ADMINISTRATIVE POLICY STATEMENT Marketplace Policy Name & Number Date Effective Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022Policy 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, 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 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 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 treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. This policy applies to the following Marketplace(s): Georgia b Indiana b Kentucky b Ohio b West Virginia Table of Contents A.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 I. State-Specific Information ……………………………………………………………………………………… 5 Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 2 A.Subject Applied Behavior Analysis Therapy for Autism Spectrum Disorder B.Background Autism Spectrum Disorder (ASD) can vary widely in severity and symptoms dependi ng on t he developmental level and chronological age of the patient. ASD is often defined by specific impairments that affect socialization, communication, and stereoty ped ( repetitive) behavior. Children with autism spectrum disorders have pervasive clinically significant deficits which are present in early childhood in areas such as intellectual functioning, language, social communication and interactions, as well as restricted,repetitive patterns of behavior, interests and activities.Ther e is currently no cure for ASD, nor is there any one single treatment for the disorder.Individuals with ASD may be managed through a combination of therapies, includi ng behav ioral, cognitive, pharmacological, and educational interventions. The goal of treatment for members with ASD is to minimize the severity of ASD symptoms,maximize learning, facilitate social integration, and improve quality of life for both t he m embers and families and/or caregivers. C. Definitions Autism Spectrum Disorder – (ASD) Any of the following pervasive developmental disorders as defined by the most recent version of the Diagnostic and StatisticalManual of Mental Disorders (American Psychiatric Association): Autism; Asperger'sDisorder; or other condition that is specifically categorized as a pervasiv e dev elopmental disorder in the Manual . Applied Behavior Analysis – (ABA) A preventive service for ASD. Board Certified Assistant Behavior Analyst ( BCABA) A professional provider of applied behavioral analysis services who has obtained an undergraduate-leve l c ertification . BCBA-BACB certified behavior analyst graduate level. BCBA-D – BACB certified behavior analyst doctoral level. RBT-BACB Registered Behavioral Technician. Supervision-All supervisory activities as well as supervisor and supervis ee r esponsibilities will be in accordance with the board from which the practitioner received a license.o Services delivered by a RBT must be supervised by a qualified RBT supervisor. o Services delivered by a BCaBA must be supervised by a BCBA, BCBA-D or a l icensed/ registered psychologist certified by the American Board of ProfessionalPsychology in Behavioral and Cognitive Psychology who has tested in ABA. o A registered behavior technician (RBT), certified by the national behavior analyst certification board (BACB), may provide ABA under the supervision of an independent practitioner. In order to provide services, they have to enroll i n t he Marketplace program and affiliate with the organization under which they are employed or contracted. Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 3 RBT Supervision-Ongoing supervision must be at a minimum of 5% of the hours spent providing behavior-analytic services per month 1. This includes a minimum of 2 f ace-to-face contacts per month. D. Policy I. Medical necessity review is required for all ABA services:A. At b aseline, then again every 6 months thereafter or sooner if clinically necessary.B. Medical review documentation must be submitted with appropriate documentation as indicated in the medical policy.I I. A n ASD diagnosis is required in order for services to be reviewed for approval.III. Li mitationsA. A Medically Unlikely Edit (MUE) for a CPT code is the maximum units of servic e t hat a provider can report for one member on one date of service.1. Maximum units allowed per CPT: CPT Max unit allowed 97151 32 97152 16 97153 32 97154 18 97155 24 97156 16 97157 16 97158 16 0362T 16 0373T 32 N OTE: If CMS updates the MUE list ,which generally occurs on a quarterly basis, the update will take precedence over the MUEs in this policy . B . E ach RBT must obtain ongoing supervision for a minimum of 5% of the hours spent providing behavior-analytic services per month.C. The treatment codes are based on daily total units of service in 15-minute i ncrements. A unit of time is attained when the mid-point is passed.1. Ti me interval examples: Units Number of minutes 1 unit >8 minutes through 22 minutes 2 units >23 minutes through 37 minutes 3 units >38 minutes through 52 minutes 4 units >53 minutes through 67 minutes 1 www.bacb.com Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 4 5 units >68 minutes through 82 minutes 6 units >83 minutes through 97 minutes 7 units >98 minutes through 112 minutes 8 units >113 minutes through 127 minutes E.Conditions of Coverage Payments may be subject to limitations and/or qualifications and will be determi ned w hen the claim is received for processing. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers.Prog ram Integrity will be engaged for an annual review of data. F.Related Policies/Rules Applied Behavior Analysis for Autism Spectrum DisorderEvidence of Coverage and Health Insurance Contract G.Review/Revision History DATES ACTION Date Issued 11/29/2018 Date Revised 04/12/2019 01/27/2020 02/ 02/2021 08/ 31/2021 08/ 17/2022 Removed U3 & U5 modifiers Revised definitions, clarified PA requirements, added ASD diagnosis as primary, added specificity to reimbursement, updated limitations, added MUE, added time intervals, added specificity to concurrent billing Updated definitions, Removed transition ABA therapy, Removed codes. Changed from PY policy. Removed coding portions in policy . Updated MUE table: 97152 MUE went from 8 to 1697154 MUE went from 12 to 180362T MUE went from 8 to 16Added Program Integrity will be engaged for an annual review of data New composite MP template; updated references; no change to MUE table. Date Ef fective 11/01/2022 Date Archived H.References 1. American Medical Association. (2018). Coding Update: Reporting Adaptive BehaviorAssessment and Treatment Services in 2019. CPT Assistant, 28(11).2. Behavior Analyst Certification Board. (2018, October 8). Adaptive BehaviorAssessment and Treatment Code Conversion Table. Retrieved August 3, 2022 fro m w ww.bacb.com . Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 5 3.Behavior Analyst Certification Board. (2019, February). Clarifications Regardi ng A pplied Behavior Analysis Treatment of Autism Spectrum Disorder. (2nd ed.).Retrieved August 3, 2022 from www.bacb.com.4. The Council of Autism Service Providers. (2020). Applied Behavior AnalysisTreatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers. Retrieved on August 3, 2022 from www.caseproviders.org. I.State-S pecific InformationA. Georgia1. Effective: 11/01/2022B. Indiana1. Effective: 11/01/2022C. Kentucky1. Effective: 11/01/2022D. Ohio1. Effective: 12/01/2022E. Wes t Virginia1. Effective: 11/01/2022 Th e Administrative Policy Stateme nt det ailed a bove has r eceived due con side ration as defined in the Administrative Policy Stateme nt Po licy a nd is a pprove d.
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Chiropractic Care-MP-PY-1358 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as t he Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addi ction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy a pplies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 Chiropractic Care-MP-PY-1358Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectChiropractic Care B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guara ntee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processin g. Health care providers and office staff are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.C. Definitions Chiropractor A Doctor of Chiropractic who is duly licensed and qualified to provide chiropractic services. Chiropractic Therapy Therapy that focuses on the joints of the spine and the nervous system, while osteopathic therapy includes equal emphasis on the joints and surrounding muscles, tendons and ligaments. Manipulation Therapy Osteopathic/chiropractic therapy used for treating problems associated with bones, joints and the back. Medically Necessary/Medical Necessity Health care services that a provider would render to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is (i) in accordance with generally accepted standards of medical practice; and (ii) clinically appropriate in terms o f type, frequency, extent, and duration. D. PolicyI A covered chiropractic service that is legally performed will not be denied when such covered service is rendered by a n in-network licensed chiropractor in the state that the covered service is performed. II. All services are subject to members share of cost (deductible, co-insurance and/orco-pays). This varies based on the members plan enrolled at the time of service.III. When manipulation services are provided in addition to an evaluation andmanagement (E/M) office visit, modifier 25 should be appended to the E/M code.This distinguishes a significant , separately identifiable E/M office visit from the additional ma nipulation service. Chiropractic Care-MP-PY-1358Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.IV. Scope of practiceA. Chiropractors must follow their states scope of practice. Any training or certification required by the state must be available to Care Source, upon request . V. Chiropractic patients whose diagnosis is not within the chiropractic scope of practice, shall be referred , by the chiropract or, to a medical doctor or other licensed healthpractitioner for treatment of that condition.VI. Manipulation therapyA. Includes chiropractic manipulation therapy used for treating problems associated with bones, joints and the back. Chiropractors would be limited to subluxations of the articulations of the human spine and its adjacent tissue. B. Annual benefit limits apply. It is the providers responsibility to validate the available remaining quantity before rendering service. Manipula tions performed will be counted toward any maximum for manipulation therapy services as specified in the members Evidence of Coverage (EOC) or Schedule of Benefits regardless if: 1. Billed as the only procedure; or 2. Done in conjunction with an exam and billed as an office visit. C. The members plan does not provide benefits for manipulation therapy services provided in the home as part of Home Health Care Services. D. Modifier AT is required to be appended to any manipulation code. E. Claims should include a pr imary diagnosis of subluxation and a secondary diagnosis that reflects the patients neuromusculoskeletal condition. VII. All codes contained within this policy are not all inclusive but provide a general reference of covered codes based on what chiroprac tors are allowed to perform within their state. Codes contained within this policy that may or may not require a prior authorization should be confirmed by accessing the Provider Look-up Tool on the CareSource website (www.procedurelookup.caresource.com). VIII. The following are a list of c odes that may be covered and do not require a prior authorization: A. Evaluation and management (E/M) codes (99202-99204, 99211-99214) B. 