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.
ADMINISTRATIV E POLICY STATEMENTMarketplace Policy Name & Number Date Effective Cystic Fibrosis Carrier Testing-MP-AD-1219 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 utiliza tion 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 n ecessary 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 disco mfort. 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 define d 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. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Cystic Fibro sis Carrier Testin g-MP-AD-1219 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. SubjectCystic Fibrosis Carrier Testing B. BackgroundCystic fibrosis is a genetic disorder that causes the body to make thick, sticky secretions that clog the lungs and other organs , such as the digestive system. More than 10 million Americans are carriers of a def ective cystic f ibrosis gene and show no symptoms of the disease. Cystic f ibrosis is a recessive disorder . Therefore , an abnormal gene must be inherited f rom both parents f or the child to develop the disease. Carrier testing may provide an early indication as to whether a f etus might be a carrier or might have cystic f ibrosis . C. Def initions Carrier – An individual who exhibits a genetic change that can result in a disease or disorder. The carrier usually has no signs of the disorder but can pass the genetic variation on to his or her child who may become a carrier, not inherit the gene, or develop the dise ase. Autosomal Recessive – A trait or disorder requiring the presence of two copies of a gene mutation , one f rom each parent , at a particular locus in order to express an observable phenotype of the disorder. Prenatal Testing -Testing that is done prior to birth to identify changes in genes or chromosomes in embryos or f etuses to identify any potential genetic or chromosomal disorders . Prenatal Screening – A non-invasive process of analysis using blood to identif y the risk of a f etus having a chromosome abnormality or birth def ect . D. Policy I. Prior authorization is not required f or cystic f ibrosis genetic testing. Cystic f ibrosis testing should be performed once in a lif etime. II. Genetic counseling is strongly suggested at the time of testing f or the disorder and should be provided by a healthcare prof essional with knowledge, education , and training in the genetic issue relevant to this disorder. III. Carrier testing is appropriate f or an individual who is f emale and who is pregnant or of reproductive age with intent and potential to procreate and has consented to the test. IV. Carrier testing is appropriate f or an individual who is a f ather or prospective f ather and whose partner tests positive while pregnant or intending to become pregnant.V. Carrier testing is appropriate f or an individual with a f amily history of cystic f ibro sis.Cystic Fibro sis Carrier Testin g-MP-AD-1219 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.E. Conditions of CoverageN/A F. Related Policies/RulesGenetic Testing and Genetic Counseling G. Review/Revision HistoryDATE ACTIONDate Issued 07/20/2022Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 MarketPlace policies were combined into a single policy covering all applicable states. Addition of policy section D, IV and V. Editorial changes. Date Archived H. Ref erences1. American Society of Medical Genetics. Policy Statement: Cystic f ibrosis population carrier screening: 2004 revision of American College of Medical Genetics mutation panel. Retrieved June 20, 2022 f rom www.acmg.net 2. Committee on Genetics. Carrier screening for genetic conditions. March 2017. American College of Obstetricians and Gynecologists. Retrieved July 6, 2022 f rom www.acog.org. 3. Cystic Fibrosis Foundation Carrier Testing f or CF retrieved June 8, 2022 from www.cf f .org 4. Grody WW , Cutting GR, Klinger KW et al , and the American College of Medical Genetics Accreditation of Genetic Services Committee, Subcommittee on Cystic Fibrosis Screening. Laboratory Standards and Guidelines f or Population based Cystic Fibrosis Carrier Screening. American College of Medical Ge netics Policy Statements. Genetic Med. 2001;3(2):149-154. 5. Langf elder-Schwind E, Karczeski B, Strecker, MN, et al. Molecular Testing f or Cystic Fibrosis Carrier Status Practice Guidelines. National Society of Genetic Counselors . 2014. Retrieved June 20, 20 22 f rom www.onlinelibrary.wiley.com . 6. MCG Health Guidelines (26 th Ed., 2022). Cystic fibrosis CFTR gene and mutation panel. Retrieved f rom www.careweb.careguidelines.com on July 5, 2022 . I. State-Specif ic Inf ormationA. Georgia 1. Ef f ective: 11/01/2022 B. Indiana 1. Ef f ective: 11/01/2022 C. Kentucky 1. Ef f ective: 11/01/2022 D. Ohio 1. Ef f ective: 12/ 01/2022 E. West Virginia 1. Ef f ective: 11/01/2022
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Gender Affirming Surgery-OH MCD-MM-0034 11/01/2022 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 assessmen t 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 o r 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 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 Cover age 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 t o 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 Statement and the plan contract (i.e., Evidence of Coverage), then the pla n contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions Of Coverage ………………………….. ………………………….. ………………………….. … 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. .. 7 H. References ………………………….. ………………………….. ………………………….. …………………. 7 Gender AffirmingSurgery-OH MCD-MM-0034Effective Dat e: 11/01/2022 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.A. SubjectGender Affirming Surgery B. BackgroundIndividuals with gender dysphoria have persistent feelings of gender discomfort and inappropriateness for assigned natal anatomical sex, strong and ongoing cross-gender identification, and a desire to live and be accepted as a member of the opposite sex. The Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5, 2013)removed the t itle Gender Identity Disorder and established the category of GenderDysphoria to reflect that gender dysphoria is no longer considered a sexual dysfunction. Clinically significant distress or impairment in social, occupational, or other important area s of functioning, in addition to the symptoms noted i n DSM-5, is required to diagnose gender dysphoria. Gender nonconformity is not considered a psychiatric disorder. There are typically three approaches utilized to alleviate or reduce the symptoms of gender dysphoria , including psychotherapy, hormonal the rapy, and gender affirmingsurgery. Not all individuals with gender dysphoria elect all these approaches but may choose one or a combination of approaches. C. Definitions Behavioral Health Provider – A provider of behavioral health services, including a psyc hologist, psychiatrist, or psychiatric nurse practitioner. Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition (DSM-5) – The standard language by which clinicians, researchers, and public health officials in the United States communicate about mental disorders and subsequent criteria and classification. Female-to-Male ( FtM or transmasculine ) – An adjective describing an individual born or assigned female at birth (natal female) changing or changed to a more masculine body or gender role. Gender Affirming Surgeon – Board-certified urologist, gynecologist, plastic surgeon , or general surgeon competent in urological diagnosis and treatment of transgender individuals. Gender Affirming Surger y-Surgery to change primary and/or secondary sex characteristics to affirm gender identity, also referred to as intersex surgery, transgender surgery, and gender confirmation surgery in the literature and includes “top” surgery, such as mastectomy, and ” genital” or “bottom” surgery, such as hysterectomy, oophorectomy, vaginectomy, metoidioplasty, and phalloplasty. Gender Dysphoria – An individuals affective and/or cognitive discontent or distress that may accompany the incongruence between ones experien ced or expressed gender and ones assigned gender, lasting at least six (6) months and meeting diagnostic criteria listed in the DSM 5. Gender Identity – A category of social identity referring to an individuals identification as male, female, neither, or a combination of male and female and may be different from an individuals sex assigned at birth. Male-to-Female ( MtF or transfeminine ) – An adjective describing an individual born or assigned male at birth (natal male) changing or changed to a more feminine body or gender role. Gender AffirmingSurgery-OH MCD-MM-0034Effective Dat e: 11/01/2022 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved. Non-Binary/Gender Queer – An adjective used to describe an individual who identifies as neither exclusively male nor female but different from gender assigned at birth, in cluding changing to either a more masculinized or feminized gender role. Sex – Usually based on the appearance of external genitalia and defined as male or female as understood in the context of reproductive capacity, such as sex hormones, chromosomes, gon ads and non-ambiguous external and internal genitalia. At times, sex is assigned when external genitalia are ambiguous. Transgender (trans) – An umbrella term for persons whose gender identity, gender expression or behavior does not conform to that typical ly associated with the sex to which they were assigned at birth. D. PolicyIt is the policy of CareSource to comply with state and federal regulations. CareSource treats all members consistent with his/her gender identity and does not deny or limit health services that ordinarily or exclusively are available to individuals of one sex to a transgender individual because the individuals sex or gender is different from the one to which health services are nor mally or exclusively available . CareSource covers those services that are medically necessary. In determining services that are medically necessary, or the coverage of health services related to gender transition, CareSource utilizes neutral standards supported by evidence-based criteria. Members under the age of twenty-one ( 21 ) years will be reviewed for medical necessityas required by the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. In general, CareSource considers hormonal treatment for members medically necessary . Refer to pharmacy policy Gender-Affirming Hormone Therapy Pharmacy Policy. Due to the virtual nonexistence of research in these populations, particularly regarding long-term outcomes, safety data, and Un ited States Institutional Review Board oversight, CareSource reviews the literature and policies annually and when new literature becomes available. Notwithstanding the foregoing, CareSource reviews each request on a case-by-case basis in accordance with m edical necessity policies, as well as federal and state regulations for sterilization. I. CareSource considers gender affirming surgeries medically necessary when ALL thefollowing clinical criteria are met:A. For breast /top surgery : Mastectomy for female to male surgery does not require a hormone trial. Breast augmentation for male-to female surgery requires all the following :1. Unless there is a well-documented contraindication or refusal to take hormones, a t least twelve (12) months of continuous hormone treatment is required to be considered for surgery. a. Hormone trial must be with a medication prescribed to the member. b. Hormones must be managed by a healthcare provider (e.g., a n endocrinologist , primary care provider or experienced prescriber working in a center/clinic specializing in the treatment of gender affirming care ). Evidence of lab monitoring of hormone levels must be provided. 2. One letter of recommendation from a behavior al health provider to the surgeon is required. The behavioral health provider must communicate willingness to be available to treat the member during transition or make appropriate referral if member needs assistance with behavioral health treatment. Gender AffirmingSurgery-OH MCD-MM-0034Effective Dat e: 11/01/2022 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.a. The behavioral health provider has evaluated the member within the past twelve months of the time of referral . 01. If member has been in behavioral health treatment, it is preferred that the recommendation is made by the treating behavioral health provider. 02. If there is not a treating behavioral health provider, a letter of recommendation may be made by a consul ting behavioral health provider. 03. If the behavioral health provider is a member of a treatment team with the surgeon, documentation in the integrated clinical record is an option in lieu of a letter. b. Content of the behavioral health provider referr al letter must address all the following: 01. Member has a gender dysphoria diagnosis persistent for six (6) months or longe r at the time of the medical necessity review request. 02. A member-specific treatment plan to address gender affirming treatment , including hormonal treatment and/or surgery, as well as behavioral health during this transition period . 03. Member has capacity to and did give informed consent for surgery , as well as understanding that surgery may not achieve the desired results . 04. Member is age 18 years or older . 