ADMINISTRATIVE POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective Provider Home Visits-OH MyCare-AD-1069 08/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. 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 Provider Home Visits-OH MyCare-AD-1069Effective Dat e: 08/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectProvider Home Visits B. BackgroundProvider home visits are medical care visits rendered in the home setting to an individual for the examination, diagnosis and/or treatment of an injury or illness. For the purposes of this policy, home is defined as the individual’s place of residence, including private residence/domicile, assisted living facility, group home, custodial care facility, long-term care facility, or skilled nursing facility. C. Definitions Home An individual’s place of residence, including private residence/domicile, assisted living facility, group homes, custodial care facility, long-term care facility, or skilled nursing facility. Participating Provider A provider that is contracted with CareSource to provide service (s) to members. Place of Service (POS) A two-digit code that indicates the setting in which a service was provided. Provider A physician with an MD or DO, a podiatrist, a nurse practitioner, or a physician assistant. Non-Participating Provider A provider who is not contracted with CareSource to provide service (s) to members. Services Services that occur in the members place of residence that normally would be performed in an office/outpatient setting, such as evaluation and management (E&M) visits, wound care, podiatry care, eye care, etc. D. PolicyI. CareSource reimburses participating or non-participating providers for services performed in a members place of residence that usually can be performed at an office visit. A. CareSource will reimburse providers according to the Medicaid fee schedule. B. Durable medical equipment (DME) services in the place of residence are subject to medical necessity review and should be provided by an in network (participating) provider. C. Ancillary services , such as labs and x-ray services , in the place of residence are subject to medical necessity review and should be provided by an in network (participating) provider. D. CareSource members do not need to be confined to a place of residence to receive services . E. The members medical record must document the medical necessity of the visit made in place of residence. F. A visit cannot be billed by a provider unless the provider was actually present in the members place of residence. Provider Home Visits-OH MyCare-AD-1069Effective Dat e: 08/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 II. Claim submission must include the appropriate Current Procedural Terminology (CPT) codes along with any applicable modifier with the appropriate place of service (POS) code , including 1 of the following:A. POS 12 Home B. POS 13 Assisted Living C. POS 14 Group Home D. POS 31 Skilled Nursing Facility (SNF) E. POS 32 Long-term Facility F. POS 33 Custodial Care/Rest Home E. Conditions of CoverageServices performed in the members place of residence may be subject to review. CareSource may request documentation of services performed. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. If med ical necessity is not confirmed based on the documentation submitted, recoupment may occur. F. Related Policies/RulesNA G. Review/Revision HistoryDATES ACTIONDate Issued 06/09/2021 New policyDate Revised 02/16/2022 05/10/202304/ 23 /202 5Change physician to provider to be more inclusive. Approved at Committee. No changes. Updated references. Approved at Committee. Periodic review. Updated references. Approved at Committee. Date Effective 08/01/2025 Date Archived H. Ref erences1. Place of service codes for professional claims. Centers for Medicare & Medicaid Services. Updated May 2, 2024 . Accessed April 7 , 2025. www.cms.gov
ADMINISTRATIVE POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective Court Mandated Health Services-OH MyCare-AD-1393 06/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. 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 ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 2 H. References ………………………….. ………………………….. ………………………….. ……………………. 2 Court Mandated Health Services-OH MyCare-AD-1393Effective Dat e: 06/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectCourt Mandated Health Services B. BackgroundCourt mandated health services are treatments ordered as a result of criminal, civil or custodial judicial proceedings. Services may include withdrawal management, medication assisted treatment , community-based services, behavioral health inpatient or outpatient treatment, medica l inpatient or outpatient treatment and /or other treatment related to one s overall health. C. DefinitionsCourt Mandated Health Services Court order issued upon the decision of a judge or the result of a judicial proceeding for health-related services. D. PolicyI. Court mandated health services are subject to all existing CareSource policies and procedures , including medical necessity determination and prior authorization as necessary. II. If court mandated health services are determined as not meet ing medical necessity criteria, the member will be referred to care management to ensure access to the proper treatment and services and assist in coordination of necessary care. E. Conditions of CoverageNA F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATES ACTIONDate Issued 10/11/2023 New Policy ; Approved at CommitteeDate Revised 02/26/2025 Annual review, approved at Committee. Date Effective 06/01/2025 Date Archived H. ReferencesNA
Admin istrative Policy StatementOhio MyCare Policy Name Policy Number Date Effective Medicaid-Covered Pharmacy Product Reviews AD-11421 1/1/2025 Policy Type Medical ADMINISTRATIVE Pharmacy Reimbursement Administrative Policy Statement s prepared by CSMG Co. and its affiliates (including CareSource) are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the serv ice(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 . Table of Contents Administrative Policy Statement ……………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 2 F. Related Policies/Rules ………………………………………………………………………………………….. 2 G. Review/Revision History ……………………………………………………………………………………….. 2 H. References …………………………………………………………………………………………………………. 3 Medicaid-Covered Product Reviews Ohio MyCare AD-11421 Effective Date: 1/1/20252A. Subject Medicaid-Covered Pharmacy Product Reviews B. Background Ohio MyCare covers Medicaid-covered drugs and products that are not covered by Medicare Part Dthrough a members Medicaid benefit. Some of these Medicaid-covered products (i.e. OTC products and non-Part Ddrugs) are covered automatically through the required Ohio Additional Demonstration Drug File list, with no restrictions. Some of these products do not carry product-specific review criteria but still require a medical necessity review. CareSource, in partnership with our Pharmacy Benefit Manager, Express Scripts , will review these products per the policy below upon prior authorization request. C. Definitions Hierarchical Ingredient Code List unique primary active ingredient or combination of active ingredients OAC Ohio Administrative Code ORC Ohio Revised Code D. Policy I. If a Medicaid-covered drug or product not covered by Medicare Part Drequires review and product-specific criteria is not present, approval will be provided if the following criteria are met: A. Trial of at least three preferred alternatives within the same Hierarchical Ingredient Code List or Specific Therapeutic Class; AND B. Submission of two peer-reviewed medical articles citing efficacy and safety of the drug or product E. Conditions of Coverage If approval is warranted, authorization will be placed for 1 year. F. Related Policies/Rules OAC 5160-9-03 – Pharmacy services: covered drugs and associated limitations . ORC 5167.12 – Requirements when prescribed drugs are included in care management system. OAC 5160-58-03.1 – MyCare Ohio plans: primary care and utilization management. G. Review/Revision History DATE S ACTIONDate Issued 10/31/2024 Policy ComposedDate Revised Medicaid-Covered Product Reviews Ohio MyCare AD-11421 Effective Date: 1/1/20253Date Effective 01/01/2025 Date Archived H. References N/A
ADMINISTRATIVE POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective Retrospective Authorization Review-OH MyCare-AD-1340 02/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. 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 Retrospective Authorization Review-OH MyCare-AD-1340Effective Dat e: 02/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectRetrospective Authorization Review B. BackgroundA retrospective review is a request for an initial review for an authorization of care, service , or benefit for which a prior authorization (PA) is required but was not obtained prior to the delivery of the care, service, or benefit. Occasionally, situations arise in which a PA cannot be reasonably obtained prior to care, service, or benefit . In these cases, CareSource will conduct a retrospective review of medical services received by members or providers when the request is received within 30 days of the date of service or discharge. Retrospective reviews are performed by licensed clinicians who are supported bylicensed physicians. A decision is rendered within 30 days of receipt of all necessary documentation. In the event of an adverse determination, the provider and/or member are notified of the decision an d supporting rationale.C. Definitions Clinical Review Criteria The written screening procedures, decision abstracts, clinical protocols and practice guidelines used by CareSource to determine the medical necessity and appropriateness of health care services. Retrospective Authorization Review The process of reviewing and making a coverage decision for a service or procedure that has already been performed (eg, post service decision). Prior Authorization Utilization review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with CareSources requirement that the health care service or course of treatment, in whole or in part, be approved prior to provision. D. PolicyI. CareSource considers retrospective authorization review appropriate when ANY of the following circumstances has occurred: A. A CareSource member is unable to advise the provider of plan enrollment due to a condition that renders the member unresponsive or incapacitated . B. The member is retrospectively enrolled which covers the date of service . C. Urgent service(s) requiring prior authorization was/were performed, and it would have been to the members detriment to take the time to request prior authorization. D. The new service was not known to be needed at the time the original prior authorized service was performed . E. The need for the new service was revealed at the time the original authorized service was performed . F. The service was directly related to another service for which prior approval has already been obtained and that has already been performed. Retrospective Authorization Review-OH MyCare-AD-1340Effective Dat e: 02/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 II. All retro spective authorization requests must be submitted within 30 calendar days of the date of service or date o f discharge or as specified in a provider contract . III. Unless the CareSource member is transitioning and qualifies under the retroactive coverage requirements , retrospective reviews , which are requested greater than 30days past date of service or date of discharge, will be administratively denied. Administrative denials do not require a review by a CareSource Medical Director. IV. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.E. Conditions of Coverage NA F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATE ACTIONDate Issued 06/21/2023 New policy. Approved at Committee.Date Revised 11/06/2024 Periodic review. Updated references. Approved at Committee. Date Effective 02/01/2025 Date Archived H. References1. CareSource Ohio Provider Manual-MyCare . CareSource; 202 4. Accessed October 21 , 202 4. www.caresource.com