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions C. 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions D. 98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions E. 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regio ns F. X-rays (radiologic examination (RE)) for diagnostic purposes: 1. 72020 RE, spine, single view, specify level 2. 72040 RE, spine, cervical; 2 or 3 views 3. 72050 RE, spine, cervical; 4 or 5 views 4. 72052 RE, spine, cervical; 6 or more views 5. 72070 RE, spin e; thoracic, 2 views 6. 72072 RE, spine; thoracic, 3 views 7. 72074 RE, spine; thoracic, minimum of 4 views 8. 72080 RE, spine; thoracolumbar junction, minimum of 2 views Chiropractic Care-MP-PY-1358Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.9. 72081 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spi ne if performed (e.g., scoliosis evaluation); one view 10. 72082 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 2 or 3 views 11. 72083 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 4 or 5 views 12. 72084 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); minimum of 6 views 13. 72100 RE, spine, lumbosacral; 2 or 3 views 14. 72110 RE, spine, lumbosacral; minimum of 4 views 15. 72114 RE, spine, lumbosacral; complete, including bending views, minimum of 6 views 16. 72120 RE, spine, lumbosacral; bending views only, 2 or 3 views 17. 72170 RE, pelvis; 1 or 2 views 18. 72190 RE, pelvis; complete, minimum of 3 views 19. 72200 RE, sacroiliac joints; less than 3 views 20. 72202 RE, sacroiliac joints; 3 or more views 21. 72220 RE, sacrum and coccyx, minimum of 2 views 22. 73000 RE; clavicle, complete 23. 73010 RE; scapula, complete 24. 73020 RE, shoulder; 1 view 25. 73030 RE, shoulder; complete, minimum of 2 views 26. 73050 RE; acromioclavicular joints, bilateral, with or without weighted distraction 27. 73501 RE, hip, unilateral, with pelvis when performed; 1 view 28. 73502 RE, hip, unilateral, with pelvis when performed; 2-3 views 29. 73503 RE, hip, unilateral, with pel vis when performed; minimum of 4 views 30. 73521 RE, hips, bilateral, with pelvis when performed; 2 views 31. 73522 RE, hips, bilateral, with pelvis when performed; 3-4 views 32. 73523 RE, hips, bilateral, with pelvis when performed; minimum of 5 views 33. 73551 RE, femur; 1 view 34. 73552 RE, femur; minimum 2 views IX. Codes that may be covered but require a prior authorization:A. 97 010 hot or cold packs B. 97012 traction C. 97014 electrical stimulation D. 97035 ultrasound E. 97139 unlisted therapeutic procedure F. 97140 manual therapy technique Chiropractic Care-MP-PY-1358Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.X. Exclusions/services not covered for Chiropractors:A. 20560 needle insertion(s) without injection(s); 1 or 2 muscle(s) -dry needling B. 20561 needle insertion(s) without injection(s); 3 or more muscles-dry n eedling 1. CareSource follows the Center for Medicare and Medicaid (CMS) analysis stating that acupuncture includes dry needling. 2. Acupuncture is not a covered benefit. E. Conditions of CoverageNA F. Related Policies/RulesModifier 25 Reimbursement policy G. Review/Revision HistoryDATE ACTIONDate Issued 08/03/2022 New policy. Replace s individual marketplace policies. Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Use of the AT modifier for Chiropractic Billing (May 7, 2019). Retrieved 07/25/2022 from www.cms.gov. 2. Department of Health and Human Services. Centers for Medicare & Medicai d Services. Local Coverage Determination (LCD L37254). Chiropractic Services (February 3,2022). Retrieved 0 7/25/2022 from www.cms.gov. 3. National Coverage Analysis for Acupuncture for Chronic Low Back Pain CAG – 00452N. January 21, 2020. Retrieved 0 7/25/2022 f rom www.cms.gov. 4. The Association of Chiropractic Colleges. (n.d.). Chiropractic Paradigm/Scope & Practice. Retrieved 0 7/25/2022 from www.chirocolleges.org. I. State-Specific Information A. Georgia 1. References a. 2020 Georgia Code. Title 43 – Professions and Business es. Chapter 9 Chiropractors. 43-9-1. Definitions. Retrieved 07/25/2022 from www.law.justia.com. b. 2020 Georgia Code. Title 43 – Professions and Businesses. Chapter 9 Chiropractors. 43-9-16. Scope of Practice; Injury From Want of Reasonable Degree of Care Is a Tort. Retrieved 07/25/2022 from www.law.justia.com. c. MARKETPLACE PLAN Georgia Evidence of C overage 2022. www.caresource.com/documents/marketplace-2022-ga-basic-eoc . Chiropractic Care-MP-PY-1358Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2. Effective: 11/01/2022B. Indiana 1. References a. 2020 Indiana Code. Title 25 ARTICLE 10. Chapter 1. Regulation of Chiropractors IC 25-10-1-1. Definitions. Retrieved 07/25/2022 from www.iga.in.gov . b. 2020 Indiana Code. Title 25 ARTICLE 10. Chapter 1. Regulation of Chiropractors IC 25-10-1-17. Authority to diagnose and treat injuries, conditions, and disorders. Retrieved 07/25/2022 from www.iga.in.g ov . c. MARKETPLACE PLAN Indiana Evidence of Coverage 2022. 2. Effective: 11/01/2022 C. Kentucky 1. References a. Kentucky Administrative Regulations. Title 907 | Chapter 003 | Regulation 125. 907 KAR 3:125. Chiropractic services and reimbursement. Retrieved 07/25/2022 f rom www.apps.legislature.ky.gov. b. MARKETPLACE PLAN Kentucky Evidence of Coverage 2022. www.caresource.com/documents/marketplace-2022-ky-basic-eoc . 2. Effective: 11/01/2022 D. Ohio 1. References a. Ohio Revised Code/Title 47 Occupations-Professions/Chapter 4734 Chiropractors. Section 4734.01 | Practice of chiropractic defined. Retrieved 07/25/2022 from www.codes.ohio.gov. b. Ohio Revised Code/Title 47 Occupations-Professions/Chapter 4734 Chiropractors. Section 4734.15 | Scope of practice of chiropractic. Retrieved 07/25/2022 from www.codes.ohio.gov. c. MARKETPLACE PLAN Ohio Evidence of Coverage 2022. www.caresource.com/documents/marketplace-2022-oh-basic-eoc . 2. Effective: 12/ 01/2022 E. West Virginia 1. References a. WEST VIRGINIA CODE CHAPTER 30. PROFESSIONS AND OCCUPATIONS. ARTICLE 16. CHIROPRACTORS. 30-16-18. Scope of practice; chiropractic assistants; expert testimony. Retrieved 07/25/2022 from www.code.wvlegislature.gov . b. WEST VIRGINIA CODE CHAPTER 30. PROFESSIONS AND OCCUPATIONS. ARTICLE 16. CHIROPRACTORS. 30-16-20. Use of physiotherapeutic devices; electrodiagnostic devices; specialty practice. Retrieved 07/25/2022 from www.code.wvlegislature.gov . c. MARKETPLACE PLAN West Virginia Evidence of Coverage 2022. www.car esource.com/documents/marketplace-2022-wv-basic-eoc/ 2. Effective: 11/01/2022
ADMINISTRATIVE POLICY STATEMENTIndiana D-SNP Policy Name & Number Date Effective Benef its Coordination-IN D-SNP-AD-0887 11/01/2022 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. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 2F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 2G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 2 H. Review/Revision History ………………………….. ………………………….. ………………………….. … 2 I. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 2 Ben efits Co o rd ination-IN D-SNP-AD-0887 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.A. Subject Benefits Coordination B. Background Indiana Medicare Dual Advantage, also known as Dual Eligible Special Needs Plan (D – SNP), is a program designed f or members in Indiana who receive both Medicaid and Medicare benef its. Care Source administers the members Medicare benefits. The purpos e of this policy is to direct providers to the appropriate CareSource policies to f ollow f or the D-SNP program. C. Def initions Dual-Eligible Special Needs Plan (D-SNP) – A member who has one health plan that administers their Medicare benefits and another health plan or f ee f or service Medicaid that manages their Medicaid benef its . CareSource administers the members Medicare benef its. D. PolicyI. D-SNP members will f ollow the CareSource Indiana Medicare Dual Special Needs policies. E. Conditions of Coverage N/A F. Related Policies/Rules N/A G. Review/Revision History DATES ACTIONDate Issued 10/14/2020Date Revised 7/20/2022 Annual review. Ref erences updated. Date Effective 11/01/2022 Date Archived H. Ref erences 1. Centers f or Medicare and Medicaid Services.(December 1, 2021). Dual Eligible SpecialNeeds Plans (D-SNPs). Retrieved July 1, 2022 f rom www.cms.go v 2. Medicare.gov . (n.d.) How Medicare Special Needs Plans (SNPs) work. Retrieved September 23, 2020 f rom www.medicare.gov
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Three-Day Window Payment-MP-AD-1227 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literatu re 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 a re 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 l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the memb er 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 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable 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 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 Three-Day Window Payment-MP-AD-1227 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectThree-Day Window Payment B. BackgroundCareSource follows the three-day window payment policy as established by the Centers for Medicare & Medicaid Services (CMS). According to the three-day rule, if an admitting hospital (or w holly owned or who lly operated physician practice ) provides diagnostic or nondiagnostic services three days prior to and including the date of the members inpatient admission, the services are considered inpatient services and are included in the inpatient payment (e.g., b undled service). This includes services performed as pre – admission or preoperative procedures when occurring within three days of the inpatient admission. T he three-day window payment will apply to diagnostic and nondiagnostic services clinically related t o the reason for the members inpatient admission regardless of whether the inpatient and outpatient diagnoses are identical. Hospitals (or wholly owned or wholly operated physician practices) are allowed to bill services separately from the inpatient admi ssion if the outpatient services are unrelated to the inpatient admission. C. Definitions Inpatient Member who is admitted to a hospital based upon the written orders of a physician or dentist and whose inpatient stay continues beyond midnight of the day of admission. Outpatient Services Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a physician or dentist which are furnished to an outpatient by a hospital. Outpatient services do not include direct – care services provid ed by physicians, podiatrists, and dentists. Inpatient Services All covered services provided to members during the course of an inpatient hospital stay except for direct-care services provided by physicians, podiatrists, and dentists. Emergency room (ER ) services are covered as an inpatient service when member is admitted from the ER. D. PolicyI. Three-Day Payment Rule. A. Claims submitted for outpatient services, including emergency room and observation services, provided within the three calendar days prior t o the inpatient admission for the same member for the same hospital may be denied, because the inpatient and outpatient services must be combined when they are related . 