited to, A. laboratory services B. after-hours services C. supplies Reimbursement of Advanced Practice Nonphysician Practitioners-MP-1662 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 D. injected or infused drugsE. diagnostic tests E. State-Specific InformationNA F. Conditions of CoverageI. Proper documentation is crucial to demonstrate compliance with supervision requirements , including maintaining clear records of services provided, the nature of the supervisory relationship, and any collaboration with the supervising physician or BH professional . CareSource reserves the right to request supervision documents or medical records that establish the validity of billed services. II. Additional criteria may exist for billing some services (eg, assistant-at-surgery ) that include the use of modifiers or other guidelines. Providers are responsible for billing these services according to federal and/or state guidelines. III. Paid claims submitted in violation of state and/or federal guidelines or filed incorrectly by providers , including a lack of modifier use, may be subject to recoupment.G. Related Policies/Rules NA H. Review/Revision HistoryDATE ACTIONDate Issued 06/04/2025 New policy. Approved at Committee.Date Revised Date Effective 09/01/2025 Date Archived I. References1. Advanced practice nonphysician practitioners. Centers for Medicare and Medicaid Services. Updated December 5, 2024. Accessed June 3 , 2025. www.cms.gov 2. Consolidated Appropriations Act, Sections 4113 and 4121(FF) (2023). 3. Incident to services and supplies. Centers for Medicare and Medicaid Services. Updated April 9, 2025 . Accessed June 3 , 2025. www.cms.gov 4. Marriage and family therapists. Centers for Medicare and Medicaid Services. Updated April 11, 2025. Accessed June 3 , 2025. www.cms.gov 5. Marriage and Family Therapist Services, 42 C.F.R. 410.53 (2023). 6. Medicare and Medicaid Programs. 42 CFR Parts 401, 405, 410, 411, 414, 423-425, 427, 428, and 491 (2024). 7. Medicare and Mental Health Coverage. Centers for Medicare and Medicaid Services; 2024. MLN1986542. Accessed May 3, 2025. www.cms.gov 8. Mental Health Counselor Services, 42 C.F.R. 410.54 (2023). 9. Payment for Physicians Services, 42 U.S.C. 1395, section 1848(g)(4)(A) (2018).

Durable Medical Equipment (DME) Modifiers

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Durable Medical Equipment (DME) Modifiers – MP-PY-1368 08/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Durable Medical Equipment (DME) Modifiers-MP-PY-1368Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDurable Medical Equipment (DME) Modifiers B. BackgroundModifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additional information to the code description of the product or service. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. The purpose of this policy is to simplify and standardize the use of modifiers when billingfor rented, purchased, or rent to purchase DME equipment. There are many modifiers that can be used when billing DME. This policy addresses the rental modifier RR and the new equipment purchase modifier NU . CareSource expects providers to use the modifiers stated in this policy to increase efficiency and timely reimbursement. Any other appropriate modifier per national or state billing standards can be appended t o a DME item along with the modifiers addressed in this policy (LT, RT, etc.). The modifiers addressed in this policy are not an all-inclusive list , and providers should adhere to national and state billing guidelines for modifier usage for all other modifiers not addressed within this policy. C. Definitions Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. This policy outlines the use of DME modifiers for the rental and/or purchase of Durable Medical Equipment (DME). II. DME items can beA. purchased B. rented C. rented on a short-term basis and then purchased at the end of the rental period III. DME items must be billed with appropriate HCPCS codes along with appropriatemodifiers when applicable:A. Purchase Modifier – NU 1. CareSource requires that Modifier NU is appended to all claims for the purchase of DME equipment. Durable Medical Equipment (DME) Modifiers-MP-PY-1368Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 B. Rental Modifier – RR1. CareSource requires that Modifier RR is appended to all claims for the rental period of DME equipment. a. The combined total reimbursement for rental and subsequent purchase of a DME item cannot exceed the maximum fee. b. At the end of the rent to purchase period, the DME becomes the property of the member.C. Disposable supplies do not require a modifier.IV. Modifiers that are not to be used for claims submission for DME equipmentA. LL – Lease/rentalB. NR – New when rented C. RB – Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement parts are new equipment) V. CareSource considers a replacement part as a