ADMINISTRATIVE POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective Continuity of Care-OH MyCare-AD-1384 02/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Continuity of Care-OH MyCare-AD-1384Effective Dat e: 02/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectContinuity of Care B. BackgroundContinuity of care (COC) comprises a series of separate health care services so that treatment remains coherent, unified over time, and consistent with a members health care needs and preferences . To ensure that care is not disrupted, COC becomes a bridge of coverage, allowing members to transition to CareSources provider network . Newly enrolled members can continue to receive services by an out-of-network provider when an established relationship exists with th at provider , and/or the member will be receiving services for which a prior authorization was received from another payer . Existing members may also utilize COC whe n a participating provider or acute care hospital terminates an agreement with CareSource. These interventions provided to transitioning members work to promote safety and efficacy. C. Definitions Continuing Care Patien t An individual who, with respect to a provider or facility (1) is undergoing a course of treatment for a serious and complex condition from the provider or facility; (2) is undergoing a course of institutional or inpatient care from the provider or facility ; (3) is scheduled to undergo nonelective surgery from the provider, including receipt of postoperative care from such provider or facility with respect to such a surgery; (4) is pregnant and undergoing a course of treatment for the pregnancy from the prov ider or facility; or (5) is or was determined to be terminally ill and is receiving treatment for such illness from such provider or facility. Course of Treatmen t A prescribed order of treatment for a specific individual with a specific condition outlined and decided upon ahead of time between the member and provider and may, but is not required to, be part of a treatment plan. Dual Benefits Member (O pt-in Member ) A member for whom CareSource is responsible for the coordination and payment of Medicare and Medicaid benefits. Home and Community-Based Services (HCBS ) Servic e available to individuals to help maintain health and safety in a community setting in lieu of institutional care as described in 42 C.F.R. 440 subpart A (October 1, 2021). Individual ized Care Pla n (ICP) An integrated, individualized, person-centered care plan developed by the member and the trans-disciplinary care management team addressing clinical and non-clinical needs identified in the assessment, including goals, interventions, and expected outcomes. Medicaid Only Member (Opt-out Member ) A member for whom CareSource is responsible for coordination and payment of Medicaid benefits. Network Provide r Any provider, group of providers, or entity that has a network provider contract with CareSource to order, refer, or render covered services as a result of a provider agreement or contract. Non-contracting Provide r Any provider with an ODM provider agreement who does not contract with CareSource but delivers health care services to members. Continuity of Care-OH MyCare-AD-1384Effective Dat e: 02/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 Primary Care Provider (PCP ) An individual physician (MD , DO), a physician group practice, an advanced practice registered nurse (APRN) , an APRN group practice within an acceptable specialty, or a physician assistant contracting with CareSource to provide services. Acceptable PCP specialty types include family/general practice, internal medicine, pediatrics, and obstetrics/gynecology (OB/GYNs). Significant Chang e A variation in the health, care or needs of a member that warrants further evaluation to determine if changes to the type, amount or scope of services are needed (i.e., differences in health or caregiver status, residence, location of service, lack of waiv er services for 30 days). D. PolicyI. COC requests from members or providers or others on behalf of members will be reviewed on a case-by-case basis . Members are allowed to maintain current providers and service levels at enrollment as described in section D.II. below. During the transition period, change s from an existing provider may only occur when A. a member requests a change B. the provider chooses to discontinue services to a member as currently allowed by Medicaid or Medicare C. CareSource, Centers for Medicare and Medicaid Services (CMS), or Ohio Department of Medicaid (ODM) identify provider performance issues that affect a members health and welfare CareSource will notify providers and members prior to the end of a transition period if a change in provider and/or service delivery is planned. II. Coverage Requirements at EnrollmentThe following coverage requirements apply to HCBS waiver members, nonwaiver members with long term care needs (home health [HH] and private duty nursing [PDN] use), nursing facility (NF) & Assisted Living (A L) members , and members not identified for LTC services , unless otherwise specified. A. Physician Services : Honored for 90 calendar days (CDs) for members identified for high-risk care management and 365 CDs for all others . B. Durable Medical Equipment (DME): CareSource will honor prior authorizations (PAs) when items have not been delivered but will review ongoing PAs for medical necessity. C. Scheduled Surgeries: CareSource will honor the specified provider. D. Chemotherapy and/or Radiation: Treatment initiated prior to enrollment must be authorized through the course of treatment with the specific provider. E. Organ, Bone Marrow, Hematopoietic Stem Cell Transplant: CareSource will honor the specified provider. F. Dialysis Treatment: Member will receive 90 CDs with the same provide r and level of service. The ICP must document successful transition planning for a new provider. G. Vision and Dental: CareSource will honor PAs for items not yet delivered. H. Medicaid HH and PDN: Continuity of Care-OH MyCare-AD-1384Effective Dat e: 02/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 1. HCBS waiver members may maintain service at current levels and with current providers at current medicaid reimbursement rates. Changes may not occur unless a. a significant change occurs as defined in OHIO ADMIN . CODE 5160-45-01 b. member elects to self-direct services c. after 365 days 2. Nonwaiver members with LTC needs (HH and PDN use) and AL members may sustain existing services for 90 CDs . A review for medical necessity will occur after an in-person assessment that includes provider observation. I. Assisted Living Waiver Services: AL members may maintain provider at current rate for life of demonstration. J. Medicaid NF Services: NF members may maintain provider at current medicaid rate for the life of demonstration. K. Waiver Services (Direct Care, Personal Care Waiver, Nur sing Home Care Attendant, Choice Home Care Attendant, Out of Home Respite, Enhanced Community Living, Adult Day Health Services, Social Work, Counseling, Individual Living Assistance): Member may maintain service at current level and with current providers at current medicaid reimbursement rates. Changes may not occur unless 1. a significant change occurs as defined in OHIO ADMIN . CODE 5160-45-01 2. member elects to self-direct services 3. after 365 days L. Waiver Services (All Others): Member may maintain service at current level for 365 days and existing service provider at the existing rate for 90 CD s. CareSource initiated changes will occur after an in-home assessment and plan for the transition to a new provider. M. Medicaid Community Behavioral Health (BH) Organizations (Provider Types 84 & 95): Members may maintain current provider and level of services documented in the BH plan of care at the time of enrollment for 365 CD s. Medicaid rate applies during transition. Inpatient and outpatient BH PAs approved on Medicaid Fee for Service (FFS) will be honored. III. CareSource will make reasonable efforts to contact out of network providers, including providers and prescribers providing services to members during the initial transition of care period to inform providers that the transition period will end on a specified date and provide information on becoming a credentialed network provider , if CareSource is accepting new applications for that provider type. CareSource may offer single-case agreements to out of network providers until a qualified network provider is available for the member. IV. CareSource will make good faith efforts to give written notice to members of termination s of provider or facility contract s regardless of whether the termination was for or without cause. A. For contract terminations involving PCP s or BH providers at least 45 CDs before the termination date, CareSource will provide members with written notice and Continuity of Care-OH MyCare-AD-1384Effective Dat e: 02/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 make 1 attempt at telephonic notice, unless the member has opted out of calls, for any member currently assigned to that PCP or BH provider within the past 3years. B. For contract terminations involving specialty types other than PCPs or BH providers at least 30 CDs prior to termination effective date, CareSource will provide written notice to all members assigned to, currently receiving care from, or have received care with in the past 3 months. E. Conditions of CoverageI. COC requirements include a process for the inclusion of member data from the electronic exchange of information with other managed care organization s, prepaid inpatient health plan s, or prepaid ambulatory health plan s. Data should be included for the previous 5 year s, and provider s will agree to make records for Medicaid eligible individuals available for transfer to new providers at no cost to the member. II. Historical claims data provided by the State of Ohio may be reviewed to identify providers utilized by members. F. Related Policies/RulesBenefits Coordination Medi cal Necessity Determinations G. Review/Revision HistoryDATE ACTIONDate Issued 10/11/2023 New policy . Approved at Committee.Date Revised 10/23 /2024 Annual review. Aligned policy with most recent contract. Updated definitions & references. Approved at Committee. Date Effective 02/01/2025 Date Archived H. References1. Confidentiality, OHIO REV . CODE ANN . 