1. The outpatient services and inpatient admission must be submitted on one inpatient clai m. 2. The dates of the claims should begin with the outpatient service through the inpatient discharge. B. If the hospital submits the outpatient claim separately before the inpatient claim, the inpatient claim may be deemed as a duplicate claim and may be denie d payment. The hospital will need to void the paid claim for the outpatient service Three-Day Window Payment-MP-AD-1227 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.and resubmit the inpatient claim so that it includes inpatient and outpatient services. C. Physician practices and entities should use modifier PD (diagnostic or related non-diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days or 1 day) to identify services subject to the payment window. D. It is recommended that ICD-10 diagnosis code Z01.81X be used to indicate an encounter for preprocedural examinations to flag the outpatient claim as related to an inpatient service/procedure. II. Outpatient hospital behavioral health services provided in the outpatient hospital setting within three calendar days prior to the inpatient admission are exempt from the three-day window policy. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. Centers for Medicare & Medicaid Services (CMS). (2021 December 1). Three Day Payment Window Implementation of New Statutory Provision pertaining to Medicare 3-Day (1-Day) Payment Window Policy Outpatient Services Treated As Inpatient. Retrieved August 1, 2022 from www.cms.gov . 2. Centers for Medicare & Medicaid Services (CMS). (2020 December 3). FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients. MLN Matters SE20024. Retrieved August 12, 2022 from www .cms.gov. 3. Centers for Medicare & Medicaid Services (CMS). (2012 June 14). Frequently Asked Questions CR 7502. Retrieved August 1, 2022 from www.cms.gov. 4. Centers for Medicare & Medicaid Services (CMS). (2011, December 21). Pub 100-04 Medicare Claims Processing, Transmittal 2373. Retrieved July 29, 2022 from www.cms.gov . I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 Three-Day Window Payment-MP-AD-1227 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.B. Indiana1. Effectiv e: 11/01/2022 C. Kentucky 1. Effect ive: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effective: 11/01/2022
ADMINISTRATIVE POLICY STATEMENT Marketplace Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-MP-AD-1222 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 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 t o, 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. Th ese 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 se rvices. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in th e 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 treatm ent of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………… 2 B. Background ………………………….. ………………………….. ………………………….. ……………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ……………………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. … 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. . 5 H . References ………………………….. ………………………….. ………………………….. ………………… 5 I. State-Specif ic Inf ormation ………………………….. ………………………….. …………………………. 5 Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. SubjectProgram Integrity Provider Prepayment ReviewB. BackgroundThis policy applies to participating (PAR) providers only.CareSource Program Integrity (PI) operates a provider prepayment review program to detect, prevent and correct fraud, waste and abuse and to f acilitate accurate claim payments. Physicians and other healthcare professionals may have the right to appeal resu lts of reviews. C. Def initionsProvider prepayment review-reviews medical record documentation and compares it to billed services.Program Integrity (PI) – Program integrity ref ers to the proper management and f unction of the health insurance program to ensure it is providing quality and ef f icient care while using f unds taxpayer dollars appropriately and with minimal waste.Certified Professional Coder (CPC) – The certified professional coder credential is of f ered through the American Academy of Prof essional Coders (AAPC).Prof essional coding is medical coding that is conducted in a prof essional environment such as a physician’s of f ice, outpatient setting, or hospital.Registered Health Information Administrator (RHIA) – A registered health inf orm ation administrator (RHIA) is a prof essional who handles patient health inf ormation. The RHIA role requires certification and must adhere to standards such as the Health Insurance Portability and Accountability Act and other privacy and security rules.Reg istered Health Information Technician (RHIT) – An RHIT is a certif ied prof essional who stores and verif ies the accuracy and completeness of electronic health records. An RHIT also analyzes patient data with the goal of controlling healthcare costs and impr oving patient care.D. PolicyI. A p rovider prepay review involves reviewing medical records compared to services billed prior to claim adjudication.A. Providers are placed on prepay review to monitor f or improper billing of medical claims including but not limited to the f ollowing reasons:1. Overutilization of services .2. Billing f or items or services not rendered .3. Selection of wrong CPT/HCPCS code or supplies .4. Lack of medical necessity .5. Billing/dispensing unnecessary services .6 . Procedure repetition .7. Upcoding . Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 8. Billing f or services outside of provider specialty .II. Placement on prepayment review will require the provider to submit medical records with each claim allowing CareSource to review the medical records in comparis on to the billed services.A. CareSource will provide a written 30 day notice to the provider/provider group advising them of the ef fective date of prepayment review.1. Prepayment review will be implemented f or a period of 6 months2. The 6 month period b egins upon the f irst successful adjudication of a claim submission under prepayment review.3 . All claims must be submitted with medical records.4. Medical records may be sub m itted in one of the f ollowing ways:a. Electronically with a claim .b. Submitted via the provider portal.Note: CareSource will not accept medical records via f ax. 5 . Failure to submit medical records to CareSource in accordance with this provisionwill result in claim denial.6 . Failure to meet minimal documentation sta ndards such as member name and date of service on each page of the medical record, a signed dated order and a valid provider signature will result in claim denial.7 . Providers must bill timely and accurate claims during the prepayment review period.III. CareSource utilizes our published decision hierarchy to conduct our reviews, in addition we may use:A. Centers f or Medicare and Medicaid Services guidelines as stated in Medicare manuals.B. Medicare local coverage determinations and national coverage determination s .C. All CareSource published policies (Administrative, Medical and Reimbursement),c ode-editing policies and CareSource provider manuals.D. National Unif orm Billing Guidelines f rom the National Billing Committee.E. American Medica l Association Current Procedural Terminology (CPT) guidelines.F. American Medical Association Healthcare current Common Procedure CodingSystem (HCPCS) Level II.G. ICD 10-CM of ficial guidelines for coding and reporting.H. American Association of Medical Audit Specialists national healthcare billing audit guidelines.I. Industry-standard utilization management criteria and/or care guidelines such asMCG guidelines (current edition on date of service).J. Food and Drug Administration guidance.K. National prof essional medical societys guidelines and consensus statements.L. Publication f rom specialty societies, such as the American Society f or Parenteral and Enteral Nutrition, the Substance Abuse and Mental Health ServiceAdministration, and the A merican Association of Neuromuscular & Mental HealthServices Administration .M. Nationally recognized, evidence-based published literature including, but not limited to, sources such as: Medscape, the American Academy of Pediatrics(AAP), and the American College of Obstetricians and Gynecologists (ACOG). Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. IV. The PI Provider Prepayment Review Team is made up of clinical review and coding specialists who maintain CPC, RHIA, or RHIT designation.A. The team reviews provider documentation to determine whethe r the claim is appropriate f or payment based on criteria including, but not limited to, provider documentation which establishes that:1. Services were provided according to CareSource policy requirements.2. Billed services were medically necessary and ap propriate, and not in excess of the member s need.3. Members were benefit eligible on the date the services were provided.4. Prior authorization was obtained if required by policy.5. Providers and their staf f were qualif ied as required by state or f ederal law.6. The providers possessed the proper license, certifications, or other accreditation requirements specific to the providers scope of practice at the time the service was provided to the member.V. Providers whose claims are determined not pa yable may send in new corrected claims, a dispute or an appeal, whichever is appropriate, within timely f iling limitations as outlined in their provider manual.A. Providers and/or billing managers may reach out directly to the PI prepayment review team to discuss specif ic claim denials.VI. Providers are prohibited from billing covered individuals f or services we have determined not payable as a result of the prepayment review process, whether due to f raud, abuse, waste of any other billing issue, or f or f ailure to submit medical records as set f orth above.VII. On completion of the six month review periodA. CareSource will determine if the provider is eligible f or release f rom prepayment review if :1. The provider has achieved an 85% or more approval rate on claim submissions f or 3 consecutive months and2. The volume of its claims submissions remained within 10% of the volume bef ore prepayment reviewB. If the provider successfully completes both requirements under A above bef ore the six month deadline th e provider may be removed f rom the prepayment review process at the discretion of CareSource.C. If the provider fails to satisf y the requirements above they may be placed under an additional 6 month prepayment review period and be required to submit a cor rective action plan.1. If af ter the second 6 month interval prescribed under sub section Cthe provider f ails to satisf y the requirements under sub section A1 and A2,CareSource may do the f ollowing :a. Deny payment f or medical assistance services rendered during a specif ied period of time b. Terminate the provider agreement c. Require a corrective action plan Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 2. Providers who are able to demonstrate accurate billing practices and have been removed f ro m prepayment review may be subject to f uture f ollow up reviews to ensure continued compliance with billing practices.3. If a provider has been on a prepayment review f or 12 monthsCareSource may terminate the provider agreement if :a. There has been no bi lling activity f or 6 months; or b. The volume of claim submissions during the review period is not within10% of its volume bef ore prepayment review.4. Upon completion of the prepayment review period, the provider/provider group will receive notif ication in writings as to the ef fective end date of review.E. Conditions of CoverageN/AF. Related Policies/RulesN/AG. Review/Revision HistoryDATE ACTION Date Issued 08/17/2022 New Policy Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date Archived H . Ref erences1, Centers f or Medicare and Medicaid Services. Medicare Program Integrity Manual(April 21, 2022). Retrieved July 11, 2022 f rom www.cms.govI.State-Specific Information a. Georgia1. Effective: 11/01/2022b. Indiana1. Effective: 11/01/2022c. Kentucky1. Effective: 11/01/2022d. Ohio1. Effective: 12/01/2022e. West Virginia Pro g ram In teg rity Pro vid er Prep aymen t Review-MP-AD-1222 Effective Dat e: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. i. Effective: 11/01/2022 I nd e pe n de nt med i ca l r e v iew