new equipment purchase , andmodifier NU should be used instead of modifier RB.VI. DME items submitted for reimbursement without a modifier are considered apurchase. If the DME item was intended to be a rental and the modifier RR was left off the claim in error, CareSource may verify the use of any modifier through post payment audit and proper reimbursement adjustment will occur. All information regarding the use of these modifiers must be made available upon CareSources request. VII. KX ModifierA. The KX modifier indicates that the supplier has ensured that coverage criteria for the DMEPOS billed is met and that documentation does exist to support the medical necessity of the item. Documentation must be available upon request.1. The K Xmodifier must be appended as required by the specific DMEPOS item. 2. Claims that do not have the KX modifier appended in accordance with the policy will be denied. E. Conditions of CoverageModifier Description KX Confirmation that services are medically necessary RR Rental (use the RR modifier when DME is to be rented) NU Purchase New Equipment (use the NU modifier when DME is to be purchased) Reimbursement policies are designed to assist providers when submitting claims toCareSource . They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be Durable Medical Equipment (DME) Modifiers-MP-PY-1368Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate 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. F. State-Specific InformationNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 09/14/2022 New policyDate Revised 10/11/2023 05/07 /2025Annual review. Added KX modifier language. Updated references. Approved at Committee.Periodic review. Updated KX modifier requirement. Updated references. Approved at Committee. Date Effective 08/01/2025 Date Archived I. References1. Durable Medical Equipment (DME). Accessed March 31, 2025. www.healthcare.gov 2. Healthcare Common Procedure Coding System (HCPCS). Accessed March 31, 2025 . www.nlm.nih.gov 3. Use of the KX modifier. Medicare Claims Processing Manual: Chapter 5-Part B Outpatient Rehabilitation and CORF/OPT Services. US Centers for Medicare and Medicaid Services; 2021. Rev 11129. Accessed March 31, 2025. www.cms.gov 4. What are medical coding modifiers? 2022. American Academy of Professional Coders. Accessed March 31, 2025. www.aapc.com

Facility Charges For Hospital Based Outpatient Clinics

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Facility Charges for Hospital-Based Outpatient Clinics-OH MP-PY-1600 05/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Facility Charges for Hospital-Based Outpatient Clinics-OH MP-PY-1600 Effective Dat e: 05/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectFacility Charges for Hospital-Based Outpatient Clinics B. BackgroundThis policy outlines the guidelines for facility charges associated with services provided in hospital-based outpatient clinics. Patients receiving care in these settings may notice a facility charge on their bill, which is distinct from the fees for the s pecific procedures or treatments. These charges are typically billed using a UB-04 institutional claim form. C. Definitions CMS-1500 A standard claim form that professional providers and medical billing professionals use to bill insurance companies for health care services. Facility Charges A charge that is part of the overhead cost of a hospital, which supports the location and other services the hospital must provide and are not directly related to the care a patient receives. Also known as a facility fee. Hospital-Based Outpatient Clinics An outpatient facility that may or may not be on the hospital grounds, is operating under the ownership or administrative control of the hospital and offers the same or similar services as the hospital. Network Provider Healthcare professionals in good standing who have successfully passed a CareSource credentialing or recredentialing program. Participation Agreement An agreement between a health plan and providers or hospitals, which includes terms, such as information about compensation, billing, payment, network participation, provider licensing and insurance, provider credentialing, maintenance of records, termi nation, and state contracting and filing requirements. Health plans compensate providers for covered services rendered to members and compensate hospitals through facility charges under the terms of the agreement. Revenue Code A 4-digit number that is used on hospital bills to inform insurance companies either where the patient was when they received treatment, or what type of item a patient may have received as a patient. UB-04 Claim form used by hospitals and other providers to bill for institutional services. A valid procedure code must accompany a revenue code for it to be accepted by the insurance provider. D. PolicyI. CareSource does not provide reimbursement