5122.31 (2017). 2. Confidentiality of Records Pertaining to Person’s Mental Health Condition, Assessment, Provision of Care or Treatment, or Payment for Assessment, Care or Treatment , OHIO REV . CODE ANN . 5119.28 (2017) . 3. Co ntinued Services to Enrollees , 42 C.F.R. 438.62 (202 4). 4. Continuity and Coordination of Care: A Practice Brief to Support Implementation of The WHO Framework on Integrated People-Centered Health Services . World Health Organization; 2018. Accessed October 9, 2024 . www.who.int 5. Coordination and Continuity of Care , 42 C.F.R. 438.208 (2023). 6. Harris E. Review finds benefits of primary care continuity. JAMA . 2023;329(24):2119. doi:10.1001/jama .2023.9930 7. Managed Care: Definition s, OHIO ADMIN . CODE 5160-26-01 (2022). Continuity of Care-OH MyCare-AD-1384Effective Dat e: 02/01/2025The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.6 8. Managed Care: Provider Network and Contracting Requirements, OHIO ADMIN . CODE5160-26-05 (2022). 9. Managed Care: Third Party Liability and Recovery, OHIO ADMIN . CODE 5160-26 – 09.1 (2022). 10. MyCare Ohio Plans: Definitions, OHIO ADMIN . CODE 5160-58-01 (2022). 11. Nonrenewal of Contract, 42 C.F.R. 422.506 (2018). 12. Nursing Facility-Based Level of Care Home and Community Based Services Programs: Community Transition Services, OHIO ADMIN . CODE 5160-44-26 (2020). 13. Ohio Dept of Medicaid (ODM) -Administered Waiver Program: Definitions, OHIO ADMIN . CODE 5160-45-01 (2020). 14. Services: General Provisions, 42 C.F.R. 440 (2023). 15. Special Rules for Ambulance Services, Emergency and Urgently Needed Services, and Maintenance and Post-St abilization Care Services, 42 C.F.R. 422.113 (2023).
ADMINISTRATIVE POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective Hospice Services-OH MyCare-AD-1130 01/01/2025 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry s tandards, and published MCO clinical policy 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 wit hout 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 l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Hospice Services-OH MyCare-AD-1130 Effective Date: 01/01/2025 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.2A. Subject Hospice Services B. Background Hospice services are provided to individuals who are terminally ill and at the end of life. These services are intended to provide comfort or palliative care. Hospice care is a type of care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to his or her emotional and spiritual needs. Hospice care has a palliative focus without curative intent. Usually, it is used for patients with no further options for curing disease or who have decided not to pursue further options that are arduous, likely to cause more symptoms, and unlikely to succeed . C. Definitions Hospice Care Program A coordinated program of home, outpatient, and inpatient care and services operated by a person or public agency providing the following care to patients and families through a medically directed interdisciplinary team pursuant to section 3712.06 of the Ohio Revised Code (ORC) : o nursing care by or under the supervision of a registered nurse o physical, occupational, or speech or language therapy, unless waived by the Department of Health o medical social services by a social worker under the direction of a physician o services of a home health aide o medical supplies, including drugs and biologicals, and the use of medical appliances o physician's services o short-term inpatient care, including both palliative and respite care and procedures o counseling for hospice patients and hospice patients' families o services of volunteers under the direction of the provider of the hospice care program o bereavement services for hospice patients' families . These services are provided under interdisciplinary plans of care established pursuant to section 3712.06 of the ORC in order to meet the physical, psychological, social, spiritual, emotional, and other special needs that are experienced during the final stages of illness, dying, and bereavement. Hospice Patient A patient, other than a pediatric respite care patient, diagnosed with a terminal illness, has a life expectancy of 6 months or less, and has voluntarily requested and is receiving care from a person or public agency licensed under Ohio law to provide a hospice care program. Palliative Care Specialized care for a patient of any age diagnosed with a serious or life-threatening illness provided at any stage of the illness by an interdisciplinary team working in consultation with other health care professionals, including those who may be seeking to cure the illness, and that aims to do all of the following: o relieve the symptoms, stress, and suffering resulting from the illness Hospice Services-OH MyCare-AD-1130 Effective Date: 01/01/2025 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.3o improve the quality of life of the patient and the patient's family o address the patient's physical, emotional, social, and spiritual needs o facilitate patient autonomy, access to information, and medical decision making. Terminal Illness A qualifying condition for which a prospective patient has received a diagnosis for a life expectancy of 6 months or less if the illness runs its normal course . D. Policy I. CareSource considers hospice services a covered service with the following requirements: A. Election of hospice benefits form must be signed by the CareSource member and submitted. B. Provider must produce and submit a Certificate of Terminal Illness form. C. CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented upon CareSource request to validate medical necessity. D. Criteria for determination of terminal illness: 1. Hospice care is provided for 2 90-day periods followed by increments of 60-day periods as recertifications occur. 2. Patient must have a qualifying condition with a diagnosis of a life expectancy of 6 months or less if the illness runs its normal course. 3. At the start of the first 90-day benefit period, the patient must be certified as terminally ill. 4. The patient must be recertified as terminally ill at the start of each benefit period following the first 90-day period by the hospice physician. E. Short-term inpatient care may be provided in hospital, hospice inpatient unit, or a participating skilled nursing facility or n ursing facility on an intermittent, non-routine basis: 1. For relief of the individual's caregivers . 2. General inpatient care for the purpose of respite, pain control and acute or chronic symptom management that cannot feasibly be provided in other settings. F. When an individual younger than age 21 elects to receive hospice care, it does not constitute a waiver of any rights of the individual to receive curative services related to the treatment of a terminal condition. G. When an adult over the age of 21 elects to receive hospice care, the member agrees to waive Medicaid services provided for the cure and treatment of the terminal condition. II. When the reason for discharge from hospice care is death, routine home care provided in an in-home visit by a registered nurse and/or a social worker during the last 7 days of a patients life requires documentation of medical necessity. Hospice Services-OH MyCare-AD-1130 Effective Date: 01/01/2025 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.4III. Billing for Hospice Services A. Professional claims must be billed on a CMS 1500 (HCFA) form with the following documentation: 1. Ohio Medicaid ID and the name of the nursing facility where the services were delivered. 2. National Provider Identifier (NPI) of the service facility . 3. Consistent with the current process set forth by the Ohio Administrative Code (OAC) , providers must submit claims as a single line with date of service span and units billed to match . B. Institutional claims must be billed on a UB04 form with the following documentation: 1. Ohio Medicaid ID and the name of the nursing facility where the services were delivered. 2. If the hospice services are billed in a Health Care Isolation Center (HCIC) Room and Board, the claims must be billed using the HCIC revenue codes as provided in the Ohio Department of Medicaid guidance. C. Hospice providers deliver ing any component of services via telehealth must add the GT modifier on those claims, in addition to the appropriate procedure code. IV. For the administration of hospice services, CareSource follows the rules set forth in Chapter 5160-56, Medicaid Hospice Program in the OAC and Chapter 3712, Hospice Care in the ORC. E. Conditions of Coverage N/A F. Related Policies/Rules N/A G. Review/Revision History DATES ACTIONDate Issued 07/21/2021 New PolicyDate Revised 08/17/2022 10/17/2022 10/11/2023 10/0 9/2024 Updated references; no changes Ohio Medicaid ID to sec. IV.A.1. and IV.B.1. Removed pediatric references as the MyCare market is for members 18 and older . Updated references. Approved at Committee. Updated references. Approved at Committee. Date Effective 01/01/2025 Date Archived H. References1. Hospice Care, O HIO REV . CODE 3712.01- .99 (2023). 2. Hospice Services: Covered Services, OHIO ADMIN . CODE 5160-56-05 (2021). Hospice Services-OH MyCare-AD-1130 Effective Date: 01/01/2025 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.53. Hospice Services: Definitions, O HIO ADMIN . CODE 5160-56-01 (2021). 4. Hospice Services: Discharge Requirements, O HIO ADMIN . CODE 5160-56-03 (2017). 5. Hospice Services: Eligibility and Election Requirements, O HIO ADMIN . CODE 5160-56-02 (2017). 6. Hospice Services: Provider Requirements, O HIO ADMIN . CODE 5160-56-04 (2021). 7. Hospice Services: Reimbursement, O HIO ADMIN . CODE 5160-56-06 (2021). 8. Hospital Emergency Services for Victims of Sexual Offenses, O HIO REV . CODE 2907.29 (2012). 9. Informed Consent to Surgical or Medical Procedure or Course Of Procedures, O HIO REV . CODE 2317.54 (2023). 10. Outpatient Services for Minors Without Knowledge or Consent of Parent or Guardian, OHIO REV . CODE 5122.04 (1989). 11. Telehealth, O HIO ADMIN . CODE 5160-1-18. (2022). 12. Telehealth Billing Guidelines: Applies to Dates of Service on or After November 15, 2020. Ohio Dept of Medicaid; 2020. Updated February 8, 2021. Accessed September 3, 2024 . www.medicaid.ohio.gov.