05. If co-existing mental illness and/or substance related disorder are present, it is relatively well controlled, and there ha s been no active intravenous drug use with no recent suicide attempts or behaviors . 06. The degr ee to which the member has followed the standards of care to date and the likelihood of future compliance . 3. Surgeon documentation requirements include all the following: a. Results of medical and psychological assessment , including diagnosis (- es) and identifying characteristics . b. Surgery plan. c. Documentation of informed consent discussion , including: 01. Notation of discussion of risks, benefits , and alternatives to treatment , including no hormonal or surgical tre atment , and member understand ing that surgery may not resolve gender dysphoria. 02. Medical stability for surgery and anesthesia. 03. Expected outcome(s). B. For genital /bottom surgery:1. At least twelve (12) months of continuous hormone treatment is required to be considered for surgery , unless there is a well-documented contraindication or refusal to take hormones. a. A hormone trial must be with a medication prescribed by a provider. b. Hormones must be managed by a healthcare provider (e.g., an endocrinologist, primary care provider or experienced prescriber working in a center/clinic specializing in the treatment of gender affirming care). Evidence of lab monitoring of hormone levels must be provided. 2. Hair removal may be approved based on medical necessity when skin flap area contains hair needing to be removed. Gender AffirmingSurgery-OH MCD-MM-0034Effective Dat e: 11/01/2022 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3. Two letters of recommendation from separate behavior health providers to the surgeon are required. One of the letters provided should be by a psychologist or psychiatrist , or psychiatric nurse practitioner , and one provider must communicate willingness to be available to treat the member during transition or make appropriate referral if member needs assistance with behavi oral health treatment. a. The behavioral health provider has evaluated the member within the past twelve months of the time of referral. 01. If member has been in treatment, it is preferred that one of the recommendations is made by the treating behaviora l health provider. 02. If there is not a treating behavioral health provider, one letter of recommendation needs to be made from a psychologist or psychiatrist , or psychiatric nurse practitioner . 03. If the behavioral health provider is a member of a treat ment team with the surgeon, documentation in the integrated clinical record is an option in lieu of a letter. b. Content of referral must address all the following: 01. Duration of evaluators relationship with the member. 02. Member has a gender dysphori a diagnosis persistent for six (6) months or longer at the time of the medical necessity review request. 03. Member has capacity to and did give informed consent for surgery. 04. A member specific treatment plan to address gender affirming treatment, incl uding hormonal treatment and/or surgery, as well as behavioral health during this transition period. 05. Member is age 18 years or older. 06. Member has had a twelve (12) month or longer real-life experience congruent with their gender identity. This time line may be modified with corroborating documentation indicating a safety concern. 07. If co-existing mental illness and/or substance related disorder are present, it is relatively well controlled, and there has been no active intravenous drug use with no recent suicide attempts or behaviors . 08 . The degree to which the member has followed the standards of care to date and the likelihood of future compliance . 4. Surgeon documentation requirements include all the following: a. Results of medical and psychological assessment, including diagnosis ( – es) and identifying characteristics. b. Surgery plan. c. Documentation o f informed consent discussion , including: 01. Notation of discussion of risks, benefits , and alternatives to treatment , including no treatment , and member understand ing that surgery may not resolve gender dysphoria. 02. Hair removal. 03. Medical stability for surgery and anesthesia. 04. Expected outcome(s). II. The following items are not covered :Procedures or surgeries to enhance secondary sex characteristics are considered cosmetic and are not medically necessary. A list of services, procedures or surgeries not covered is included below . T his list may not be all inclusive. Gender AffirmingSurgery-OH MCD-MM-0034Effective Dat e: 11/01/2022 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.1. Reversal of genital surgery or reversal of surgery to revise secondary sex characteristics2. Abdominoplasty 3. Blepharoplasty 4. Brow lift 5. Body contouring 6. Botox treatments 7. Calf , cheek, chin, malar, pectoral and/or nose implants 8. Collagen injections 9. Drugs for hair loss or hair growth 10. Face lifts 11. Facial bone reduction or facial feminization 12. Perineal skin hair removal 13. Hair removal for vaginoplasty without creation of neovagina or when genital surgery is not yet required or not approved 14. Hair replacement 15. Lip enhancement or reduction 16. Liposuction 17 . Mastopexy 18 . Neck tightening 19 . Plastic surgery on eyes 20. Reduction thyroid chondroplasty 21 . Rhinoplasty 22. Skin resurfacing 23. Voice modification surgery (laryngoplasty or shortening of the vocal cords) , voice therapy or voice lessons 24 . Any other surgeries or procedures deemed not medically necessary 25 . Reproduction services including but not limited to sperm preservation, oocyte preservation, cryopreservation of embryos, surrogate parenting, donor eggs and donor sperm and host uterus. III. CareSource treats all members consistent with gender identity and does not deny or limit health services that ordinarily or exclusively are available to individuals of one sex to a transgender individual because the individuals sex or gender is different from the one to which health services are normally or exclusively available. Examples of such services include: A. Breast cancer screening for transgender men and nonbinary people who were assigned female at birth . B. Prostate cancer screening for transg ender women and nonbinary people who were assigned male at birth . E. Conditions Of CoverageNA F. Related Policies/RulesMedical Necessity Determinations Gender AffirmingSurgery-OH MCD-MM-0034Effective Dat e: 11/01/2022 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.G. Review/Revision HistoryDates Action Date issued 05/18/2017 Date Revised 05/29/2019 09/02/202007/07/202105/19/2022 Updated evidence, changed policy number (MM-0080), removed pharmacy portions, added additional requirements for surgery, added specifics on hair removal, items not covered and types of surgery for medical necessary review . Updated definitions, removed research and put in references, removed codes, updated references, changed letter recommendation requirement, and changed title. Removed endocrinologist rule, added psychiatric NP, added safety considerations . Annual review. Updated and added definitions. Added primary care provider to hormone therapy requirement. Removed conception counseling as requirement for bottom surgery. Removed breast augmentation from the exclusion list. Date Effectiv e 11/01/2022 Date Archived H. References1. Adelson, S. (2012, September) Practice Parameter on Gay, Lesbian, or Bisexual Sexual Orientation, Gender Nonconformity, and Gender Discordance in Children and Adolescents Adelson, Stewart L. Journal of the American Academy of Child & Adolescent Psychiatry, 51(9), 957 974. 