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-OH MCD-AD-0767 12/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and i ts 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. Medi cally 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 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 procedur es. 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 Ad ministrative 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 dete rmination. 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 appl y to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Pro g ram In teg rity Pro vid er Prep aymen t Review-OH MCD-AD-0767 Effective Dat e: 12/25/2030 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.A. SubjectPro g ram Integrity Provider Prepayment Review B. Background This policy applies to participating (PAR) providers only. CareSo urce Pro gram Integrity (PI ) o perates a p rovider prepayment review program to detect, p revent , and correct fraud, waste , and abuse , and to facilitate accurate claim p ayments. Physicians and o ther healthca re professiona ls may have the right to ap peal results of reviews. C. Def initions Provider Prepayment Review – Reviews of medical record documentation and compar ison billed services. Prog ram Integrity (PI) – The proper management and f unction ing of a health insurance program to ensure it is providing quality and ef f icient care while using f unds taxpayer dollars appropriately and with minimal waste. Certified Professional Coder (CPC) – The certified professional coder credential is of f ered through the American Academy of Prof essional Coders (AAPC). Professional coding is medical coding that is conducted in a prof essional environment such as a physician’s of f ice , outpatient setting , or hospital. Reg istered Health Information Administrator (RHIA) – A prof essional who handles patient health inf ormation. The RHIA role requires certification and must adhere to standards such as the Health Insurance Portability and Accountability Act and other privacy and security rules. Registered Health Information Technician (RHIT) – A certif ied professional who stores and verif ies the accuracy and completeness of electronic health records and analyzes patient data with the goal of controlling healthcare costs and improving patient care. D. PolicyI. A pro vider pre pay review involves reviewing medical record s compared to services b illed p rio r to claim adjudication. Providers are p laced o n pre pay review to monitor for improper b illing of medical claims including b ut not limited to the following reasons: A. Overutilization o f services B. Billing for items or services not rendered C. Selection of wro ng CPT/HCPCS code o r supplies D. Lack o f medical necessity E. Billing /dispensing unnecessary services F. Pro ced ure repetition G. Up co ding H. Billing for service s outside of p rovider specialty II. Placemen t on p repayment review will req uire the provider to submit medical records with each claim allo wing CareSource to review the medical records in comparison to the billed services. CareSource will p rovide a written 30-day no tice to the provider/provider gro up ad vising them of the effective date of prepayment review. A. Prep ayment review will be implemented for a p eriod of 6 months . B. The 6-mo nth p eriod b egins up on the first successful adjudication of a claim submission und er p rep ayment review. Pro g ram In teg rity Pro vid er Prep aymen t Review-OH MCD-AD-0767 Effective Dat e: 12/25/2030 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.C. Med ical records MUST b e submitted via paper format to the P .O. Box listed on the p ro vider p repayment notification letter. D. All claims must b e submitted with medical record s. E. Failure to sub mit medical records to CareSource in accordance with this p rovision will result in claim d enial. F. Failure to meet minimal documentation standards such as member name and date of service o n each page of the medical record, a signed d ated ord er and a valid provider sig nature will result in claim d enial. G. Pro viders must b ill timely and accurate claims during the prepayment review period. III. CareSo urce utilizes a p ublished decision hierarchy to cond uct reviews . In ad d ition,CareSo urce may use the following: A. Centers f o r Medicare and Medicaid Services ( CMS ) g uidelines , as stated in Medicare manuals . B. Med icare lo cal and national coverage determinations . C. All CareSo urce published policies (Administrative, Medical and Reimbursement), code – ed iting policies and CareSource p rovider manuals. D. Natio nal Unif orm Billing Guidelines fro m the National Billing Committee . E. American Med ical Association Current Procedural Terminology (CPT) g uidelines . F. Current American Medical Association Healthcare Co mmon Procedure Co ding System (HCPCS) Level II . G. ICD 10-CM o f ficial g uidelines for coding and reporting . H. American Association of Medical A udit Specialists national healthcare billing aud it g uid elines . I. Ind ustry-standard utilization management criteria and /or care guidelines , such as MCG g uid elines (current edition o n date of service) . J. Fo o d and Drug Administration guidance . K. Natio nal p rofession al medical societys guidelines and consensus statements . L. Pub lication from specialty societies, such as the American Society for Parenteral and Enteral Nutritio n, the Substance Abuse and Mental Health Service Administration, and the American Association of Neuromuscular & Mental Health Services Administration . M. Natio nally recognized , evidence-b ased published literature including, b ut not limited to, so urces , such as Medscape, the American Academy of Pediatrics (AAP) and the American Co llege of Obstetricians and Gynecologists (ACOG) . IV. The P ro g ram Integrity Provider Prepayment Review Team is comprised of clinical review andco d ing specialists who maintain CPC, RHIA, o r RHIT d esignation s.A. The team reviews p rovider d ocumentation to determine whether the claim is appropriate f o r p ayment based on criteria including, b ut not limited to, provider d ocumentation which estab lishes that: 1. Services were p rovided according to CareSource policy req uirements . 2. Billed services were medically necessary and appropriate and not in excess of the memb ers need . 3. Memb ers were b enefit eligible on the d ate the services were p rovided . 4. Prio r autho rization was o btained , if required b y policy . 5. Pro viders and staff were q ualifie d, as req uired by state or f ederal law . 6. The p ro vider p ossessed the p roper license, certification , or o ther accreditation req uirements specific to the providers scope of p ractice at the time the service was p ro vided to the member. V. Pro viders whose claims are d etermined not payable may send in new corrected claim s, a d isp ute , or an ap peal, whichever is ap propriate, within timely filing limitations as o utlined in the p ro vide r manual. A. Pro viders and/or billing managers m ay reach out directly to the program integrity p rep ayment review team to discuss specific claim denials. Pro g ram In teg rity Pro vid er Prep aymen t Review-OH MCD-AD-0767 Effective Dat e: 12/25/2030 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.VI. Pro viders are p rohibited from b illing covered individuals for services determined not payable as a result o f the p repayment review p rocess, whether d ue to fraud, abuse, waste of any o ther b illing issue, or f or failure to submit medical records as set forth ab ove. VII. On co mp letion of the 6 mo nth review period :A. CareSo urce will d etermine if the p rovider is eligib le for release from prepayment review if: 1. The p ro vider has achieved an 85% o r more approval rate o n claim submissions for 3 co nsecutive months , and 2. The vo lume of claims submissions remained within 10% of the volume b efore p rep ayment review . B. If the p ro vider successfully complete s both requirements under A ab ove before the 6 mo nth d eadline , the provider may be removed from the p repayment review p rocess at the d iscretion of CareSource. C. If the p ro vider fails to satisfy the requirements ab ove , an ad ditional 6 month p repayment review p erio d may b e necessary, and the provider may be req uired to submit a corrective actio n p lan. 1. If af ter the second 6 month interval p rescribed und er sub se ction Cthe p rovider fails to satisfy the r eq uirements under sub sections A1 and A2 , CareSource may do the f o llowing : a. Deny p ayment for medical assistance services rendered d uring a specified period o f time b . Terminate the p ro vider ag reement c. Req uire a co rrective action plan 2. Pro viders who d emonstrate accurate billing practices and have b een removed from prep ayment review may be subject to future follow up reviews to ensure continued co mp liance with billing p ractices. 3. If a p ro vider has been on a p repayment review for 12 months , CareSource may terminate the p rovider ag reement if: a. There has b een no b illing activity for 6 months; o r b . The vo lume of claim submissions during review period is not within 10% of the vo lume b efore p repayment review. 4. Up o n co mpletion of the prepayment review period, the p rovider/provider g roup will receive no tification in writing as to the effective end d ate of review. E. Conditions of Coverage N/A F. Related Policies/Rules N/A G. Review/Revision History DATES ACTIONDate Issued 01/08/2020 New Po licyDate Revised 08/19/2020 07/20/2022 Up d ated Section VII , Ed itorial updates o nly. Date Effective 12/ 01/2022 Date Archived Pro g ram In teg rity Pro vid er Prep aymen t Review-OH MCD-AD-0767 Effective Dat e: 12/25/2030 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.H. Ref erencesN/A