ADMINISTRATIVE POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective MyCare Payer Sequencing Guideline-OH MyCare-AD-1115 11/01/2024 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. 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 MyCare Payer Sequencing Guideline-OH MyCare-AD-1115Effective Dat e: 11/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectMyCare Payer Sequencing Guideline B. BackgroundThe purpose of this policy is to provide understanding of the proper payer sequencing regarding billing for products and s ervices to MyCare members. MyCare members are both Medicare and Medicaid eligible and adherence to th e information contained within this policy will decrease delay in proper payment. People who are dually enrolled in both Medicare and Medicaid, also known as duallyeligible individuals or Medicare-Medicaid enrollees, fall into several eligibility categories.These individuals may either be enrolled first in Medicare and then qualify for Medicaid, or vice versa. Medicare and Medicaid cover many of the same services. All providers, including Medicare providers, must enroll in the Medicaid system for provider claims review, processing, and payment. Providers should contact the state Medicaid agency foradditional information regarding Medicaid provider enrollment.Medicare pays first for Medicare-covered services that are also covered by Medicaid ,because Medicaid is always the payer of last resort. Medicaid may cover care thatMedicare does not cover , such as a variety of long-term services and supports. Medicaid waiver is a program that allows individuals with disabilities and chronic conditions to have more control over care and remain active in the community. C. Definitions Waiver Services Medicaid waivers allow individuals with disabilities and chronic conditions to receive care in their homes and communities rather than in long-term care facilities, hospitals or intermediate care facilities. Community Well Individuals who are eligible for Medicare and Medicaid services creating dual eligibility but who do not meet level of care for Waiver services. D. PolicyI. Providers who do not adhere to the appropriate processing, according to this policy, may be subject to claims auditing and recoupment. A. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. II. Members who do not have CareSource for Medicare coverage but have CareSourcefor their Medicaid coverage are considered opt-out members .A. All providers for opt out members must submit the Medicare denial documentation with the request for prior authorization once a request for a product or service is denied by Medicare . B. CareSource will then review for medical necessity under Medicaid guidelines. MyCare Payer Sequencing Guideline-OH MyCare-AD-1115Effective Dat e: 11/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 C. Medicaid is the payer of last resort.III. Members who have CareSource for their Medicar e and Medicaid coverage are considered opt-in members . A. CareSource will determin e whether the product or service can be covered under the members Medicare Part B . B. If the request is denied under Medicare guidelines, CareSource will review for medical necessity under Medicaid guidelines . C. Medicaid is the payer of last resort. IV. Members who are eligible for Medicaid coverage and have been approved to receive waiver services are considered waiver members. A. Products and services provided to waiver members are only reimbursed through the waiver program after all other payment options are exhausted. B. Waiver is the payer of last resort. C. If the member is a Waiver member , the provider must seek denials through Medicare and Medicaid as appropriate . D. Documentation of the denial must be submitted before a request can be considered under the Waiver benefit. V. No separate payment will be made for items or services for which full remuneration ismade through other payment mechanisms (eg, diagnosis-related groups, per diem payments, workers’ compensation, commercial insurance) . E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 07/21/2021 New policyDate Revised 10/26/2022 08 /14 /2024 Annual review. No changes. Updated references. Annual review. Updated references. Approved at Committee Date Effective 11/01/2024 Date Archived H. References1. Ohio Department of Medicaid. The Ohio Home Care Waiver Program. 202 4. Access ed August 5, 2024. www. medicaid.ohio.gov 2. Ohio Home Care Waiver Handbook . Ohio Dept of Medicaid; 2023. Accessed August 5, 2024. www.medicaid.ohio.gov
ADMINISTRATIVE POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective Independent Provider-OH MyCare-AD-1062 11/01/2024 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. 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 Independent Provider-OH MyCare-AD-1062Effective Dat e: 11/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectIndependent Provider B. BackgroundAn independent provider is an individual who has met the criteria to obtain an Ohio Department of Medicaid (ODM) provider number and has been approved as a Waiver provider by ODM . The provider must have a CareSource provider identification to provide Waiver services to MyCare members. This type of provider is not affiliated with an agency. C. Definitions All Service Plan The service coordination and prior authorization document that supports care plan specific goals, objectives and measurable outcomes for consumer health and functioning expected as a result of services provided by both formal and informal caregivers and t hat addresses the physical and medical conditions of the consumer. o At a minimum, the All Services Plan shall include: Essential information needed to provide care to the consumer that assures the consumer’s health and welfare; Billing authorization: associated codes for services approved. o The All Services Plan is not the same as the physician’s plan of care. Care Manager The Care Manager that works with the member and transdisciplinary team to develop the services and supports and authorization on the All Service Plan. Prior Authorization Authorization obtained prior to services and supports provided on the All Service Plan and is based on a combination of medical necessity, medical appropriateness and benefit limits. Trans-Disciplinary Care Team (TDCT) The primary team responsible for assessment, planning, and evaluation of the member care needs. D. PolicyI. CareSource provides coverage for Waiver services when it meets the criteria outlined in this policy. The Waiver Care Manager and member work collaboratively to establish Long Term Services and Supports (LTSS) in the home. II. CareSource will reimburse independent providers for services utilized through the MyCare/Waiver program when approved by CareSource Care Manager or designee and on service plans.III. Independent providers must obtain prior authorization for services before services are performed. IV. Independent providers must complete their review of the All Service Plan (ASP) on the Waiver portal and attest and acknowledge ASP for all service plan changes. Independent Provider-OH MyCare-AD-1062Effective Dat e: 11/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 A. Please note attestation is required by CareSource and ODM .B. In order to comply with 42 CFR 441.301, the MyCare Ohio Plan ( MCOPs ) will be required to obtain provider signatures on the waiver service responsible for its implementation effective 12/31/18. This policy is not retroactive and is applicable to waiver service plans developed and/or updated on or after 12/31/18. V. Prior Authorization (PA) is required for all Waiver services that include long termservices supports including: Waiver nursing and Waiver homecare attendant/aide, as well as other waiver services. RN assessment/consultation does not require PA at this time thr u utilization management and are state plan codes. VI. Independent providers must submit their prior authorization number with their claim form, as well as appropriate HCPCS and/or CPT codes along with appropriate modifiers and valid ICD-10 diagnosis codes in accor dance with Ohio AdministrativeCode (OAC) .VII. Independent providers must submit their claims using their CareSource Waiver Tax ID number and National Provider Identifier (NPI ).VIII. All Waiver providers must have an NPI number .A. Effective November 25, 2019, ODM implemented a policy under OAC 5160-1-17 requiring all providers to obtain a National Provider Identifier (NPI) and keep it on file with ODM. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/17/2021 New policyDate Revised 04/12/2023 08/14/2024 Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Date Effective 11/01/2024 Date Archived H. References1. Code of Federal Regulations. Title 42 – Public Health: Contents of request for a waiver. Accessed June 3, 2024 . www. ecfr.gov 2. Eligible Providers , OHIO ADMIN . CODE 5160-1-17 (2019) . Accessed June 3, 2024 . www.codes.ohio.gov Independent Provider-OH MyCare-AD-1062Effective Dat e: 11/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 3. Ohio Home Care Waiver Program: Reimbursement Rates and Billing Procedures ,OHIO ADMIN . CODE 5160-46-06 (2024) . Accessed June 3, 2024 . www.codes.ohio.gov 4. Ohio Home Care Waiver Program: Home Care Attendant Services Reimbursement Rates and Billing Procedures , OHIO ADMIN . CODE 5160-46-06.1 (2024) . Accessed June 3, 2024 . www.codes.ohio.gov 5. Registered nurse assessment and registered nurse consultation services , OHIO ADMIN . CODE 5160-12-08 (2021) . Accessed June 3, 2024 . www.codes.ohio.gov