for facility charges associated with clinic services rendered by a network provider for any hospital-based outpatient clinics when billed using the UB-04 form. Specifically, facility charges billed with revenue code 510 are n ot reimbursed. as these charges are not considered covered services under the health plan participation agreements. II. CareSource will only reimburse for clinic services provided for a member that are rendered on the same day in which the treatment is rendered at the hospital-basedoutpatient clinic when billed on a CMS-1500 professional claim form.Facility Charges for Hospital-Based Outpatient Clinics-OH MP-PY-1600 Effective Dat e: 05/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 III. Hospitals are prohibited from seek ing reimbursement for facility charges at hospital-based outpatient clinics from CareSource, CareSource members, or CareSource subsidiaries when billed using revenue code 510. E. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource. These policies are routinely updated to promote accurate coding and policy clarification. There 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 o ffice staff are encouraged to use self-service channels to verify members eligibility. Reimbursement id dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individu al fee schedule for appropriate codes. The following list of revenue codes are provided as a reference and are not reimbursable.Revenue Code Description0510 General F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 03/12/2025 New policy. Approved at Committee.Date Revised Date Effective 05/01/2025 Date Archived H. References1. Brocks J. Health plan network provider agreement essentials. LexisNexis. Published April 20, 2019. Accessed November 6, 2024. www.lexisnexis.com 2. Facility fees and how they affect health care prices. Health Care Cost Institute. Accessed November 6, 2024. www.healthcostinstitute.org 3. Professional paper claim form (CMS-1500). Centers for Medicare & Medicaid Services. Accessed November 6, 2024. www.cms.gov 4. What is outpatient facility coding and reimbursement. AAPC. Reviewed December 14, 2023. Accessed November 6, 2024. www.aapc.com

Chiropractic Care

REIMBURSEMENT POLICY STATEMENTOhio Marketplace Policy Name & Number Date Effective Chiropractic Care-OH MP-PY-1445 05/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Chiropractic Care-OH MP-PY-1445Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectChiropractic Care B. BackgroundReimbursement 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 member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.C. Definitions Chiropractor A Doctor of Chiropractic licensed and qualified to provide chiropractic services. Chiropractic Therapy Therapy that focuses on joints of the spine and the nervous system, while osteopathic therapy includes equal emphasis on the joints and surrounding muscles, tendons and ligaments. Manipulation Therapy Osteopathic/chiropractic therapy used for treating problems associated with bones, joints and the back. Medically Necessary/Medical Necessity Health care services that a provider would render to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is (i) in accordance with generally accepted standards of medical practic e; and (ii) clinically appropriate in terms of type, frequency, extent, and duration. D. PolicyI. A covered chiropractic service that is legally performed will not be denied when such covered service is rendered by a n in-network , licensed chiropractor in the state when the covered service is performed. II. All services are subject to members share of cost (deductible, co-insurance and/orco-pays). This varies based on the members plan enrolled at the time of service.III. When manipulation services are provided in addition to an evaluation andmanagement (E/M) office visit, modifier 25 should be appended to the E/M code.This distinguishes a significant , separately identifiable E/M office visit from the additional manipulation service. Chiropractic Care-OH MP-PY-1445Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 IV. Scope of practiceChiropractors must follow the states scope of practice. Any training or certification required by the state must be available to CareSource, upon request . V. Chiropractic patients whose diagnosis is not within the chiropractic scope of practice, shall be referred , by the chiropractor , to a medical doctor or other licensed healthpractitioner for treatment of that condition.VI. Manipulation therapyA. Chiropractic manipulation therapy used for treating problems associated with bones, joints and the back is included . Chiropractors are limited to subluxations of the articulations of the human spine and the adjacent tissue. B. Annual benefit limits apply. It is the providers responsibility to validate the available remaining quantity before rendering service. Manipulations