ADMINISTRATIVE POLICY STATEMENT Ohio Medicare Advantage Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-OH MA AD-0768 12/01/2022 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 hea lth 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. 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 ne cessary 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 it s 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 Administrative Policy Statement. If there is a conflict between the A dministrative 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 Addictio n Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Pro gram In teg rity Pro vid er Prep aymen t Review-OH MA AD-0768 Effective Date 12/01/2022 The ADMINIS TRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. SubjectProgram Integrity Provider Prepayment ReviewB. BackgroundThis policy applies to participating (PAR) providers only.CareSource Program Integrity (PI ) operates a provider prepayment review program to detect, prevent and correct fraud, waste and abuse and to f acilitate accurate claim payments. Physicians and other he althcare professiona ls may have the right to appeal results of reviews . C. Def initionsProvider Prepayment Review-reviews medical record documentation and compares it to billed services.Program Integrity (PI) – Program integrity ref ers to the proper management and f unction of the health insurance program to ensure it is providing quality and ef f icient care while using f unds taxpayer dollars appropriately and with minimal waste.Certified Professional Coder (CPC) – The certified professional coder credential is of f ered through the American Academy of Prof essional Coders (AAPC). Professional coding is medical coding that is conducted in a prof essional environment such as a physician’s of f ice, outpatient setting, or hospital.Registered Health Information Administrator (RHIA) – A registered health inf ormation administrator (RHIA) is a prof essional who handles patient health inf ormation. The RHIA role requires certification and must adhere to standards such as the Health Insura nce Portability and Accountability Act and other privacy and security rules.Registered Health Information Technician (RHIT) – An RHIT is a certif ied prof essional who stores and verif ies the accuracy and completeness of electronic health records. An RHIT also analyzes patient data with the goal of controlling healthcare costs and improving patient care.D. PolicyI. A Provider pre pa y review involves reviewing medical records compared to services billed prior to claim adjudication.A. Providers are placed on pre pay review to monitor f or improper billing of medical claims including but not limited to the f ollowing reasons:1. Overutilization of services2. Billing f or items or services not rendered3. Selection of wron g CPT/HCPCS code or supplies4. Lack of medical necessity5. Billing/dispensing unnecessary services6. Procedure repetition7. Upcoding8. Billing f or service s outside of provider specialty Pro gram In teg rity Pro vid er Prep aymen t Review-OH MA AD-0768 Effective Date 12/01/2022 The ADMINIS TRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. II. Placement on prepayment review will require the provider to submit medical records with each claim allowing CareSource to review the medical records in comparison to the billed services.A. CareSource will provide a written 30-day notice to the provider/provider group advising them of the ef fective date of prepayment review.1. Prepayment review will be implemented f or a period of 6 months2. The 6 month period begins upon the f irst successful adjudication of a clai m submission under prepayment review.3. All claims must be submitted with medical records.4. Medical records may be submitted in one of the f ollowing ways :a. Electronically with a claim .b. Submitted via the provider portal.Note: CareSource will not accept medical records via f ax. 5. Failure to submit medical records to CareSource in accordance with this provision will result in claim denial.6. Failure to meet minimal documentation standards such as member name and date of service on each page of the medical record, a signed dated order and a valid provider signature will result in claim denial.7. Providers must bill timely and accurate claims during the prepayment review period.III. CareSource utilizes the published decision hierarchy to conduct reviews, in additionCareSource may use:A. Centers f or Medicare and Medicaid Services guidelines as stated in Medicare manuals .B. Medicare local coverage determinations and national coverage determinations .C. All CareSource published policies (Administrative, Medical and Reimbursement),Code-editing policies and CareSource provide r manuals.D. National Unif orm Billing Guidelines f rom the National Billing Committee .E. American Medical Association Current Procedural Terminology (CPT) guidelines .F. American Medical Association Healthcare Current Common Procedure CodingSystem (HCPCS) Level II .G. ICD 10-CM of ficial guidelines f or coding and reporting .H. American Association of Medical Audit Specialists national healthcare billing audit guidelines .I. Industry-standard utilization management criteria and/ or care guidelines such asMCG guidelines (current edition on date of service) .J. Food and Drug Administration guidance .K. National prof essional medical societys guidelines and consensus statements .L. Publication f rom specialty societies, such as the American Society f or Parenteral and Enteral Nutrition, Substance Abuse and Mental Health ServiceAdministration, and the American Association of Neuromuscular & Mental HealthServices Administratio n.M. Nationally recognized, evidence-based published literature including, but not limited to, sources such as: Medscape, American Academy of Pediatrics (AAP)and the American College of Obstetricians and Gynecologists (ACOG) .IV. The PI Provider Prepayment Review Team is made up of clinical review and coding specialists who maintain CPC, RHIA, or RHIT designation. Pro gram In teg rity Pro vid er Prep aymen t Review-OH MA AD-0768 Effective Date 12/01/2022 The ADMINIS TRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. The team reviews provider documentation to determine whether the claim is appropriate f or payment based on criteria including, but not l imited to, provider documentation which establishes that:1. Services were provided according to CareSource policy requirements .2. Billed services were medically necessary and appropriate, and not in excess of the member s need .3. Members were benefit eligible o n the date the services were provided .4. Prior authorization was obtained if required by policy .5. Providers and their staf f were qualif ie d as required by state or f ederal law .6. The provider possessed the proper license, certification, or other accreditation requirements specific to the providers scope of practice at the time the service was provided to the member.V. Providers whose claims are determined not payable may send in new corrected claim s , a dispute or an appeal, whichever is appropria te, within timely f iling limitations as outlined in their provide r manual.A. Providers and/or billing managers m ay reach out directly to the PI prepayment review team to discuss specif ic claim denials.VI. Providers are prohibited f rom billing covered individu als f or services we have determined not payable as a result of the prepayment review process, whether due to f raud, abuse, waste of any other billing issue, or f or f ailure to submit medical records as set f orth above.VII. On completion of the six month review periodA. CareSource will determine if the provider is eligible f or release f rom prepayment review if :1. The provider has achieved an 85% or more approval rate on claim submissions f or 3 consecutive months and2. The vol ume of its claims submissions remained within 10% of the volume bef ore prepayment reviewB. If the provider successfully complete s both requirements under A above bef ore the six-month deadline the provider may be removed f rom the prepayment review process at the discretion of CareSource.C. If the provider f ails to satisf y the requirements above they may be placed under an additional 6 month prepayment review period and be required to s ubmit a corrective action plan.1. If af ter the second 6 month interval prescribed under sub section Cthe provider f ails to satisf y the r equirements under sub sections A1 and A2 ,CareSource may do the f ollowing a. Deny payment f or medical assistance services rendered during a specif ied period of time b. Terminate the provider agreement c. Require a corrective action plan2. Providers who are able to demonstrate accurate billing practices and removed f rom prepayment revi ew may be subject to f uture f ollow up reviews to ensure continued compliance with billing practices.3. If a provider has been on a prepayment review f or 12 months CareSource may terminate the provider agreement if :a. There has been no billing activ ity f or 6 months; or Pro gram In teg rity Pro vid er Prep aymen t Review-OH MA AD-0768 Effective Date 12/01/2022 The ADMINIS TRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. b. The volume of claim submissions during review period is not within 10% of its volume bef ore prepayment review.4. Upon completion of the prepayment review period, the provider/provider group will receive notif ication in writings as to the ef fective end date of review.E. Conditions of CoverageN/AF. Related Policies/RulesN/AG. Review/Revision HistoryDATES ACTION Date Issued 01/08/2020 New Po licy Date Revised 0 8/19/2020 08/13/2022 Up d ated Section VII , up dated title . Remo ved req uirement for paper format f o r submission; instead claims should be sub mitted electronically . Date Effective 12/01/2022 H. Ref erencesI. Centers f or Medicare and Medicaid Services. Medicare Program Integrity Manual (April21, 2022). Retrieved July 11, 2022 f rom www.cms.gov