10.1016/j.jaac.2012.07.004 . 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington , VA, American Psychiatric Association, 2013. 3. American Psychological Association (2015, December), Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. American Psychologist. 70(9), 832-864. http://dx.doi.org/10.1037/a0039906 . 4. Centers for Medicare & Medicaid (CMS). Decision Memo for Gender Dysphoria and Gender Reassignment Surgery (CAG 00446N). (2016, August 30). Retrieved July 28, 2022 from www.cms.gov . 5. Ferrando, C., Zhao, L, & Nikolavsky, D. (2021, March). Transgender surgery: Female to male. Retrieved July 28, 2022 from www.uptodate.com . 6. Hembree, W, Cohen-Kettenis, PT-Sjoen, G. (2017, November). Endocrine Treatment of Gender-Dyshporic/Gender-Incongruent Persons: An Endocrine Society Clini cal Practice Guideline. The Journal of clinical Endocrinology & Metabolism. 102(11), 3869-3903. https://doi.org/10.1210/jc.2017-01658 . 7. Safer, J & Tangpricha, V. (2020, April). Transgender men: Evaluation and management. Retrieved July 28, 2022 from www.upt odate.com . 8. Safer, J. & Tangpricha, V. (2020, April). Transgender women: Evaluation and management. Retrieved July 28, 2022 from www.uptodate.com . 9. Sex Reassignment Surgery for the Treatment of Gender Dysphoria. (2019, August). Retrieved July 28, 2022 from w ww.hayesinc.com Adelson, S. (2012, September) Practice Parameter on Gay, Lesbian, or Bisexual Sexual Orientation, Gender Nonconformity, and Gender Discordance in Children and Adolescents Adelson, Stewart L. Journal of the American Academy of Child & Adoles cent Psychiatry , 51(9), 957 974. 10.1016/j.jaac.2012.07.004 . 10. Thomas, T. & Ferrando, C. (2020, April). Transgender surgery: Male to female. Retrieved July 28, 2022 from www.uptodate.com . Gender AffirmingSurgery-OH MCD-MM-0034Effective Dat e: 11/01/2022 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.11. United States of America Department of Defense. (2018, February). Department of Defense Report and Recommendations on Military Ser vice by Transgender PersonsRetrieved July 28, 2022 from https://partner-mcoarchive.s3.amazonaws.com . 12. United States of America Department of Defense. (2020, September 4). Military Service by Transgender Persons and Persons with Gender Dysphoria: An Impleme ntation Handbook. Retrieved July 28 , 2022 from www.prhone.defense.gov . 13. World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [7th Version]. Retrieved July 28, 2022 from www.wpath.org. 14. Zhang, W. R., Garrett, G. L., Arron, S. T., & Garcia, M. M. (2016). Laser hair removal for genital gender affirming surgery. Translational Andrology and Urology, 5(3), 381 – 387. doi:10.21037/tau.2016.03.27 Independent med ical review 10/2015
ADMINISTRATIVE POLICY STATEMENT Ohio MyCare Policy Name & Number Date Effective Hospice Services OH-MyCare-AD-1130 12/01/2022Policy TypeADMINISTRATIVE 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. Ple ase 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. 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 Hospice Services OH-M yCare-AD-1 130 Effective Date: 12/01/2022 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.A. SubjectHospice Services B.Background Hospice services are provided to individuals who are terminally ill and at the end of life.These services are intended to provide comfort or palliative care. Hospice care is a ty pe of care that focuses on the palliation of a terminally ill patient's pain and symptomsand at tending to their emotional and spiritual needs. Hospice care has a palliative focus without curative intent. Usually, it is used for patients with no further options for curi ng di sease or who have decided not to pursue further options that are arduous, likely t o c ause more symptoms, and unlikely to succeed . C. Definitions Hospice Care Program-a coordinated program of home, outpatient, and inpatient care and services that is operated by a person or public agency and that provides the following care and services to hospice patients and to hospice patients' families,through a medically directed interdisciplinary team:o Nursing care by or under the supervision of a registered nurse o Physical, occupational, or speech or language therapy, unless waived by t he depar tment of health o Medical social services by a social worker under the direction of a physician o Services of a home health aide o Medical supplies, including drugs and biologicals, and the use of medical appliances o Physician's services o Short-term inpatient care, including both palliative and respite care andpr ocedures o Counseling for hospice patients and hospice patients' families o Services of volunteers under the direction of the provider of the hospice car e pr ogram o Bereavement services for hospice patients' families .These services are provided under interdisciplinary plans of care establis hed pur suant to section 3712.06 of the Revised Code, in order to meet the physical,psychological, social, spiritual, emotional, and other special needs that are experienced during the final stages of illness, dying, and bereavement.Hospice Patient-a patient, other than a pediatric respite care patient, who has been diagnosed with a terminal illness, has a life expectancy of six months or less,and has voluntarily requested and is receiving care from a person or public agency licensed under Ohio law to provide a hospice care program.Palliative Care-specialized care for a patient of any age who has been diagnos ed wit h a serious or life-threatening illness that is provided at any stage of the illness by an interdisciplinary team working in consultation with other health care professionals,including those who may be seeking to cure the illness, and that aims to do all of the following : oR elieve the symptoms, stress, and suffering resulting from the illness Hospice Services OH-M yCare-AD-1 130 Effective Date: 12/01/2022 