performed will be counted toward any maximum for manipulation therapy services as specified in the member s Evidence of Coverage (EOC) or Schedule of Benefits regardless if billed as the only procedure or done in conjunction with an exam and billed as an office visit . C. The members plan does not provide benefits for manipulation therapy services provided in the home as part of Home Health Care Services. D. Modifier AT is required to be appended to any manipulation code. E. Claims should include a primary diagnosis of subluxation and a secondary diagnosis that reflects the patients neuromusculoskeletal condition. VII. All codes contained within this policy are not all inclusive but provide a general reference of covered codes based on what chiropractors are allowed to perform. Codes contained within this policy that may or may not require a review of medical necessity p rior to the service should be confirmed by accessing the Provider Look-upTool on the CareSource website (www.procedurelookup.caresource.com). VIII. The following are a list of codes that may be covered and do not require a review of medical necessity prior to service: A. Evaluation and management (E/M) codes (99202-99204, 99211-99214) B. 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions C. 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions D. 98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions E. 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions F. X-rays [radiologic examination (RE) ] for diagnostic purposes IX. Codes that may be covered but require a review of medical necessity prior to service or treatment :A. 97 010 hot or cold packsB. 97012 traction C. 97014 electrical stimulation D. 97035 ultrasound Chiropractic Care-OH MP-PY-1445Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 E. 97139 unlisted therapeutic procedureF. 97140 manual therapy technique X. CareSource follows the Centers for Medicare and Medicaid (CMS) analysis stating that acupuncture includes dry needling. Acupuncture is not a covered benefit. The following exclusions/services are not medically necessary and, therefore, not covered for chiropractors:A. 20560 needle insertion(s) without injection(s); 1 or 2 muscle(s) -dry needling B. 20561 needle insertion(s) without injection(s); 3 or more muscles-dry needling E. Conditions of CoverageNA F. Related Policies/RulesModifier 25 Reimbursement policy Marketplace Plan Evidence of Coverage G. Review/Revision HistoryDATE ACTIONDate Issued 08/03/2022 New policyDate Revised 09/27/2023 01/ 29 /2025Policy number changed from PY-1358. Updated references . Approved at Committee. Periodic review. Updated VII, VIII, IX, and Xand references. Approved at Committee. Date Effective 05/01/2025 Date Archived H. References1. Local Coverage Determination: Chiropractic Services L37254. Medicare Coverage Database. November 6, 2017. Revised February 1, 2024. Accessed December 2, 2024. www.cms.gov 2. National Coverage Analysis: Acupuncture for Chronic Low Back Pain CAG-00452N. Medicare Coverage Database. January 21, 2020. Accessed December 2, 2024. www.cms.gov 3. Practice of Chiropractic Defined, OHIO REV . CODE 4734.01 (2001) 4. Scope of Practice of Chiropractic – Permissible Titles, OHIO REV . CODE 4734.15 (2020) 5. Use of the AT Modifier for Chiropractic Billing . US Centers for Medicare and Medicaid Services; 2021. Accessed December 2, 2024. www.hhs.gov www.cms.gov

Single Dose Vial – Claims Modifiers

REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name Policy Number Effective Date Single Dose Vial Claims Modifiers PY-PHARM-0104 01-01-2025 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ……………………………………………………………………………………………………… 4 F. Related Policies/Rules …………………………………………………………………………………………… 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 4 Reimbursement Policy Statement: 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, indust ry-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 re ferral, 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. Single Dose Vial Claims Modifiers Marketplace PY-PHARM-0104 Effective Date: 01-01-202 5 2 A. SubjectThis policy provides guidance for claims billing documentation and reimbursement of single dose injectable vials. B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. 