ADMINISTRATIVE POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective Custom and Power Wheelchairs OH MyCare AD-0845 05/01/2024 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy 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, dysfunctio n of a body organ or part, or significant pain and discomfort. T hese 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in t he Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treat ment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. Re ferences ………………………….. ………………………….. ………………………….. ……………………. 5 Custom and Power Wheelchairs OH MyCare AD-0845Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectCustom and Power Wheelchair s B. BackgroundA nursing home qualifies as a beneficiarys home only if it does not provide primarily skilled care or rehabilitation. Only a small number of nursing homes that are certified Medicaid-only, called nursing facilities (NF), or distinct parts of nursing homes (hereafter referred to as distinct part nursing homes) may qualify as a beneficiarys home. Consequently, each nursing home must provide durable medical equipment ( DME ) asan integral part of its basic daily rate unless it is not providing primarily skil led care or rehabilitation. Yet, very few nursing homes provide care lower than skilled. In contrast, no skilled nursing facilit ies (SN Fs) or dually certified nursing homes (thosecertified for both Medicare and Medicaid) qualify as a beneficiarys home , because they provide primarily skilled care or rehabilitation. To identify inappropriate payments for DME, resident assessment data was use d from the Centers for Medicare & Medicaid Services (CMS) to determine all nursing home stays nationwide during 2006. Related Medicare claims data for any DME payments during these stays was then analyzed . When setting DME payment policy, Congress recogni zed the responsibility of institutionsto meet patients medical needs, regardless of the primary payer for the stays (i e,Medicare, Medicaid, or private resources). Although payment contractors routinely deny DME payment for claims submitted with a nursing home place of service desi gnation, an incorrect place of service designation (i e, home) results in inappropriate payment. Past Office of Inspector General (OIG) studies have highlighted this issue , however, payment controls are still insufficient to stop inappropriate DME paymen ts. This non-coverage stems from the legal requirement that DME is to be used in abeneficiarys home or an institution that can be considered a home. Section 1861(n) of the Act states that any nursing home meeting the basic definition of a SNF in 1819(a)(1) of the Act may not be considered a patients home for this purpose. Thus, only when a nursing home provides primarily a nonskilled level of care and few rehabilitation services can it be considered a beneficiarys home and qualify for DME paymen t. If the nursing home provides primarily skilled care or rehabilitation, DME is not covered. Suppliers and Place of Service Coding Suppliers must designate the physical location of the beneficiary, called place of service, on submitted claims. C. Definitio ns Customized Wheelchair A customized item if the wheelchair has been measured, fitted, or adapted in consideration of the patients body size, disability period of need, or intended use, and has been assembled by a supplier or ordered from a manufac turer who makes available customized features, modification or components Custom and Power Wheelchairs OH MyCare AD-0845Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 for wheelchairs that are intended for an individual patients use in accordance with instructions from the patients physician. Durable Medical Equipment (DME) Covered under Part B as a medical or other health service of the Social Security Act and is equipment that: o can withstand repeated use o primarily and customarily used to serve a medical purpose o generally not useful to a person in the absence of an illness or injury o appropriate for use in the home Long Term Care Facility (LTCF) Facilities providing a spectrum of medical and non-medical supports and services to frail or older adults unable to res ide independently in the community. Place of Service (POS) Two-digit codes placed on health care professional claims to indicate the setting in which a service was provided . Place of Residence A non-temporary , physical location that a member resides at as a home. Skilled Nursing Facility (SNF) A nursing home that provides primarily skilled care or rehabilitation. D. PolicyI. Those members who do not have CareSource for Medicare Advantage, but do have CareSource for Medicaid , are considered opt-out members . A. When a request for a custom or power wheelchair is denied by Medicare, all providers for opt out members must submit the Medicare denial along with the request to CareSource for prior authorization. B. Once the Medicare denial is received , CareSource will review for medical necessity under Medicaid guidelines as payer of last resort. C. If the requested item is listed as not covered on the Medicare fee s chedule , a Medicare denial letter is not required before CareSource review s the request using the Medicaid benefit. II. Those members who have CareSource for both Medicare Advantage and Medicaid are considered opt-in members . A. When a request for a custom or power wheelchair is submitted for opt-in members, CareSource can internally take an active part in determining whether the custom or power wheelchair can be covered under the members Medicare Part B. B. If the request is denied under Medicare guidelines, CareSource will review for medical nece ssity under Medicaid guidelines as payer of last resort. III. To prevent unnecessary delay in prior authorization requests, CareSource encourages providers to adhere to the following:A. If the member is in custodial care, the DME provider should indicate POS 33 (custodial care) on the Medicare claim submission, so the request will not be automatically rejected. POS 33 indicates that the member is not receiving skilledCustom and Power Wheelchairs OH MyCare AD-0845Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 nursing care , and the POS is considered the member s place of residence, as defined above. B. If the member is in a SNF or a nursing facility and receives skilled nursing care, the facility cannot be considered a place of residence for purposes of DME coverage under Part B. POS 31 (SNF) and POS 32 (NF) indicates that the member receives skilled nursing care . 1. When an inpatient in a hospital or SNF is not entitled to Part A inpatient benefits, payment may not be made under Part Bfor DME provided in the hospital or SNF , because such facilities do not qualify as a patient’s home. 2. DME is covered by Part Bonly when intended for use in the home, which explicitly does not include a SNF or hospital. IV. Any DME furnished to inpatients under a Part A covered stay is included in the SNFor hospital PPS rate.V. DME providers need to verify with the facility/member to ensure that the member istruly in custodial care at the nursing facility and also not receiving skilled care (at that point in time).A. If member i s only in custodial care, this would categorize the nursing facility as being the members home. Providers should submit prior authorization request and claims with POS 33 . B. If the member is receiving any skilled services, then the nursing facility is no t constitute d as the members home. Providers should submit prior authorization request and claims with POS 31 or POS 32. VI. Ensuring the appropriate POS is utilized will decrease processing time and ensure proper reimbursement according to the Medicare/ Medicaid guidelines.VII. Providers that do not adhere to the appropriate processing, according to this policy, may be subject to claims auditing and investigation.E. Conditions of Coverage NA F. Related Policies/RulesNA G. Review/Revision HistoryDATES ACTIONDate Issued 10/14/2020 New policyDate Revised 04/12/2023 02/14/2024 Updated references. Approved at Committee . Added D.I.C. Updated references. Approved at Committee. Date Effective 05/01/2024 Custom and Power Wheelchairs OH MyCare AD-0845Effective Dat e: 05/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 Date ArchivedH. References1. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) . Medicare Claims Processing Manual . Centers for Medicare & Medicaid Services ; 2023: chap 20. November 22, 2023. Accessed January 2, 2024. www.cms.gov 2. Place of service codes for professional claims. Centers for Medicare & Medicaid Services. Updated September 2023. Accessed January 2, 2024. www.cms.gov