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Nutritional Supplements-MP-MM-1330 IN, GA, WV, KY : 11/01/2022 OH: 12/01/2022 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical 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 o rgan 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 necessar y 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. Medical 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 Medical Policy Statement. If there is a conflict between the Medical Policy Sta tement 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 determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), co verage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 8 Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.A. SubjectNutritional Supplements B. BackgroundNutrition may be delivered through oral intake or through a tube into the stomach or small intestine. Enteral nutrition may be medically necessary to maintain optimal health status for individuals with diseas es or structural defects of the gastrointestinal ( GI ) tract that interfere with transport, digestion, or absorption of nutrients. Such conditions may include anatomic obstructions due to cancer motility disorders such as gastroparesis or metabolic absorpti ve disorders such as PKU. Considerations are given to medical condition, nutrition and physical assessment, metabolic abnormalities, gastrointestinal function, and expected outcome. Enteral nutrition may be either for total enteral nutrition or for supplem ental enteral nutrition. C. Definitions Chronological Age The time elapsed after birth, usually described in days, weeks, months, and/or years. Corrected Age A term most appropriately used to describe children up to 3 years of age who were born preterm or before gestational age of 37 weeks. This term represents the age of the child from the expected date of delivery (mothers due date). Corrected age is calcula ted by subtracting the number of weeks born before 40 weeks of gestation from the chronological age. Donor Human Milk Breast milk that is expressed by a mother and processed by a human milk bank for use by a recipient that is not the donor mothers own i nfant. Enteral Nutrition Nutritional support given via the gastrointestinal (GI) tract, either directly or through any of a variety of tubes used in specific medical conditions. This includes oral feeding, as well as feeding using tubes such as orogastri c, nasogastric, gastrostomy, and jejunostomy tubes. Human Milk Bank A service which recruits human breast milk donors, collects, pasteurizes, and stores donor human milk, tests the donor milk for bacterial contamination, and distributes donor human milk to recipient infants in need. Inborn Errors of Metabolism (IEM) Inherited biochemical disorders resulting in enzyme defects that interfere with normal metabolism of protein, fat, or carbohydrate. Medical Food Specially formulated and processed for indi viduals who are seriously ill or who require the product as a major treatment modality. This term does not pertain to all foods fed to ill individuals. Medical foods are intended solely to meet the nutritional needs of individuals who have specific metabol ic or physiological limitations restricting their ability to digest regular food. This can include specially formulated infant formulas. According to the Food and Drug Administrations (FDA), a product must meet all the following minimum criteria to be cons idered a medical food: o The product must be a food for oral or tube feeding. o The product must be labeled for the dietary management of a specific medical disorder, disease, or condition for which there are distinctive nutritional requirements. o The product m ust be used under the supervision of a physician. Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved. Oral Nutrition (oral feeding) Nutritional support given via the oral route. RELiZORB The only FDA-approved product indicated to hydrolyze (break down) fats in enteral feeding. RELiZORB is indicated for use in pediatric patients (ages 5 years and older) and adult patients. Standard Food Regular grocery products including typical, not specially formulated, infant formulas. Supplemental Nutrition Fewer than 50% of daily calories are supplied by enteral nutrition products. Therapeutic Oral Non-Medical Nutrition : o Food Modification Some conditions may require adjustment of carbohydrate, fat, protein, and micronutrient intake or avoidance of specific allergens (e.g., diabetes mellitus, celiac disease). o Fortified Food Food products that have additives to increase energy or nutrient density. o Functional Food Food that is fortified to produce specific beneficial health effects. o Texture Modified Food and Thickened Fluids Liquidized/thin puree , thick puree, finely minces, or modified normal. o Modified Normal Eating normal foods by avoiding particulate foods that are a choking hazard. Total Enteral Nutrition (TEN) More than 50% of daily calories are supplied by enteral nutrition products. D. Po licyI. Oral Nutrition : Prior authorization is required except for inborn error of metabolism conditions. A. Total oral nutrition is considered medically necessary when ALL the following criteria are met: 1. The product must be a medical food for oral feeding; 2. The product must be used under medical supervision; 3. The member has the ability to swallow without increased risk of aspiration; 4. The product is documented to make up more than 50% of the members daily intake, which, by definition, is the members primary source of nutrition; 5. The product must be labeled and used for nutritional management of a members specific medical condition without which serious morbidities (physical or mental) may develop OR the product is used to promote normal development or function for the member; 6. The member must have one of the following medical conditions: a. A condition caused by an inborn error of metabolism, including but not limited to the following: Phenylketonuria; Homocystinuria; Methylmalonic academia; Galactosemia; OR b. A condition that interferes with nutrient absorption and digestion, including, but not limited to: Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.01. Current diagnosis of non-IgE-mediated cows milk allergy (CMA) as defined by any of the following: (1). Abnormal stools, defined as hemoccult positive, mucous – containing, foam-containing, or diarrheal; (2). Poor weight gain trajectory for age (e.g., failure to thrive); (3). Atopic dermatitis: age of onset less than 3 months, severe eczema, exacerbation of eczema noted with introduction of cows milk, cow s milk formula, or maternal ingestion of cows milk (if breastfed); 02. Allergy to specific foods, including food-induced anaphylaxis, or severe food allergy indicating a sensitivity to intact protein product, as diagnosed through a formal food challenge; 03. All ergic eosinophilic enteritis (colitis/proctitis, esophagitis, gastroenteritis); 04. Cystic fibrosis with malabsorption ; 05. Diarrhea or vomiting resulting in clinically significant dehydration requiring treatment by a medical provider; 06. Malabsorption unresponsive t o standard age-appropriate interventions when associated with failure to gain weight or meet established growth expectations; 07. Failure to thrive unresponsive to standard age-appropriate interventions (e.g., nutritionally complete liquid meal supplements) wh en associated with weight loss, failure to gain weight, or to meet established growth expectations, including but not limited to: (1). Premature infants who have not achieved the 25 th percentile for weight based on their corrected gestational age; (2). Individuals w ith end-stage renal disease and hypoalbuminemia (albumin less than 4gm/dl); 7. The product must be used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care pro vider authorized to prescribe dietary treatments; 8. Approval duration can be up to 12 months for all oral nutrition products. B. Oral supplemental nutrition is considered medically necessary when ALL the following apply: 1. The members diet consists of less than 50% enteral nutrition and more than 50% standard diet for age; 2. The product is used as part of a defined and limited plan of care for a member transitioning from total enteral nutrition to standard diet for age; 3. Documentation of a medical basis for the members inability to maintain appropriate body weight and nutritional status (initial and ongoing) with normal or therapeutic oral nutrition; 4. The product must be used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authorized to prescribe dietary treatments; 5. The primary reason is not for convenience of the member or caregiver; Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6. All avenues of coverage available must be exhausted first. For example,members eligible for their county Women, Infant, and Children (WIC) program must apply for an eligibility evaluation before supplemental nutrition coverage will be considered; 7. Approval duration can be up to 12 months for all oral suppl emental nutrition products. Documentation of ongoing evidence of members positive response to the oral nutrition is required for future approvals. II. Enteral Nutrition via Tube : Prior authorization is required except for inborn error of metabolism condition s and for low-profile gastrostomy/jejunostomy/gastrojejunostomy tubes. A. Total enteral nutrition via tube feeing is considered medically necessary when the member has a functioning, accessible gastrointestinal tract, and ALL the following: 1. Enteral nutrition comprises the majority (greater than 50%) of the members diet; 2. The product is used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authorized to prescribe dietary treatments; 3. There is documentation that the member cannot ingest nutrients orally dur to a medical condition (physical or mental) which: a. Interferes with swallowing (e.g., dysphagia from a neurological condition, severe chronic anorexia nervosa or serious cases of oral aversion in children, which render member unable to maintain weight and nutritional status with oral nutrition alone); OR b. Puts member at risk for aspiration if nutrition is given by oral route; OR c. Is associated with anatomical abnormality of the proximal GI tract (e.g., tumor of the esophagus causing obstruction); 4. Approval duration can be up to 12 months for all enteral nutrition products. B. Enteral supplemental nutrition via tube is considered medically necessary when ALL the following are met: 1. The members diet consists of less than 50% enteral nutrition and more than 50% standard diet for age; 2. The enteral product is used as part of a defined and limited plan of care for a member transitioning from total enteral nutrition to standard diet for age; 3. Documentation of a medical basis for the inability of the member to maintain appropriate body weight and nutritional status (initial and ongoing) with normal or therapeutic enteral nutrition; 4. Documentation of ongoing evi dence of members positive response to the enteral nutrition; 5. The product must be used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authoriz ed to prescribe dietary treatments; 6. The primary reason is not for convenience of the member or caregiver; 7. All avenues of coverage available must be exhausted first (e.g., members eligible for their county Women, Infant, and Children (WIC) program must appl y for an eligibility evaluation before supplemental nutrition coverage will be considered); Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8. Approval duration can be up to 12 months for all supplemental enteral nutrition products.III. Donor breast milk : p rior authorization is required. See Section I for add itional criteria for Kentucky and Georgia. A. CareSource considers human milk medically necessary when ALL the following criteria are met: 1. Provider must be in good standing with the Human Milk Banking Association of North America; 2. Documentation support s medical necessity; 3. Documentation support s that the provider has attested to educating the member in the donation process and about human milk; and 4. Documentation supports that the provider discussed the risks and benefits with the member . B. Per the Food & Dr ug Administration, only human milk banks that screen their milk donors and take precautions to ensure the safety of its milk should be utilized. IV. CareSource does NOT consider the following medically necessary:A. Nutritional formulas and dietary supplements that can be purchased over the counter, which by law do not require either a written prescription or dispensing by a licensed pharmacist. B. Use of a nutritional product for the convenience or preference of the mem ber or caregiver. C. Therapeutic diets where non-medical foods are tolerated , including any of the following: 1. Food modification . 2. Texture modified food . 3. Thickened fluids . 4. Fortified food . 5. Functional food . 6. Modified normal . 