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 their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/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. This policy describes documentation requirements and reimbursement guidelines for billing of the administered and discarded portion(s) of drugs and biologicals. Providers shall bill and receive reimbursement for both the dose administered and the unused portion of weight-based or variable dosing injectable drugs that are manufactured and supplied only in single dose or single use format. The JW modifier is required to be reported on a claim to report the amount of drug that is discarded and eligible for payment and should be used only for claims that bill single-dose container drugs. The discarded portion of single use or single dose vials must be identified with the JW Modifier as a separate line item from the dose or administered portion. Providers may be reimbursed for the discarded portions of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropriately reported based on the policy reimbursement guidelines. As of July 1, 2023, providers and suppliers are required to report the JZ modifier on all claims that bill for drugs from single-dose containers when there are no discarded amounts. The JZ modifier is reported on a claim to attest that no amount of drug was discarded and should only be used for claims that bill for single-dose container drugs. Claims containing drug administered from multi-dose vials are not subject to this requirement. Under this policy, all claims for separately payable single dose format injectable drugs must include either a JW modifier or a JZ modifier after 7-1-2023 in order to be reimbursed Single Dose Vial Claims Modifiers Marketplace PY-PHARM-0104 Effective Date: 01-01-202 5 3 MODIFIER SHORT DESCRIPTOR LONG DESCRIPTORJW Discarded portion of drug not administered Drug amount discarded/not administered to any patient JZ All drug administered none discarded Zero drug amount discarded/not administered to any patient C. DefinitionsModifier JW refers to the drug amount discarded (wasted)/not administered to any patient. Modifer JZrefers to zero drug amount discarded/not administered to any patient.Discarded Wastage or Unused Portion is defined as the amount of a single use/dose vial or other single use/dose package that remains after administering a dose/quantity of a drug or biological. Single Dose Vial i s defined as a vial of medication intended for administration by injection or infusion that is meant for use in a single patient for a sing le procedure. These vials are labeled as single-dose or single-vial by the manufacturer and typically do not contain a preservative. Multi-Dose Vial is defined as a vial of medication intended for administration by injection or infusion that contains more than one dose of medication. These vials are labeled as multi-dose by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria.D. Policy Modifier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modifier JW. Both details are reimbursable. CareSource will consider reimbursement for: I. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not administered to another patient. CareSource will NOT consider reimbursement for: I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. NOTE: The JZ modifier is required when there are no discarded amounts of a single-dose container drug for which the JW modifier would be required if there were discarded Single Dose Vial Claims Modifiers Marketplace PY-PHARM-0104 Effective Date: 01-01-202 5 4 amounts. The JZ modifier is required to attest that there were no discarded amounts, and no JW modifier amount is reported.E. Conditions of Coverage Providers must not use the JW modifier for medications manufactured in a multi-dose vial format. Providers must choose the most appropriate vial size(s) required to prepar e a dose to minimize waste of the discarded portion of the injectable vials. Claims considered for reimbursement must not exceed the package size of the vial used for preparation of the dose. Providers must not bill for vial contents overfill. Providers must not use the JW modifier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modifer is only applied to the amount of drug or biological that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modifier. 1. Claim Line #1 HCPCS code for drug administered and the amount admistered to the patient. 2. Claim Line #2 HCPCS code for drug discarded (wasted) with JW modifier appended to indicate waste and the amount discarded (wasted). The JZ Modifier is applied when zero amounts of a single-dose container drug is discarded. F. Related Policies/Rules Chapter 17, Section 40.1 of CMS Medicare Claims Processing Manual G. Review/Revision History DATE ACTIONDate Issued 01-22-2023 Original effective dateDate Revised 08-25-2023 Updated policy to include JZ modifier. Updated policy name and references. 10-11-2024 Annual review. No changes.Date Effective 01-01-202 5Date Archived H. References1. Billing and Coding: JW and JZ Modifier Billing Guidelines Article-Billing and Coding: JW and JZ Modifier Billing Guidelines (A55932) (cms.gov)2. New JZ Claims Modifer for Certain Medicare Part BDrugs https://www.cms.gov/files/document/mm13056-new-jz-claims-modifier-certain-medicare-part-b- drugs.pdf3. Discarded Drugs and Biologicals JW Modifier and JZ Modifier Policy FAQs. jw-modifier-faqs.pdf (cms.gov) The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.