Admin istrative Policy StatementOHIO MYCARE Policy Name Policy Number Date Effective COVID-19 Vaccination PAD-0088-OH-MCP 11/1/2022 Policy Type Medical ADMINISTRATIVE Pharmacy Reimbursement Administrative Policy Statement s prepared by CSMG Co. and its affiliates (including CareSource) are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy 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 standar ds 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the serv ice(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement 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. Table of Contents Administrative Policy Statement ……………………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 4 D. Policy ……………………………………………………………………………………………………………………. 4 E. Conditions of Coverage …………………………………………………………………………………………… 6 F. Related Policies/Rules …………………………………………………………………………………………….. 6 G. Review/Revision History ………………………………………………………………………………………….. 6 H. References ……………………………………………………………………………………………………………. 7 COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 2 A. Subject COVID-19 Vaccination B. Background The 2019 novel coronavirus, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes the disease known as coronavirus disease 2019 (COVID-19). The Food and Drug Administration (FDA) has issued full authorization for the Pfizer-BioNTech vaccine for prevention of COVID-19 for individuals 12 years and older and Moderna vaccine for prevention of COVID-19 for individuals 18 years and older. The Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EAU) for the following vaccines for the prevention of COVID-19: Pfizer-BioNTech for individuals 6 months and older, Moderna for individuals 6 months and older, Janssen for individuals 18 years and older for whom other COVID-19 vaccines are inaccessible or clinically inapprorpriate, and Novavax for individuals 12 years and older as of Oc tober 2022. The CDC recommends that the J&J COVID-19 vaccine only be considered in certain situations, due to safety concerns. The Pfizer-BioNTech, Moderna, and Novavax vaccines are offered as a two-dose series. The Janssen vaccine is offered as a single-dose vaccine. The EUA allows a third primary dose of Pfizer-BioNTech and Moderna vaccines for immunocompromised individuals and allows booster doses of Pfizer-BioNTech, Moderna, and Janssen. Pfizer-BioNTech Bivalent boosters are available for individuals 5 years and older and Moderna Bivalent boosters are available for individuals 6 years and older. The EUA allows the vaccines to be widely distributed in the United States. The Advisory Committee on Immunization Practices (ACIP) has issued interim recommendations for the use of Pfizer-BioNTech, Moderna, Novavax, and Janssen COVID-19 vaccines for the prevention of COVID-19 in the US. The interim recommendations are derived from the EAU of the vaccines, other data sources, general best practice guidelines for im munization, and expert opinion. Considerations will be updated as additional information becomes available or if additional vaccine products are authorized. The purpose of this policy is to provide background on the use of the vaccines in accordance with the ACIP interim recommendations, fact sheets, and the EAU fact sheets of the available COVID-19 vaccines. The following recommendations are derived from the latest guidelines and scientific based literature available: Pfizer COVID-19 Vaccine: Vaccination w ith the Pfizer-BioNTech COVID-19 vaccine consists of 2 doses (30 g, 0.3 mL each) administered intramuscularly, 3 weeks apart for age 12 years and older. For children age 5 through 11 years old, the vaccine consists of 2 doses (10 g, 0.2mL each) administered intramuscularly, 3 weeks apart. For individuals 6 months through 4 years old, the vaccine cosists of 2 doses ( 3 g, 0.2mL each) administered intramuscularly, 3 weeks apart followed by a third dose administered at least 8 weeks after the second dose. Pfizer-BioNTech COVID-19 Vaccine, Bivalent is authorized for use to prevent COVID-19 in individuals 5 years of age and older as a single booster COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 3 dose administered at least 2 months after either completion of primary vaccination with any authorized or approved monovalent COVID-19 vaccine, or receipt of the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine. For the Pfizer-BioNTech Bivalent formulation, a 0.2 mL dose (10 g) is administered IM to individuals age 5-11 years old and a 0.3 mL dose (30 g) is administered to indivudals 12 years and older. Pfizer-BioNTechs COVID-19 vaccinations come in multiple formulations including one for adult/adolescents in a vial with a purple cap, two for adult/adolescents in a vial with a gr ey cap, two for pediatric use (5 11 year olds) in a vial with an orange cap, and another for pediatric use (6 months 4 year olds) in a vial with a maroon cap. Formulations specific for adults /adolescents can not be used to prepare pediatric doses and vice versa. On December 11, 2020, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Pfizer-BioNTech COVID-19 vaccine in persons aged 16 years for the prevention of COVID-19. On May 10 th, 2021, the FDA expanded the EUA to include adolescents 12 through 15 years of age. On August 23, 2021, the FDA approved the Pfizer-BioNTech COVID-19 Vaccine for the prevention of COVID-19 caused by SARS-CoV-2 in individ uals of 16 years old and older. The licensed vaccine is now marked as Comirnaty, can be interchanged with the EUA-authorized formulation of the Pfizer-BioNTech COVID-19 Vaccine for ages 12 years of age and older without presenting safety or efficacy concer ns. On September 22, 2021, the FDA expanded the EUA to include a single booster dose of the Pfizer-BioNTech COVID-19 Vaccination booster dose, for all adults age 18 and older. On December 9, 2021, the FDA expanded this to include a single booster for age 16 and 17. The FDA has since updated bivalent booster recommendation to be administered at least 2 months after initial series or initial booster in individuals 5 years of age and older. On October 29, 2021, the FDA expanded the EUA to include children aged 5 through 11 years of age. On January 3, 2022, the FDA expanded the EUA to include a single booster dose in individuals 12 and older which has since been updated. On June 17, 2022, the Food and Drug Administration (FDA) issued Emergency Use Authorization (EUA) amendments for the mRNA-1273 (Moderna) COVID-19 vaccine for use in children aged 6 months 5 years, administered as 2 doses (25 g, 0.25 mL each), 4 weeks apart, and BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine for use in children aged 6 months 4 years, administered as 3 doses (3 g, 0.2 mL each), at intervals of 3 weeks between doses 1 and 2 and 8 weeks between doses 2 and 3. COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 4 On October 12, 2022, the FDA amended the emergency use authorizations (EUAs) of the Moderna and Pfizer-BioNTech COVID-19 bivalent vaccines to authorize their use as a single booster dose in younger age groups . The Pfizer-BioNTech COVID-19 bivalent vaccine was authorized for administration as a single booster dose at least 2 months following completion of primary or booster vaccination in children 5 years of age and older. The recommendation for the Pfizer-BioNTech COVID-19 vaccine should be implemented in conjunction with ACIPs interim recommendation for allocating initial supplies of COVID-19 vaccines. The ACIP rec ommendation for the use of the Pfizer-BioNTech COVID-19 vaccine under FDA approval as well as the interim EUA will be updated as additional information becomes available. Before vaccination, the Fact Sheet or EUA Fact Sheet should be provided to recipients and caregivers. Providers should counsel Pfizer-BioNTech COVID-19 vaccine recipients about expected systemic and local reactogenicity. Additional clinical considerations, including details of administration and use in special populations (e.g., persons who are pregnant or immunocompromised or who have severe allergies) are available at www.cdc.gov Moderna COVID-19 Vaccine: Vaccination with the Moderna COVID-19 vaccine consists of 2 doses : 0.5 mL (100 g) each for individuals 12 years and older , 0.5 mL (50 g) each for individuals 6-11 years old, or 0.25 mL (25 g) each for children 6 months 5 years old administered intramuscularly, 4 weeks apart. Moderna COVID-19 Vaccine, Bivalent is authorized for use in individuals 6 years of age and older as a single booster dose administered at least 2 months after either completion of primary vaccination with any authorized or approved monovalent COVID-19 vaccine, or receipt of the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine. For the Moderna Bivalent formulation, a 0.25 mL dose (25 g) is administered IM to individuals age 6-11 years old and a 0.5 mL dose (50 g) is administered to indivudals 12 years and older. The Moderna COVID-19 vaccinations come in multiple different formulations including one for adult/adolescents 12 years and older in a vial with a red cap & light blue border, one for individuals 6 years and older in a vial with a dark blue cap & grey border, one for pediatric use (6 11 year olds) in a vial with a dark blue cap with a purple border, and another for pediatric use (6 months 5 year olds) in a vial with a dark blue cap & majenta border. Formulations specific for adults/adolescents can not be used to prepare pediatric doses and vice versa. On December 18, 