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.o Improve the quality of life of the patient and the patient's family o Address the patient's physical, emotional, social, and spiritual needs o Facilitate patient autonomy, access to information, and medical decision making. Pediatric Hospice Care-a program operated by a person or public agency that p rovides inpatient respite care and related services to pediatric respite care patients,and pediatric respite care patients' families to meet the physical, psychological,social, spiritual, and other special needs that are experienced during or leading up t o the final stages of illness, dying, and bereavement .T erminal Illness-a qualifying condition for which a prospective patient has received a diagnosis for a life expectancy of six months or less if the illness runs its normal course. D. Policy I. CareSource considers hospice services a covered service with the followi ng r equirements:A. Election of hospice benefits form must be signed by the CareSource member and submitted.B. Provider must produce and submit a Certificate of Terminal Illness form.C. CareS ource may request documentation to support medical necessity.Appropriate and complete documentation must be presented upon CareSourc e r equest to validate medical necessity.D. Criteria for determination of terminal illness:1.Hospice care is provided for two ninety-day periods followed by increments of sixty-day periods, as recertifications occur.2. Patient must have a qualifying condition with a diagnosis of a life expectancy of six months or less if the illness runs its normal course.3. At the start of the firs t ninety-day benefit period, the patient must be certifi ed a s terminally ill.4. The patient must be recertified as terminally ill at the start of each benefit period following the first ninety-day period by the hospice physician.E. Short-term inpatient care may be provided in hospital, hospice inpatient unit, or a participating Skilled Nursing Facility or Nursing Facility on an intermittent, non-routine basis:1. For relief of the individual's caregivers, and/or2. General inpatient care for the purpose of respite, pain control and acute or chronic symptom management that cannot feasibly be provided in other settings.F. When an individual younger than age 21 elects to receive hospice care, it does not constitute a waiver of any rights of the individual to receive curative service s r elated to the treatment of a terminal condition.G. When an adult over the age of 21 elects to receive hospice care, he or sh e agr ees to waive Medicaid services provided to him or her for the cure and treatment of the terminal condition.H. Ohio law considers people who are 18 years of age or older capable of givi ng v alid, legally enforceable consent to receive hospice services. Hospice Services OH-M yCare-AD-1 130 Effective Date: 12/01/2022 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.II. Hospice care for under age 18 years requires the consent of a parent or guardi an unl ess certain exceptions exist as noted under Ohio law.II I. When the reason for discharge from hospice care is death, routine home car e pr ovided in an in-home visit by a registered nurse and/or a social worker during the last seven days of a patients life requires documentation of medical necessity.I V. Billing for Hospice ServicesA. Professional claims must be billed on a CMS 1500 (HCFA) form with t he f ollowing documentation:1. The name of the nursing facility where the services were delivered and2. The National Provider Identifier (NPI) of the service facility.3. Consistent with the current process set forth by the OAC, providers must submit claims as a single line with date of service span and units billed to match .B. Institutional claims must be billed on a UB04 form with the followi ng doc umentation:1. The name of the nursing facility where the services were delivered.2. If the hospice services are billed in a Health Care Isolation Center (HCIC)Room and Board, the claims must be billed using the HCIC revenue codes as provided in the Ohio Department of Medicaid guidance.C. Hospice providers that deliver any component of services via telehealth must add the GT modifier on those claims, in addition to the appropriate procedure code.V. For the administration of Hospice Services, CareSource follows the rules sets forth inChapter 5160-56, Medicaid Hospice Program in the Ohio Administrative Code (OAC)and Chapter 3712, Hospice Care in the Ohio Revised Code (ORC ). E.Conditions of Coverage N/A F.Related Policies/Rules N/A G.Review/Revision History DATES ACTION Date Issued 07/21/2021 New Policy Date Revised 08/17/2022 Updated references; no changes Date Effective 12/01/2022Date ArchivedH.References 1. Lawriter-OAC-5160-1-18. Telehealth (2020, November 15). Retrieved August 2,2022 from www.codes.ohio.gov. Hospice Services OH-M yCare-AD-1 130 Effective Date: 12/01/2022 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.2. Lawriter-OAC-5160-56-01 Hospice services; definitions . Retrieved August 2, 2022from www.codes.ohio.gov.3. Lawriter-OAC-5160-56-02 Hospice services; eligibility and election requirements.Retrieved August 2, 2022 from www.codes.ohio.gov.4. Lawriter-OAC-5160-56-03 Hospice services; discharge requirements . Retriev ed A ugust 2, 2022 from www.codes.ohio.gov.5. Lawriter-OAC-5160-56-04 Hospice services; provider requirements, Ret riev ed A ugust 2, 2022 from www.codes.ohio.gov.6. Lawriter-OAC-5160-56-05 Hospice services; covered services . Retrieved August2, 2022 from www.codes.ohio.gov.7. Lawriter-OAC-5160-56-06 Hospice services; reimbursement. Retrieved August 2,2022 from www. codes.ohio.gov .8. Lawriter-ORC-2317.54 Informed consent to surgical or medical procedure or course of procedures. Retrieved August 2, 2022 from www.codes.ohio.gov.9. Lawriter-ORC 2907.29 Hospital emergency services for victims of sexual offenses.Retriev ed August 2, 2022 from www.codes.ohio.gov.10. Lawriter-ORC 2919.121 Unlawful abortion upon minor. Retrieved August 2, 2022from www.codes.ohio.gov.11. Lawriter-ORC 3709.241 Minor may give consent for diagnosis or treatment of venereal disease. Retrieved August 2, 2022 from www.codes.ohio.gov.12. Lawriter-ORC-Chapter 3712 Hospice Care. Retrieved August 2, 2022 from www.codes.ohio.gov . 13. Law riter ORC-3719.012 Minor may give consent to diagnosis or treatment of condition caused by drug or alcohol abuse. Retrieved August 2, 2022 fro m w ww.codes.ohio.gov.14. Lawriter ORC-5122.04 Outpatient services for minors without knowledge or consent of parent or guardian. Retrieved July 21, 2022 from www.codes.ohio.gov.15. ODM. Telehealth Billing Guidelines for Dates of Service on or after 11/15/2020. Retrieved August 2, 2022 from www.medicaid.ohio.gov.