Standard Medical Billing Guidance

REIMBURSEMENT POLICY STATEMENT OHIO MARKETPLACE Policy Name Policy Number Effective Date Standard Medical Billing Guidance PY-PHARM-0130 – OH-MP 02-01-202 3 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standa rd 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 re ferral, 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 patien t 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 lowes t 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 Statem ents, 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 thi s 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 limitatio ns that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………….. . 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. … 2 B. Background ………………………….. ………………………….. ………………………….. ………………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ….. 3 E. Conditions of Coverage. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …….. 5 H. References ………………………….. ………………………….. ………………………….. ………………………. 5 Standard Billing Reimbursement StatementOHIO MARKETPLACEPY-PHARM-0130-OH-MP Effective Date: 02-01-2023 2 A. SubjectStandard Medical Billing Guid ance B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. 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 their office sta ff 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 beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. This reimbursement policy applies to all health care services reported using theCMS 1500 Health Insurance Professional Claim Form (a/k/a HCFA ), th e CMS 1450Health Insurance Institutional Claim Form (a/k/a UB04) or its electronic equivalent or any successor form. This policy applies to all products, all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Additionally, this policy applies to drugs and biologicals being used for FDA-approved indications or label s. Drugs and biologi cals used for indications other than those in the approved labeling may be covered if it is determined that the use is medically accepted, taking into consideration the major drug compendia, authoritative medical literatures and/or accepted standards of me dical practice. C. Definitions Indication is defined as a diagnosis, illness, injury, syndrome, condition, or other clinical parameter for which a drug may be given. FDA approved Indication /Label is the offic ial description of a drug product which includes indication (what the drug is used for); who should take it; adverse events (side effects); instructions for uses in pregnancy, children, and other populations; and safety information for the patient. Labels are often found inside drug product packaging. Off-label/Unlabeled use of a drug is defined as a use for a non-FDA approved indication, that is, one that is not listed on the drugs official label/prescribing information. Off-label use is further defined as giving the drug in a way that deviates significantly from the labeled prescribing information for a particular indication. This includes but is not necessarily limited to, dosage, route of administration, duration and frequency of ad ministration, and population to whom the drug would be administered. Standard Billing Reimbursement StatementOHIO MARKETPLACEPY-PHARM-0130-OH-MP Effective Date: 02-01-2023 3 Unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label . Drug compendia , defined as summaries of drug information that are compiled by experts who have reviewed clinical data on drugs. CMS (Center for Medicare and Medicaid Services) recognizes the following compendia: American Medical Association Drug Evaluations (AMA-DE), United States Pharmacopoeia-Drug Information (USP-DI) or its successor publication and American Hospital Formulary Service-Drug Information (AHFS-DI) as authoritative sources for use in the determination of a “medical ly-accepted indication” of drugs and biologicals used off – label in an anticancer chemotherapeutic regimen. The USP DI is a database of drug information developed by the U.S. Pharmacopoeia but maintained by Micromedex, which contains medically accepted uses for generic and brand name drug products . D. PolicyCare Source requires that the u se of a drug or biological must be safe and effective and otherwise reasonable and necessary. Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for indications specified on the labeling. Therefore, reimbursement may be provided for the use of an FDA approved drug or biological, if: It was administered on or after t he date of the FDAs approval; It is reasonable and necessary for the individual patient; and All other applicable coverage requirements are met. An unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label may be covered if it is determined that the use is medically necessary , taking into consideration the major drug compendia, authoritative medical literatur e and/or accepted standards of medical practice. The following guidelines identify three categories in which medications would not be reasonable and necessary according to accepted standards of medical practice. Not for Particular Illness Medications gi ven for a purpose other than the treatment of a particular condition, illness, or injury are not covered (except for certain immunizations .) Route of Administration Not Indicated Medication given by injection (parenterally) is not covered if standard me dical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. Excessive Medications Medications administered for treatment of a disease which exceed the freque ncy or duration of dosing indicated by accepted standards of medical practice are not covered. Effective January 1, 1994, off-label, medically accepted indications of Food and Drug Administration (FDA) approved drugs and biologicals used in an anti-neoplas tic chemotherapeutic regimen are identified under the indications described below : Standard Billing Reimbursement StatementOHIO MARKETPLACEPY-PHARM-0130-OH-MP Effective Date: 02-01-2023 4 A regimen is a combination of anti-neoplastic agents clinically recognized for the treatment of a specific type of cancer. Off-label, medically accepted indications are supp orted in either one or more of the compendia or in peer-reviewed medical literature. E. Conditions of Coverage A medically accepted indication is one of the following: An FDA approved, labeled indication or a use supported in the American Hospital Formulary Service Drug Information (AHFS-DI), NCCN Drugs and Biologics Compendium, Truven Health Analytics Micromedex Drug Dex , Elsevier/Gold Standard Clinical Pharmacology and Wolters Kluwer Lexi – Drugs as the acceptable compendia based on CMS’ Change Request 619 1 (Compendia as Authoritative Sources for Use in the Determination of a “Medically Accepted Indication” of Drugs and Biologicals Used Off-Label in an Anti-Cancer Chemotherapeutic Regimen); or Articles o f Local Coverage Determinations (LCDs) published by C MS. In general, a use is identified by a compendium as medically accepted if the: Indication is a Category 1 or 2A in NCCN, or Class I, Class IIa, or Class IIb in DrugDex; or, Narrative text in AHFS-DI or Clinical Pharmacology is supportive, or Indication is listed in Lexi-Drugs as Use: Off-Label and rated as Evidence Level A A use is not medically accepted by a compendium if the: Indication is a Category 3 in NCCN or a Class III in DrugDex; or, Narrative text in AHFS or Clinical Pharmacol ogy is not supportive, or Indication is listed in Lexi-Drugs as Use: Unsupported If a use is identified as not indicated by CMS or the FDA, or if a use is specifically identified as not indicated in one or more of the compendia listed, or if it is dete rmined, based on peer-reviewed medical literature, that a particular use of a drug is not safe and effective, the off-label use is not supported and the drug will not be covered. Reimbursement is dependent on, but not limited to claims submissions reporte d usingCMS 1500/HCFA, CMS 1450/UB 04 or electronic equivalent, and must include the following: 11-digit NDC (National Drug Code) HCPCS/CPT Code Correct HCPCS units ( not NDC units) Correct NDC unit of measure PLEASE NOTE THE FOLLOWING: Providers are responsible for sourcing and submitting accurate codes. Multi-source brands are not accepted without an additional medical necessity review for Dispense as Written (DAW). Medical Necessity for DAW policies can be found at CareSource.com under the applicable markets administrative policies tab. Standard Billing Reimbursement StatementOHIO MARKETPLACEPY-PHARM-0130-OH-MP Effective Date: 02-01-2023 5 If applicable, individual drug reimbursement information may be found in a drugs Pharmacy Policy .F. Related Policies/Rules G. Review/Revision History DATE ACTIONDate Issued 07/22/2022 Original effective dateDate Revised 12/06/2022 Additions to clarify claims submission requirements, responsibility for sourcing of codes, and MSBs not accepted without additional DAW review. Individual drug reimbursement information may be found in a drugs Pharmacy Policy Date Effective 02/01/2023 Date Archived H. References1. Drugs@FDA Glossary of Terms https://www.fda.gov/drugs/drug-approvals-and-databases/drugsfda – glossary-terms 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publi cations and services https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals 3. United States Federal Food, Drug and Cosmetic Act https://www.fda.gov/regulatory-information/laws-enforced-fda/federal-food-drug-and-cosmetic-act-fdc-act The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.

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