2020, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Moderna COVID-19 vaccine in persons aged 18 years for the prevention of COVID-19. COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 5 On August 12, 2021, the FDA expanded the EUA to allow for an additional dose to be given to certain immunocompromised individuals. On October 20, 2021, the FDA amended the Moderna COVID-19 Vaccine EUA to allow for a single booster dose, for all adults age 18 and older. The FDA has since updated bivalent booster recommendation to being administered at least 2 months after initial series or initial booster in individuals 6 years of age and older. On June 17, 2022, the Food and Drug Administration (FDA) issued Emergency Use Authorization (EUA) amendments for the mRNA-1273 (Moderna) COVID-19 vaccine for use in children aged 6 months 5 years, administered as 2 doses (25 g, 0.25 mL each), 4 weeks apart, and BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine for use in ch ildren aged 6 months 4 years, administered as 3 doses (3 g, 0.2 mL each), at intervals of 3 weeks between doses 1 and 2 and 8 weeks between doses 2 and 3. On October 12, 2022, the FDA amended the emergency use authorizations (EUAs) of the Moderna and Pfi zer-BioNTech COVID-19 bivalent vaccines to authorize their use as a single booster dose in younger age groups . The Moderna COVID-19 bivalent vaccine is authorized for administration as a single booster dose at least 2 months following completion of primary or booster vaccination in children 6 years of age and older. Use of all COVID-19 vaccines authorized under an EUA, including the Moderna COVID-19 vaccine, should be implemented in conjunction with ACIPs interim recommendations for allocating initial supplies of COVID-19 vaccines ( 3). The ACIP recommendation for the use of Moderna COVID-19 vaccine under EAU is interim and will be updated as additional information becomes available. The interim recommendation and clinical considerations are based on use of the Moderna COVID-19 vaccine under an EUA and might change as more evidence becomes available. Before vaccination, the EUA Fact Sheet should be provided to recipients and caregivers. Providers should counsel Moderna COVID-19 vaccine recipients about expected systemic and local reactogenicity. Additional clinical considerations, including details of administration and use in special populations (e.g., persons who are pregnant, immunocompromised or who have a history of severe allergic reactions) are available at www.cdc.govJanssen COVID-19 Vaccine: Vaccination with the Janssen COVID-19 vaccine consists of a single dose (0.5mL) administered intramuscularly and a single booster dose at least 2 months after completing primary vaccination in individuals 18 years of age and older. On February 27, 2021, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 6 Janssen COVID-19 vaccine as the first single-shot COVID-19 vaccine in individuals 18 years of age or older for the prevention of COVID-19. The use of the Janssen COVID-19 vaccine under the EUA should be implemented in conjunction with ACIPs interim recommendations for allocating initial supplies of COVID-19 vaccines. The interim recommendations and clinical consi derations are based on use of the Janssen COVID-19 vaccine under an EUA and might change as more evidence becomes available. On October 20, 2021, the FDA expanded the EUA to include a single booster dose of the Janssen (Johnson and Johnson) COVID-19 Vaccin ation booster dose for adults age 18 and older. The single booster must be administered at least 2 months after completion of the primary vaccine dose. The single booster dose is the same dosage as the initial vaccine (0.5mL). Janssen COVID-19 vaccine should be considered for individuals 18 years and older for whom other COVID-19 vaccines are inaccessible or clinically inapprorpriate. The CDC recommends that the J&J COVID-19 vaccine only be considered in certain situations, due to safety concerns such as TTS. Before vaccination, the EUA Fact Sheet should be provided to the recipient and caregivers. Providers should counsel Janssen COVID-19 vaccine recipients about any expected systemic and local reactogenicity. Additional clinical considerations, including details of administration and use in special populations (e.g., persons who are pregnant. Immunocompromised or who have a history of severe allergic reactions) are available at www.cdc.gov . Novavax COVID-19 Vaccine: Vaccination with the Novavax COVID-19 vaccine consists of 2 doses (0.5 mL each) administered intramuscularly, 3 weeks apart for age 12 years and older. The vaccine is authorized for emergency use as a two-dose primary series. On July 19th, 2022, the Advis ory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Novavax COVID-19 vaccine in persons aged 18 and older as a primary 2-dose series for vaccination in the prevention of COVID-19. Use of all COVID-19 vaccines auth orized under an EUA, including the Novavax COVID-19 vaccine, should be implemented in conjunction with ACIPs interim recommendations for allocating initial supplies of COVID-19 vaccines. The interim recommendations and clinical considerations are based on use of the Novavax COVID-19 vaccine under an EUA and might change as more evidence becomes available. FDA since updated recommendations to include individuals aged 12 years of age and older. Before vaccination, the EUA Fact Sheet should be provided to recipients and caregivers. Providers should counsel Novavax COVID – COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 7 19 vaccine recipients about expected systemic and local reactogenicity. Additional clinical considerations, including details of administration and use in special populations (e.g., persons who are pregnant, immunocompromised or who have a history of severe allergic reactions) are available at www.cdc.gov Guidance for COVID-19 Vaccination Boosters Indviduals age 5 years and older (or 6 years and older for Moderna) may get the updated (bivalent) booster . Individuals should no longer receive an original (monovalent) Pfizer-BioNTech or Moderna booster. For individuals with prior COVID-19 infection, experts have recommended that individuals get a booster dose at least 3 months after symptoms began, or if asymptomatic, after the first positive test. Chlidren under 5 years of age are not yet eligible to receive any booster. For those who received the Janssen COVID-19 vaccination as their primary vaccine, if eligible, should receive a single vaccine booster at least 2 months after receiving their dose. Any FDA-approved or authorized COVID-19 vaccination can be used as a booster dose. Novavax is not currently authorized to be used as a booster and is only authorized for primary dose series. On October 21, 2021, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the COVID-19 Booster Shots for those who received a mRNA primary COVID-19 vaccination (Pfizer-BioNTech or Moderna), if eligible, should receive a single vaccine booster. The FDA has since updated the booster recommendations several times with the most recent recommendation on October 12, 2022. On October 12, 2022, the FDA amended the emergency use authorizations (EUAs) of the Moderna and Pfizer-BioNTech COVID-19 bivalent vaccines to authorize their use as a single booster dose in younger age groups. The Pfizer-BioNTech COVID-19 bivalent vaccine was authorized for administration as a single booster dose at least 2 months following completion of primary or booster vaccination in children 5 years of age and older . The Moderna COVID-19 bivalent vaccine is authorized for administration as a s ingle booster dose at least 2 months following completion of primary or booster vaccination in children 6 years of age and older. Note: Additional Vaccines Newly developed vaccines are still moving through the clinical trial process before submission for regulatory approval. CareSource is closely monitoring FDA approval of these vaccines. COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 8 C. Definitions Emergency Use Authorization (EUA) A mechanism to facilitate the availability and use of medical countermeasures, including vaccines, during public health emergencies. Vaccine Adverse Event Reporting System (VAERS) A national early warning system to detect possible safety problems in vaccines used in the United States. Immunization Information System (IIS) A confidential, population-based, computerized databases that record all immunization doses administered by participating providers to persons residing within a specific geopolitical area. D. Policy I. COVID-19 vaccination providers participating in the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program are required to sign a CDC COVID-19 Vaccination Program Provider Agreement. Providers are responsible for adhering to all requirements outlined in the agreement. II. Providers must follow the prioritization schedule as determined by the states and/or the Department of Healths plan for distributing the vaccines (e.g., Phase 1a includes healthcare personnel, Phase 1b includes persons 75 years of age, etc.): A. COVID-19 vaccine providers are prohibited from selling USG-purchased COVID-19 vaccine, receiving any inducement (whether direct or