ADMINISTRATIVE POLICY STATEMENTOhio D-SNP Policy Name & Number Date Effective Benef its Coordination-OH D-SNP-AD-078 6 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 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 E vidence 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 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 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 2 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Ben efits Co o rd ination-OH D-SNP-AD-0786 Effective Dat e:12/01/2022 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. SubjectBenefits Coordination B. Background Ohio Medicare Dual Advantage, also known as Dual Eligible Special Needs Plan (D – SNP) , is a program designed f or members in Ohio who receive both Medicaid and Medicare benef its. CareSource administers the members Medicare benefits. This policy is developed to direct providers to the appropriate CareSource policies to f ollow f or the D-SNP p rogram. C. Def initions Dual-Eligible SNP (D-SNP) – A member has one health plan that administers their Medicare benef its and another health plan or FFS Medicaid that manages their Medicaid benef its . CareSource administers the members Medicare benefits. D. PolicyI. D-SNP members will f ollow the CareSource Ohio Medicare Dual Special Needs policies. E. Conditions of CoverageNonmedical community supports and services (NCSS) are available under f ederal authority in sections 1905, 1915(c), and/or 1915(i) and included in the PASSE program created under Arkansas Act 775. NCSS are provided with the intention to prevent or delay en try into an institutional setting or to assist or prepare an individual to leave an institutional setting . T he service should assist the individual to live saf ely and successf ully in his/her own home or in the community. NCSS must be rooted in specif ic me mber needs f ound identified through the Independent Assessment leading to placement in the PASSE and included within an individually created Person-Centered Service Plan (PCSP). NCSS should be reviewed and updated regularly through the care coordination a nd PCSP process. NCSS are not medical in nature but instead support pursuit of saf e i ndependent living and member goals clearly established in the members PCSP. F. Related Policies/RulesN/A G. Review/Revision HistoryDATES ACTIONDate Issued 02/05/2020Date Revised 10/14/2020 Title changed f rom Coordination of Benefits; Updated plan name; Updated hierarchy to match www.caresource.com 7/20/2022 Annual Review. Ref erences updated.Date Effective 12/ 01/2022Ben efits Co o rd ination-OH D-SNP-AD-0786 Effective Dat e:12/01/2022 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.Date ArchivedH. Ref erences 1. Centers f or Medicare and Medicaid Services . (December 1, 2021 ). Dual Eligible Special Needs Plans (D-SNPs) . Retrieved July 1, 2022 f rom www.cms.gov 2. Medicare.gov . (n.d.) How Medicare Special Needs Plans (SNPs) work. Retrieved July 1, 2022 f rom www.medicare.gov
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 STATEMENTOhio MyCare Policy Name & Number Date Effective Benef its Coordination-OH MYCARE-AD-0785 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 asses sment 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 diagnosi s 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 mee t 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 Cove rage 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 r efer 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 Cove rage), 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 behavio ral 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 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 2 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 I. Appendix A…3 Ben efits Co o rd ination-OH MYCARE-AD-0785 Effective Dat e:12/01/2022 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. SubjectBenefits Coordination B. Background Ohio MyCare is a program designed f or members in Ohio who receive both Medicaid and Medicare benef its. During enrollment, eligible members have two choices f or how to receive their MyCare benefits: Members can choose e ither dual-benefits or Medicaid – only ben ef its. The primary advantage of dual-benefits f rom one health plan is to have coordinated services with a single point of contact. C. Def initions Dual-benefits (Opt in) – A member who has the same health plan administer both their Medicaid and Medicare benef its. Medicaid-only benefits (Opt out) – A member who has one health plan administer their Medicaid benef its in conjunction with the ir traditional Medicare plan or priv ate insurance company. Eligible members – o Are age 18 years or older; o Live in one of the 29 demonstration counties; and o Currently have f ull Medicaid and Medicare parts A, B, and D. D. Policy I. CareSource will f ollow the hierarchy specified in Appendix A below f or dual-benefit members. II. Medicaid-only members will f ollow CareSource Ohio Medicaid policies.E. Conditions of CoverageN/A F. Related Policies/Rules Medical Necessity Determinatio n G. Review/Revision History DATES ACTIONDate Issued 02/05/2020Date Revised 10/14/2020 Title change f rom Coordination of Benefits; updated hierarchy to match www.caresource.com 07/20/2022 Annual review. OH MYCARE hierarchy updatedDate Effective 12/ 01/2022Date Archived Ben efits Co o rd ination-OH MYCARE-AD-0785 Effective Dat e:12/01/2022 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.H. Ref erences1. Ohio Department of Medicaid . MyCare-Ohio . (May 20 2021 ). Retrieved July 1, 2022 f rom www.medicaid.ohio.gov 2. Ohio Department of Medicaid. ( 2022 ). MyCare Ohio FAQ. Retrieved July 1, 2022 f rom www.ohiomh.com 3. Ohio Laws and Administrative Rules. (January 1, 2021). Rule 5160-20-01 | Coordinated services program . Retrieved July 1, 2022 from www.codes.ohio.gov I. Appendix A