7. Flavorings . D. Relizorb ( insufficient publ ished evidence). E. Oral nutrition products for meal replacements or snack alternatives. F. Feeding tubes for individuals with a dvanced dementia . G. Products administered in an outpatient provider setting. These items are not separately reimbursable. E. Conditions of CoverageNA F. Related Policies/RulesNA Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. American Geriatric Society Committee and Clinical Practice and Models of Care Committee. (2014). American Geriatrics Society feeding Tubes in Advanced Dementia Position Statement. JAmerican Geriatric Society. 2014;62(8):1590-1593. Retrieved July 26, 2022 from www.agsjournals.onlinelibrary.wiley.com . 2. Burris A, Burris J, Jarvinen. Cows Milk Protein Allergy in Term and Preterm Infants: Clinical Manifestations, Immunologic Pathophysiology, and Management Strategies. NeoReviews. 2020 December; 21(12):e795-e80 8. 3. Cederholm T, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clinical Nutrition. 2017;36(1):49-64. Doi:10.1016/j.clnu.2016.09.004. 4. Dipasquale V, Ventimiglia M, Gramaglia SMC, et al. Health-related quality of life and home enteral nutrition in children with neurological impairment: report from a multicenter survey. Nutrients. 2019;11(12):2968. 5. Druyan ME, Compher C, Boullata JI, et al. Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pedia tric Patients: applying the GRADE system to development of A.S.P.E.N. clinical guidelines. JParenter Enteral Nutr. 2012;36(1):77-80. 6. Klek S, Hemanowicz A, Dziwiszek G, et al. Home enteral nutrition reduces complications, length of stay, and health care co sts: results from a multicenter study. Am JClin Nutr. 2014;100(2):609-615. 7. Marchand V, Motil KJ. NASPGHAN Committee on Nutrition. Nutrition support for neurologically impaired children: a clinical report of the North American Society for Pediatric Gastroe nterology, Hepatology, and Nutrition. JPediatr Gastroenterol Nutr. 2006;43(1):123-135. 8. Moro GE, Billeaud C, Rachel B, et al. Processing of donor human milk: update and recommendations from the European Milk Bank Association (EMBA). Front Pediatr. 2019;7(4 9):1-10. 9. Robinson D, et al. (2018, May). American Society for Parenteral and Enteral Nutrition (ASPEN) Definition of Terms, Style, and Conventions Used in ASPEN Board of Directors-Approved Documents. Retrieved July 26, 2022 from www.nutritioncare.org . 10. U.S. Food and Drug Administration (FDA). Center for Food Safety and Applied Nutrition. Office of Nutritional Products, Labeling, and Dietary Supplements. May 2016: Frequently Asked Questions about Medical Foods. Retrieved July 26, 2022 from www.fda.gov . 11. U.S. F ood and Drug Administrations (FDA). (2017, December 6). Medical Foods Guidance Documents & Regulatory Information. Retrieved July 26, 2022 from www.fda.gov . Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.12. U.S. Food and Drug Administrations (FDA). Regulatory Information. Section 5 of Orphan Drug Act. Ret rieved July 26, 2022 from www.fda.gov .13. U.S. Social Security Administration (SSA). Disability Evaluation under Social Security. 105.08 Digestive System Childhood. Retrieved July 26 , 2022 from www.ssa.gov . 14. U.S. Social Security Administration (SSA). P rogram Operations Manual System (POMS). DI 24598.002. Failure to Thrive. March 2017. Retrieved 2022 from www.secure.ssa.gov . 15. Wanden-Berghe C, et al. Complications associated with enteral nutrition: CAFANE study. Nutrients. 2019;11(9):2041. 16. Worthington P, e t al. When is Parenteral Nutrition Appropriate? JParent er Enteral Nutr . 2017;41(3):324-377. doi:10.1177/0148607117695251. I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 2. Additional donor milk cover age criteria: As per the evidence of coverage, a benefit is provided for 100% human diet, if the 100% human diet and supplemented milk fortifier products are prescribed for the prevention of necrotizing enterocolitis and associated co-morbidities and admi nistered under the direction of a physician. 100% human diet means the supplementation of a mothers expressed breast milk or donor milk with a milk fortifier. 3. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Georgia (2022). Retrieved July 26, 2022 from www.caresource.com. B. Indiana 1. Effective: 11/01/2022 2. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Indiana (2022). Retrieved July 26, 2022 from www.caresource.com. C. Kentucky 1. Effective: 11/01/2022 2. Additional donor milk coverage criteria: As per the evidence of coverage, a benefit is provided for 100% human diet, if the 100% human diet and supplemented milk fortifier products are prescribed for the prevention of necrotizing enterocolitis and associated co-morbidities and administered under the direction of a physician. 100% human diet means the supplementation of a mothers expressed breast milk or dono r milk with a milk fortifier. 3. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Kentucky (2022). Retrieved July 26, 2022 from www.caresource.com. D. Ohio 1. Effective: 12/01/2022 2. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Oh io (2022). Retrieved July 26, 2022 from www.caresource.com. E. West Virginia 1. Effective: 11/01/2022 2. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, West Virginia (2022). Retrieved July 26, 2 022 from www.caresource.com.
ADMINISTRATIVE POLICY STATEMENT Ohio D-SNP Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-OH DSNP-AD-1229 12/01/2022 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 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 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 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 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 Cove rage) 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 limita tions that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Pro gram In teg rity Pro vid er Prep aymen t Review-OH DSNP-AD-1229 Effective Date: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. SubjectProgram Integrity Provider Prepayment ReviewB. BackgroundThis policy applies to participating (PAR) providers only .CareSource Program Integrity (PI) operates a provider prepayment review program to detect, prevent and correct fraud, waste and abuse and to f acilitate accurate claim payments. Physicians and other healthcare professionals may have the right to appeal resu lts of reviews. C. Def initionsProvider prepayment review-Reviews medical record documentation and compares it to billed services.Program Integrity ( PI) – The proper management and f unction of the health insurance program to ensure it is providing quality and ef f icient care while using f unds taxpayer dollars appropriately and with minimal waste.Certified Professional Coder (CPC) – The CPC credential is of f ered through theAmerican Academy of Prof essional Coders (AAPC). Professional coding is medical coding that is conducted in a prof essional environment such as a physician’s of f ice ,outpatient setting , or hospital.Reg istered Health Information Administrator (RHIA) – A prof essional who handles patient health inf ormation. The RHIA role requires certification and must adhere to standards such as the Health Insurance Portability and Accountability Act and other privacy and security rules.Registered Health Information Technician (RHIT) – A certif ied professional who stores and verif ies the accuracy and completeness of electronic health records. AnRHIT also analyzes patient data with the goal of controlling healthcare costs and improving patient care.D. PolicyI. A p rovider prepay review involves reviewing medical records compared to services billed prior to claim adjudication.A. Providers are placed on prepay review to monitor f or improper billing of claims including but not limited to the f ollowing reasons:1. Overutilization of services2. Bill ing f or items or services not rendered3. Selection of wrong CPT/HCPCS code or supplies4. Lack of medical necessity5. Billing/dispensing unnecessary services6. Procedure repetition7. Upcoding8. Billing f or services outside of provider specialtyII. Placement on prepayment review will require the provider to submit medical records with each claim allowing CareSource to review the medical records in comparison to the billed services. Pro gram In teg rity Pro vid er Prep aymen t Review-OH DSNP-AD-1229 Effective Date: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. CareSource will provide a written 30 day notice to the provider/provider group adv ising them of the ef fective date of prepayment review.1. Prepayment review will be implemented f or a period of 6 months2. The 6 month period begins upon the f irst successful adjudication of a claim submission under prepayment review.3. All claims must be submitted with medical records.4. 4. Medical records may be submitted in one of the f ollowing ways :a. Electronically with a claim .b. Submitted via the provider por tal.Note: CareSource will not accept medical records via f ax. 5. Failure to submit medical records to CareSource in accordance with this provision will result in claim denial.6. Failure to meet minimal documentation standards such as member name and date of service on each page of the medical record, a signed dated order and a valid provider signature will result in claim denial.7. Providers must bill timely and accurate claims during the prepayment review period.III. CareSource utilizes our published decision hierarchy to conduct our reviews . I n addition we may use:A. Centers f or Medicare and Medicaid Services ( CMS ) guidelines as stated inMedicare manuals.B. Medicare local coverage determinations and national coverage determination s .C. All CareSource published policies (Administrative, Medical and Reimbursement),c ode-editing policies and CareSource provider manuals.D. National Unif orm Billing Guidelines f rom the National Billing Committee.E. American Medical Association Current Procedural Terminology (CPT) guidelines.F. American Medical Association Healthcare current Common Procedure CodingSystem (HCPCS) Level II.G. ICD 10-CM of ficial guidelines f or coding and reporting.H. American Association of Medical Audit Specialists national healthcare billing audit guidelines.I. Industry-standard utilization management criteria and/or care guidelines such asMCG guidelines (current editio n on date of service).J. Food and Drug Administration guidance.K. National prof essional medical societys guidelines and consensus statements.L. Publication f rom specialty societies such as the American Society f or Parenteral and Enteral Nutrition, Substance Abuse and Mental Health ServiceAdministration, and the American Association of Neuromuscular & Mental HealthServices Administration .M. Nationally recognized, evidenc e-based published literature including, but not limited to, sources such as Medscape, the American Academy of Pediatrics(AAP) and the American College of Obstetricians and Gynecologists (ACOG ).IV. The PI Provider Prepayment Review Team is made up of clinical review and coding specialists who maintain CPC, RHIA, or RHIT designation.A. The team reviews provider documentation to determine whether the claim is appropriate f or payment based on criteria including , but not limited to, provider documentation which establishes that:1. Services were provided according to CareSource policy requirements. Pro gram In teg rity Pro vid er