indirect) for vaccinating (or providing COVID-19 vaccine to be used for vaccinating) and individual who is not currently eligible to receive COVID-19 vaccine as a member of a group currently authori zed under prioritization specified by CDC/ACIP, the state/territorys governor or other relevant public health authority, or otherwise diverting COVID-19 vaccine from the CDC COVID-19 Vaccination Program. III. The members age must be within the age group that is authorized to receive the COVID-19 vaccination: A. Pfizer-BioNTech: age 6 months or greater; B. Moderna: age 6 months or greater; C. Janssen: age 18 years or greater; D. Novavax: age 12 years or greater. IV. The vaccination provider must follow the vaccine schedule as outlined in the EUA fact sheet. A. Pfizer-BioNTech: 2 doses, 21 days apart; third dose 28 days apart for those who have undergone solid organ transplantation or have a diagnosis with an equivalent level of immunocompromise; B. Moderna: 2 doses, 28 days apart; third dose 28 days apart for those who have undergone solid organ transplantation or have a diagnosis with an equivalent level of immunocompromise; C. Janssen: 1 dose for primary vaccination; D. Novavax: 2 doses, 21 days apart; E. People ages 6 months through 64 years, and especially males ages 12 through 39 years, may consider getting the 2nd primary Pfizer-BioNTech, Moderna, or Novavax 8 weeks after the 1st dose. V. The provider must communicate to the individual receiving the vaccine or their caregiver, information consistent with the Fact Sheet for Recipients and Caregivers prior to receiving the vaccine. COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 9 VI. The vaccination provider must follow the storage and handling instruction of the vaccine as outlined in the EUA fact sheet of the individual vaccine. VII. The vacci nation provider must include vaccination information in the state/local jurisdictions Immunization System (IIS) or other designated system: A. All COVID-19 vaccination providers must report COVID-19 vaccine inventory daily into VaccineFinder. In some jurisdi ctions, providers may report vaccine inventory to the jurisdictions IIS for the jurisdiction to upload into VaccineFinder. B. COVID-19 vaccination providers must document vaccine administration in their medical record systems within 24 hours of administration; and use their best efforts to report administration data to the relevant system for the jurisdiction (i.e., IIS) as soon as practicable and no later than 72 hours after administration. VIII. The vaccination provider is responsible for mandatory reporting of any significant adverse events to the Vaccine Adverse Event Reporting System (VAERS). A. The following adverse events are required to be reported in addition to any other events if later revised by the CDC: 1. Vaccine administration errors, whether error is assoc iated with an adverse event (AE) or not. 2. Serious AEs regardless of causality. Serious AEs are defined as: a. Death; b. A life-threating AE; c. Inpatient hospitalization or prolongation of existing hospitalization; d. A persistent or significant incapacity or substanti al disruption of the ability to conduct normal life functions; e. A congenital anomaly/birth defect; f. An important medical event that based on appropriate medical judgement may jeopardize the individual and may require medical or surgical intervention to prevent one of the outcomes listed above; g. Cases or Multisystem Inflammatory Syndrome; h. Cases of COVID-19 that result in hospitalization or death. B. Providers are encouraged to report to VAERS any additional clinically significant adverse event following vaccination, even if they are not sure if vaccination caused the event. C. Providers should also report any additional select AEs and/or any revised safety reporting requirements per FDAs conditions of authorized use of vaccine(s) throughout the duration of any COVID-19 vaccine being authorized under an EUA. IX. Claims Reimbursement and Member Cost Share A. All FDA-authorized COVID-19 vaccines will be covered at no cost for members during the public health emergency. B. Vaccine providers must administer the vaccine regardless of the members ability to pay or verify health insurance coverage status. C. Vaccine providers may not seek reimbursement, including through balance billing, from the vaccine recipient. D. Vaccine providers may seek appropriate reimbursement from a program or plan that covers COVID-19 vaccine administration fees for the vaccine recipient. E. Providers may bill the CareSource medical benefit through our standard claim process. COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 10 F. Pharmacies should submit claims through their pharmacy claims platform through our pharmacy benefits manager, Express Scripts. E. Conditions of Coverage All FDA-approved or authorized COVID-19 vaccines do not require any prior-authorization and will be covered at no cost for members. Please refer to the Reimbursement Policy for more details. HCPS and CPT Codes: Pfizer-BioNTech COVID-19 Vaccine o 91300 vaccine o 0001A 1 st dose administration o 0002A 2nd dose administration o 0003A 3rd dose administration o 0004A 4th dose administration Moderna COVID-19 Vaccine o 91301 vaccine o 0011A 1st dose administration o 0012A 2nd dose administration o 0013A 3rd dose administration o 0014A 4th dose administration Janssen COVID-19 Vaccine o 91303 vaccine o 0031A administration Novavax COVID-19 Vaccine o 91304-vaccine o 0041A-1 st dose administration o 0042A-2nd dose administration Quantity Limit: Only one vaccine is allowed per member for primary series. Member may receive a different booster vaccine than reveived for their primary series. Pfizer-BioNTech and Moderna COVID-19 Vaccine: Four doses are allowed per member. Janssen COVID-19 Vaccine: Two dose s are allowed per member. Novavax COVID-19 Vaccine: Two doses are allowed per member. Quantity limit is subject to change as more vaccines become available for use. F. Related Poli cies/Rules COVID-19 Vaccine Reimbursement Policy G. Review/Revision History DATE S ACTIONDate Issued 12/18/2020 New PolicyDate Revised 02/28/2021 Policy revised to include information about JanssenCOVID-19 vaccine. COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 11 09/01/2021 11/30/2021 12/09/2021 3/4/2022 10/ 20/2022Policy revised to update age for Pfizer vaccine, and update vaccine schedule for Pfizer and Moderna vaccine. Policy revised to update age for Pfizer vaccine, Pfizer vaccination approval, vaccine schedules for all booster shots. Policy revised to update for Pfizer vaccine booster age Policy revised to update for new booster dose length Policy revised to update for newly authorized Novavax primary series, bivalent Pfizer and Moderna booster shots and updated age recommendations for primary and booster series.Date Effective 11/1/2022 Date Archived H. References 1. Oliver SE, Gargano JW, Marin M, et al. The Advisory Committee on Immunization Practices Interim Recommendation for Use of Pfizer-BioNTech COVID-19 Vaccine United States, December 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1922-1924. 2. Oliver SE, Gargano JW, Marin M, et al. The Advisory Committee on Immunization Practices Interim Recommendation for Use of Moderna COVID-19 Vaccine United States, December 2020. MMWR Morb Mortal Wkly Rep. 2021;69(5152):1653-1656. 3. Oliver SE, Gargano JW, Marin M, et al. The Advisory Committee on Immunization Practices Interim Recommendation for Use of Janssen COVID-19 Vaccine United States, February 2021. MMWR Morb Mortal Wkly Rep. ePub: 2 March 2021. 4. Centers for Disease Control and Prevention (CDC). (2021). Emergency Use Authorization (EUA) of the Pfizer-BioNTech COVID-19 Vaccine to Prevent Coronavirus Disease 2019 (COVID-19) [Fact Sheet]. 5. Centers for Disease Control and Prevention (CDC). (2020). Emergency Use Authorization (EUA) of the Moderna COVID-19 Vaccine to Prevent Coronavirus Disease 2019 (COVID-19) [Fact Sheet]. 6. Centers for Disease Control and Prevention (CDC). (2021). Emergency Use Authorization (EUA) of the Janssen COVID-19 Vaccine to Prevent Coronavirus Disea se 2019 (COVID-19) [Fact Sheet]. 7. Ohio Department of Medicaid. COVID-19 vaccine administration billing guidelines. 8. Centers for Disease Control and Prevention (CDC). (2021). COVID-19 Vaccination Booster Shots. Updated November 9, 2021. Accessed November 12, 2021. https://www.cdc.gov/media/releases/2021/p1021-covid-booster.html 9. U.S. Food & Drug Administration. Coronavirus Disease 2019 (COVID-19). Updated October 7, 2022. Accessed October 10, 2022 . https://www.fda.gov/emergency-preparedness-and-response/counterterrorism-and-emerging-threats/coronavirus-disease-2019-covid-19 10. Centers for Disease Control and Prevention (CDC). Interim Recommendation of the Advisory Committee on Immuniastion Practices for Use of the Novavax COVID-19 Vaccine. August 5, 2022. Accessed October 10, 2022. https://www.cdc.gov/mmwr/volumes/71/wr/mm7131a2.htm The Administrative Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the Administrative Polic y Sta te m ent Polic y a nd i s a pp ro ved. COVID-19 Vaccination OHIO MYCAREPAD-0088-OH-MC P Effective Date: 11/1/2022 12
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