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Cystic Fibrosis Carrier Testing-OH MCD-AD-0837 12/25/2030 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. T hese services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in t he Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treat ment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Cystic Fibro sis Carrier Testin g-OH MCD-AD-0837 Effective Dat e: 12/ 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. SubjectCystic Fibrosis Carrier Testing B. Background Cystic fibrosis is a genetic disorder that causes the body to make thick, sticky secretions that clog the lungs and other organs , such as the digestive system. More than 10 million Americans are carriers of a def ective cystic f ibrosis gene and show no symptoms of the disease. Cystic f ibrosis is a recessive disorder . Therefore , an ab normal gene must be inherited f rom both parents f or the child to develop the disease. Carrier testing may provide an early indication as to whether a f etus might be a carrier or might have cystic f ibrosis. C. Def initions Carrier – An individual who exhibits a genetic change that can result in a disease or disorder. The carrier usually has no signs of the disorder but can pass the genetic variation on to his or her child, who may become a carrier, not inherit the g ene, or develop the disease. Autosomal Recessive – A trait or disorder requiring the presence of two copies of a gene mutation , one f rom each parent , at a particular locus in order to express an observable phenotype of the disorder. Prenatal Testing – Testing that is done prior to birth, to identify changes in genes or chromosomes in embryos or f etuses to identify any potential genetic or chromosomal disorders . Prenatal Screening – A non-invasive process of analysis using blood to identif y the risk of a f etus having a chromosome abnormality or birth def ect. D. Policy I. Prior authorization is not required f or cystic fibrosis genetic testing. Cystic f ibrosis testing should be performed once in a lif etime. II. Genetic counseling is strongly s uggested at the time of testing f or the disorder.Counseli ng should be provided by a healthcare prof essional with knowledge, education , and training in the genetic issue relevant to this disorder. III. Carrier testing is appropriate f or an individual who is f emale and pregnant or of reproductive age with intent and potential to procreate and has consented to the test. IV. Carrier testing is appropriate f or an individual who is a f ather or prospective f ather and whose partner tests positive while pregnant or intending to become pregnant.V. Carrier testing is appropriate f or an individual with a f amily history of cystic f ibrosis.E. Conditions of CoverageN/A Cystic Fibro sis Carrier Testin g-OH MCD-AD-0837 Effective Dat e: 12/ 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.F. Related Policies/RulesGenetic Testing and Genetic Counseling Review/Revision History DATES ACTIONDate IssuedDate Revised 07/2 0/2022 Addition of Section , DIV and V. Date Effective 12/ 01/2022 Date Archived G. Ref erences 1. American Society of Medical Genetics. Policy Statement: Cystic f ibrosis population carrier screening: 2004 revision of American College of Medical Genetics mutation panel. Retrieved June 20, 2022 f rom www.acmg.net . 2. Committee on Genetics. Carrier screening for genetic conditions. March 2017. American College of Obstetricians and Gynecologists. Retrieved July 6, 2022 f rom www.acog.org. 3. Cystic Fibrosis Foundation Carrier Testing f or CF . Retrieved June 20, 2022 f rom www.cf f .org . 4. Grody WW, Cutting GR, Klinger KW, et al and the American College of Medical Genetics Accreditation of Genetic Services Committee, Subcommittee on Cystic Fibrosis Screening. Laboratory Standards and Guide lines f or Population based Cystic Fibrosis Carrier Screening. American College of Medical Genetics Policy Statements. Genetic Med. 2001; 3(2):149-154. 5. Langf elder-Schwind, E., Karczeski, B., Strecker, M.N., Redman, J., Sugarman, E.A., Zaleski, C., Darrah, R (2014) Molecular Testing for Cystic Fibrosis Carrier Status Practice Guidelines: recommendations of the National Society f or Genetic Counselors . Retrieved June 20, 20 22 f rom www.onlinelibrary.wiley.com . 6. MCG Health Guidelines (26 th Ed., 2022). Cystic fibrosis CFTR gene and mutation panel. Retrieved f rom www.careweb.careguidelines.com on July 5, 2022. 7. Ohio Department of Medicaid. Medicaid f ee schedule: Laboratory Services. Retrieved June 21, 2022 from www. medicaid.ohio.gov .
El seguimiento hace la diferencia Ms de 20 millones de estadounidenses tienen problemas con el consumo de drogas y alcohol. Muchos terminan en la sala de emergencias (emergency room, ER) para recibir atencin mdica bsica o a causa de una sobredosis. Muchos nunca asisten a las visitas de seguimiento con su proveedor mdico principal (primary medical provider, PMP) o proveedor de salud conductual. Estamos aqu para usted! Servicios para Aliados 1-844-607-2829 (1-800-743-3333 or 711) de lunes a viernes, de 8:00a.m. a a 8:00p.m., hora estndar del Este Lnea directa para adicciones de CareSource 1-833-674-6437, las 24 horas del da, los siete das de la semanaControle su recuperacin No importa cul sea su tratamiento. Lo que importa es que tome medidas para mantenerse conectado. El tratamiento funciona. Aunque puede llevar tiempo, la recuperacin es posible. Una opcin es el tratamiento asistido con medicamentos (Medication Assisted Treatment, MAT). El MAT ayuda a las personas a reducir rpidamente sus impulsos de consumo de drogas y alcohol y la dependencia. Los tratamientos como el MAT pueden ayudarle a encaminarse hacia la mejora de la salud y el bienestar. Dispone de ayuda si la necesita En CareSource, nos preocupamos por usted. Podemos ayudarle a que visite a su PMP o proveedor de salud conductual en un plazo de dos a siete das despus de su visita a la sala de emergencias. Conectarse con un proveedor puede ayudarle a mantenerse en el camino hacia una mejor salud. Tambin puede evitar futuras visitas a la sala de emergencias. Estas son algunas formas en las que tambin puede ayudarle: Revisar el plan que recibi cuando fue dado de alta de la sala de emergencias. Asegurarse de que tiene los formularios correctos para su cita de seguimiento. Ayudarle a conseguir transporte a su visita de seguimiento. Asegurarse de que tenga una segunda visita en un plazo de 30 das. Ayudarle a encontrar un proveedor de tratamiento local. Vincularlo con grupos de ayuda como Alcohlicos Annimos, Alanon, Alateen o Narcticos Annimos. Hablar y resolver pr oblemas que le impiden concentrarse en su salud (p. ej., empleo, vivienda, opciones de alimentacin saludable, etc.). Repasar cules son sus benecios de salud y la atencin cubierta. Ayudarle a registrarse en nuestros programas de recompensas. Ayudarle a dar los pasos iniciales en el programa de administracin de la atencin. Vincularlo con un orientador de par es para la recuperacin. RR2022-IN-MED-M-705600-SP; Primer uso: 11/15/2021 Aprobado por OMPP: 11/15/2021 2021 CareSource. Todos los derechos reservados.