Prep aymen t Review-OH DSNP-AD-1229 Effective Date: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 2. Billed services were medically necessary and appropriate, and not in excess of the member s need.3. Members were benefit eligible on the date the services were provided.4. Prior authorization was obtained if required by policy.5. Providers and their staf f were qualif ied as required by state or f ederal law.6. The provider possessed the proper license, certification, or othe r accreditation requirements specific to the providers scope of practice at the time the service was provided to the member.V. Providers whose claims are determined not payable may send in new corrected claims, a dispute or an appeal, whichever is appropr iate, within timely f iling limitations as outlined in their provider manual.A. Providers and/or billing managers may reach out directly to the PI prepayment review team to discuss specif ic claim denials.VI. Providers are prohibited f rom billing covered ind ividuals f or services CareSource has determined not payable as a result of the prepayment review process, whether due to f raud, abuse, waste o r any other billing issue, or f or f ailure to submit medical records as set f orth above.VII. On completion of the 6 month review period :A. CareSource will determine if the provider is eligible f or release f rom prepayment review if :1. The provider has achieved an 85% or m ore approval rate on claim submissions f or 3consecutive months and2. The volume of its claims submissions remained within 10% of the volume bef ore prepayment review .B. If the provider successfully completes both requirements under A abov e bef ore the 6 month deadline the provider may be removed f rom the prepayment review process at the discretion of CareSource.C. If the provider f ails to satisf y the requirements above they may be placed under an additional 6 month prepayment review peri od and be required to submit a corrective action plan.1. If af ter the second 6 month interval prescribed under sub section Cthe provider f ails to satisf y the requirements under sub sectio n A1 and A2 ,CareSource may do the f ollowing a. Deny payment f or medical assistance services rendered during a specif ied period of time b. Terminate the provider agreement c. Require a corrective action plan2. Providers who are able to demonstrate accurate billing practices and have been removed f rom prepayment review may be subject to f uture follow up reviews to ensure continued compliance with billing practices.3. If a provider has been on a prepayment review f or 12 months Care Source may terminate the provider agreement if :a. There has been no billing activity f or 6 months; or b. The volume of claim submissions during the review period is not within10% of its volume bef ore prepayment review. Pro gram In teg rity Pro vid er Prep aymen t Review-OH DSNP-AD-1229 Effective Date: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 4. Upon completion of the prepayment review period, the provider/provider group will receive notif ication in writing as to the ef f ective end date of the review.E. Conditions of CoverageN/A F. Related Policies/RulesN/AG. Review/Revision HistoryDATES ACTION Date Issued 08/17/2022 New Po licy Date Revised Date Effective 12/01/2022 H. Ref erences1. Centers f or Medicare and Medicaid Services. Medicare Program Integrity Manual(April 21, 2022). Retrieved July 11, 2022 f rom www.cms.govTh is g uid eline co n tains custom co n ten t th at h as been mo d ified fro m th e stan d ard care g uid elin es an d h as n o t been reviewed o r ap p ro ved by MCG Health , LLC. I nd e pe n de nt med i ca l r e v iew
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Myoelectric Lower Extremity Prosthetic Technology MP-MM-1327 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type MEDICAL Medical 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, 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. Medical 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 Medical Policy Statement. If there is a confl ict between the Medical 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 4 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 5 B. State-Specific Information ……………………………………………………………………………………… 5Myoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.A. Subject Myoelectric Lower Extremity Prosthetic Technology B. Background The policy addresses the computerized limb prosthesis that is a nonstandard, external prosthetic device incorporating a microprocessor for movement control. These devices are equipped with a sensor that detects when the knee is in full extension and adjusts the swing phase automatically, permitting a more natural walking pattern of varying speeds . C. Definitions Myoelectric Lower Extremity Prosthetic Technology Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type. Classification Level Rehabilitation potential as described by Centers for Medicare & Medicaid Services : Lev el 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility a. The individual does not have sufficient cognitive ability to safely use a prosthes is with or without assistance. b. The individual requires assistance from equipment or caregiver to transfer and use of a prosthesis does not improve mobility or independence with transfers. c. The individual is wheelchair dependent for mobility and use of a prosthesis does not improve transfer abilities. d. The individual is bedridden and has no need or capacity to ambulate or transfer. Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence, typical of the limited and unlimited household ambulator. a. The individual has sufficient cognitive ability to safely use a prosthesis with or without an assistive device and/or the assistance/supervision of one person. b. The individual is capable of safe but limited ambulation within the home with or without an assistive device and/or with or without the assistance/supervision of one person. c. The individual requires the use of a wheelchair for most activities outside of their residence. d. The individual is not capable of most of the functional activities designated in Level 2. Myoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.Level 2: Has the ability or potential for ambu lation with the ability to transverse low level environmental barriers such as curbs, stairs or uneven surfaces. This level is typical of the limited community ambulator. a. The individual can ambulate with or without an assistive device (which may inc lude one or two handrails) and/or with or without the assistance/supervision of one person: i. Perform the Level 1 tasks designated above ii. Ambulate on a flat, smooth surface iii. Negotiate a curb iv. Access public or private transportation v. Negotiate 1-2 stairs vi. Negotiate a ramp built to ADA specifications. b. The individual may require a wheelchair for distances that are beyond the perimeters of the yard/driveway, apartment building, etc. c. The individual is only able to increase his/her generally observed speed of walking for short distances or with great effort. d. The individual is generally not capable of accomplishing most of the tasks at Level 3 (or does so infrequently with great effort). Level 3: Has the ability or potential for ambulation with variable cadence, typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic, or exercise activity that d emands prosthetic utilization beyond simple locomotion. a. With or without an assistive device (which may include one or two handrails), the individual is independently capable (i.e. requires no personal assistance or supervision) of performing the Level 2 tasks above and can: i. Walk on terrain that varies in texture and level (e.g., grass, gravel, uneven concrete) ii. Negotiate 3-7 consecutive stairs iii. Walk up/down ramps built to ADA specifications iv. Open and close doors v. Ambulate through a crowded area (e.g., grocery store, big box store, restaurant) vi. Cross a controlled intersection within his/her community wi thin the time limit provided (varies by location) vii. Access public or private transportation viii. Perform dual ambulation tasks (e.g. carry an item or meaningfully converse while ambulating) b. The individual does not perform the activities of Level 4. Level 4: Has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress or energy levels typical of the prosthetic demands of the child, active adult, or athlete. With or without an assistiv e device , which may include one or two handrails, this individual is independently capable (i.e. , requires no personal assistance or supervision) of performing high impact domestic, vocational or recreational activities such as: a. Running b. Repetitiv e stair climbing c. Climbing of steep hills d. Being a caregiver for another individualMyoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d.e. Home maintenance (e.g. repairs, cleaning) NOTE: Consideration is given to bilateral amputees who often cannot be strictly bound by the Classification Levels .D. PolicyI. CareSource considers myoelectric lower limb prosthetic technology medically necessary when the following criteria are met: A. The member is 18 years of age or older . B. Has a lower extremity prosthesis( es). C. Documentation submitted supports medical necessity and includes the following: 1. A written order/prescription from a treating practitioner for the additional technology ; 2. Sufficient documentation of the rehabilitation potential including, but not limited to clear documentation supporting the expected potential classification l evel of K3 or above; and 3. Member: a. Is emotionally ready; b. Is able and willing to participate in training; c. Is able and willing to care for the technology; d. Is physically able to use the equipment; and e. Has adequate cardiovascular and pulmonary reserve for ambulation at faster than normal walking speed. NOTE: Documentation for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies is followed E. Conditions of Coverage NA F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 07/20/2022Date Revised Updated references; no changes Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedMyoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.H. References 1. Centers for Medicare & Medicare Services Health Technology Assessment. (2017, September). Lower Limb Prosthetic Workgroup Consensus Document. Retrieved July 5, 2022 from www.cms.gov . 2. Centers for Medicare & Medicare Services. (2020, December 30). Medicare Program Integrity Manual Chapter 5 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations. Retrieved July 5, 2022 from www.cms.gov . 3. Centers for Medicare & Medicare Services . (2 020, January 10. Local Coverage Determination Lower Limb Prosthesis L33787). Retrieved July 5, 2022 from www.cms.gov . 4. MCG.MCG Guidelines. 26th edition (2022). A-0487 (AC). Lower Limb Prosthesis. Retrieved July 5, 2022 from www.careweb.careguidelines.com . 5. Optum 360. EncoderProc.om for Payers Professional. (2005, January 1). HCPCS Code Detail L5856-L5859. Retrieved July 5, 2022 from www.encoderprofp.com .B. State-Specific Information A. Georgia 1. Effective: 11/01/2022 B. Indiana 4. Effectiv e: 11/01/2022 C. Kentucky 1. Effective: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effective: 11/01/2022
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