Consentimiento del afiliado/Formulario de autorizacin de la Ley de Portabilidad y Responsabilidad de los Seguros Mdicos (HIPAA) Este formulario permite a CareSource Management Group Co. y sus planes mdicos afiliados (CareSourcePASSE) compartir su informacin mdica como se detalla a continuacin. Debe llenar este formulario por completo. Envelo por correo o por fax a la direccin que figura en la ltima parte de e ste formulario. Tambin puede llenar este formulario en lnea CareSourcePASSE.com . Seccin 1: Informacin del afiliadoApellido Inic. 2. nombre Nombre Fecha de nacimientoDireccin Ciudad Estado Cdigo postalTelfono particular Telfono celular Nmero de ID de afiliado a CareSource PASSEAl proporcionar su nmero de telfono celular, usted afirma que CareSource PASSE puede usarlo para comunicarse con usted. Seccin 2: Consentimiento para compartir la informacin mdicaMediante este formulario, usted da su consentimiento para compartir la informacin mdica con otros. Esta informacin se comparte para brindarle una mejor atencin y tratamiento o para ayudarlo con los beneficios. Es posible que su informacin mdica se comparta con los proveedores que le hayan brindado atencin en el pasado, en la actualidad o se la brinden en el futuro. Tambin es posible que se comparta con los Intercambios de informacin mdica (Health Information Exchanges, HIE). Los HIE permiten que los proveedores consulten la informacin mdica que CareSource PASSE tiene acerca de los afiliados. Tambin puede compartir su informacin mdica en las aplicaciones de atencin mdica propias que utilice. Tiene derecho a solicitar una lista de todas las personas a las c uales CareSource PASSE les proporcion su informacin mdica. Marque esta casilla si desea que su informacin mdica se comparta con cualquiera de los proveedores que haya tenido en el pasado, tenga actualmente o en el futuro, o en las aplicaciones de ate ncin mdicapersonales. La informacin se compartir para brindarle tratamiento, administrar su atencin o ayudarlo con los beneficios. Incluye informacin mdica sensible, como el tratamiento por abuso de sustancias y por VIH/SIDA. Tiene mayor control so bre la informacin que se comparte en las aplicaciones de atencin mdica personales. Obien Marque esta casilla si no desea que su informacin mdica se comparta con cualquiera de los proveedores que haya tenido en el pasado, que tenga actualmente o en el futuro. Esta informacin no se compartir para brindarle tratamiento, administrar su atencin o para ayudarlo con los beneficios. Nada de su informacin mdica se compartir con sus proveedores, salvo estas excepciones: Es posible que su proveedor de atencin primaria (Primary Care Provider, PCP) reciba un informe que incluye informacin sobre el tratamiento de salud fsica y conductual que pueda haber recibido. No incluir informacin sobre el abuso de sustancias o sobre VIH/SIDA, a menos que usted marque la casilla de arriba diciendo que desea compartir su informacin mdica. Es posible que su informacin mdica se comparta con un HIE. No incluir informacin sobre el abuso de sustancias o sobre VIH/SIDA, a menos que usted marque la casilla de arriba diciendo que desea compartir su informacin mdica. Si no autoriza que se comparta la informacin, sus proveedores no podrn administrar su atencin tan bien como lo haran si usted autorizara que se comparta.Seccin 3: Designacin del representanteSi desea designar a una persona para que se comunique con CareSource PASSE en su nombre, llene esta seccin. CareSource PASSE compartir toda su informacin mdica con la persona que haya designado. Si designa a un grupo, como un bufete de abogados, ese gr upo se conoce como entidad. Proporcione los datos de la entidad y el nombre de una persona de contacto que forme parte de la entidad. Apellido del representante Inic. 2. nombre Nombre del representanteNombre de la entidad (si es un bufete de abogad os u otra entidad)Direccin del representante Ciudad Estado Cdigo postalTelfono particular del representante Telfono celular del representanteSeccin 4: Revisin y aprobacinAl firmar, acepto lo siguiente: Permitir que CareSource PASSE comparta mi informacin mdica como se detall en la Seccin 2 y/o 3. Firmar este formulario es mi propia eleccin. La informacin compartida se podr divulgar nuevamente por la persona o entidad que la recibe. Despus de eso, ya no estar protegida por la s leyes federales de privacidad. La informacin relativa al trastorno por abuso de sustancias de los programas de tratamiento especficos (Art. 42, Cdigo de Reglamentos Federales [Code of Federal Regulations, CFR], Parte 2) puede permanecer en estricta re serva y no volver a compartirse sin mi autorizacin. Este formulario no es un Poder notarial para la atencin mdica. Puedo cancelar mi autorizacin en cualquier momento. Para cancelar la autorizacin, debo enviar una carta por escrito a CareSource PASSE. Puedo enviar la carta a la direccin que figura en la parte inferior de este formulario. Tambin puedo enviarla por fax al nmero que figura en la parte inferior de este formulario. Es posible que cancele mi autorizacin en CareSourcePASSE.com . Si cancelo esta autorizacin, no habr ningn cambio en las acciones que CareSource PASSE haya llevado a cabo antes de la cancelacin de dicha autorizacin. Mi tratamiento, el pago de, la inscripcin o la elegibilidad para los beneficios no dependen de que firme este formulario. Firme a continuacin. Su firma (Firma del padre/de la madre/del tutor de un menor de edad o del representante legal designado) *Fecha:Fecha de terminacin de esta autorizacin:Si no se proporciona ninguna fecha, la autorizacin permanecer en nuestros registros, a menos/hasta queusted solicite que se cancele. En el caso de menores de edad, esta autorizacin terminar al cumplir los 18 aos.*Si la persona que firma no es el afiliado o el padre, la madre, el tutor de un afiliad o menor de edad, solo podr firmar en caso de ser el representante legal designado. Un representante legal designado es alguien a quien se ha otorgado la autoridad de actuar en nombre del afiliado. Si an no lo ha hecho, debe proporcionar una copia del Pod er notarial o los documentos del tribunal que demuestren que la persona es un representante legal designado. Tambin debe completar los siguientes campos: Representante legal (escriba el nombre completo con letra de imprenta)Relacin legal con el afiliado (Poder notarial, tutor designado por un tribunal o custodio) Direccin del representante legal Ciudad Estado Cdigo postalEnve su formulario completo a: CareSource PASSE Attn: Privacy Officer, P.O. Box 8738, Dayton, OH 45401-8738 o Enve un fax al 1-833-334-4722 o llene este formulario en lnea en CareSourcePASSE.com . 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