PO Box 723308, Atlanta, GA 31139-1308 | www.caresource.com Asunto: Resumen de los cambios a la PDL, con vigencia partir del 1 de octubre de 2022 Estimado(a) afiliado(a) a CareSource: Su atencin mdica es nuestra prioridad. Es por eso que le escribimos para informarle que el 1 de octubre de 2022, CareSource cambiar su lista de medicamentos preferidos (PDL). Una PDL es una lista de medicamentos preferidos. LOS SIGUIENTES MEDICAMENTOS SERN PREFERIDOS EN LA PDL A PARTIR DEL 1 DE OCTUBRE DE 2022. Nombre de marca Nombre genrico Dosis Notas Carbaglu cido carglmico 200 mg Se requiere autorizacin previa. No corresponde a atencin entre embarazos Insulin Lispro lapicera, vial Insulin Lispro 100 unidades/ml Insulin Lispro Jr Pen Insulin Lispro 100 unidades/ml Nocdurna Acetato de desmopresiona 27.7 mcg, 55.3 mcg Se requiere autorizacin previa. No corresponde a atencin entre embarazos Pyrukynd Sulfato de mitapivato 5 mg, 20 mg, 50 mg, 20-5 mg, 50-20 mg Se requiere autorizacin previa. No corresponde a atencin entre embarazos LOS SIGUIENTES MEDICAMENTOS SERN NO PREFERIDOS EN LA PDL A PARTIR DEL 1 DE OCTUBRE DE 2022. Nombre de marca Nombre genrico Dosis Notas Admelog Solostar, vial Insulin Lispro 100 unidades/ml Producto preferido: Insulin Lispro 100 unidades/ml lapicera, vial, o Jr. Pen Tecfidera Dimetil fumarato 120 mg, 240 mg El genrico es preferido con autorizacin previa. No cor responde a atencin entre embarazos Qu debe hacer? Primero, hable con su proveedor de atencin mdica. En caso de ser necesario, su proveedor puede enviar una autorizacin previa para un medicamento que se haya eliminado de la PDL si usted debe seguir usndolo debido a una necesidad mdica. Es posible que haya otros medicamentos en la PDL de CareSource que usted pueda usar en su lugar. Hay varias formas para que usted o la persona que se los receta puedan encontrar medicamentos: Puede consultar nuestro sitio web en www.caresource.com . En la pgina Afiliados, vaya a Herramientas y recursos y haga clic en Encontrar mis medicamentos con receta. Ollame a nuestro Departamento de Servicios para Afiliados al 1-855-202-0729 (TTY: 1-800-255-0056 o 711). Estamos aqu para ayudarle. El Departamento de Servicios para Afiliados de CareSource atiende de lunes a viernes, de 7:00 a. m. a 7:00 p. m. Atentamente, CareSource RX Innovations CareSource cumple con las leyes de derechos civiles estatales y federales pertinentes y no discrimina en funcin de la edad, el sexo, el gnero, la identidad de gnero, el color de piel, la raza, una discapacidad, la nacionalidad, el estado civil, la preferencia sexual, la creencia religiosa, el estado de salud o el estado de asistencia pblica. Si usted o alguien a quien ayuda tienen preguntas sobre CareSource, tiene derecho a recibir esta informacin y ayuda en su propio idioma sin costo. Para hablar con un intrprete, por favor, llame al nmero de Servicios para Afiliados que figura en su tarjeta de identificacin. GA-MMED-2705-V.18 Aprobado por DCH: 7/23/2019
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
ADMINISTRATIVE POLICY STATEMENT Marketplace Policy Name & Number Date Effective Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. This policy applies to the following Marketplace(s): Georgia b Indiana b Kentucky b Ohio b West Virginia Table of Contents A.Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 I. State-Specific Information ……………………………………………………………………………………… 5 Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 2 A.Subject Applied Behavior Analysis Therapy for Autism Spectrum Disorder B.Background Autism Spectrum Disorder (ASD) can vary widely in severity and symptoms dependi ng on t he developmental level and chronological age of the patient. ASD is often defined by specific impairments that affect socialization, communication, and stereoty ped ( repetitive) behavior. Children with autism spectrum disorders have pervasive clinically significant deficits which are present in early childhood in areas such as intellectual functioning, language, social communication and interactions, as well as restricted,repetitive patterns of behavior, interests and activities.Ther e is currently no cure for ASD, nor is there any one single treatment for the disorder.Individuals with ASD may be managed through a combination of therapies, includi ng behav ioral, cognitive, pharmacological, and educational interventions. The goal of treatment for members with ASD is to minimize the severity of ASD symptoms,maximize learning, facilitate social integration, and improve quality of life for both t he m embers and families and/or caregivers. C. Definitions Autism Spectrum Disorder – (ASD) Any of the following pervasive developmental disorders as defined by the most recent version of the Diagnostic and StatisticalManual of Mental Disorders (American Psychiatric Association): Autism; Asperger'sDisorder; or other condition that is specifically categorized as a pervasiv e dev elopmental disorder in the Manual . Applied Behavior Analysis – (ABA) A preventive service for ASD. Board Certified Assistant Behavior Analyst ( BCABA) A professional provider of applied behavioral analysis services who has obtained an undergraduate-leve l c ertification . BCBA-BACB certified behavior analyst graduate level. BCBA-D – BACB certified behavior analyst doctoral level. RBT-BACB Registered Behavioral Technician. Supervision-All supervisory activities as well as supervisor and supervis ee r esponsibilities will be in accordance with the board from which the practitioner received a license.o Services delivered by a RBT must be supervised by a qualified RBT supervisor. o Services delivered by a BCaBA must be supervised by a BCBA, BCBA-D or a l icensed/ registered psychologist certified by the American Board of ProfessionalPsychology in Behavioral and Cognitive Psychology who has tested in ABA. o A registered behavior technician (RBT), certified by the national behavior analyst certification board (BACB), may provide ABA under the supervision of an independent practitioner. In order to provide services, they have to enroll i n t he Marketplace program and affiliate with the organization under which they are employed or contracted. Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 3 RBT Supervision-Ongoing supervision must be at a minimum of 5% of the hours spent providing behavior-analytic services per month 1. This includes a minimum of 2 f ace-to-face contacts per month. D. Policy I. Medical necessity review is required for all ABA services:A. At b aseline, then again every 6 months thereafter or sooner if clinically necessary.B. Medical review documentation must be submitted with appropriate documentation as indicated in the medical policy.I I. A n ASD diagnosis is required in order for services to be reviewed for approval.III. Li mitationsA. A Medically Unlikely Edit (MUE) for a CPT code is the maximum units of servic e t hat a provider can report for one member on one date of service.1. Maximum units allowed per CPT: CPT Max unit allowed 97151 32 97152 16 97153 32 97154 18 97155 24 97156 16 97157 16 97158 16 0362T 16 0373T 32 N OTE: If CMS updates the MUE list ,which generally occurs on a quarterly basis, the update will take precedence over the MUEs in this policy . B . E ach RBT must obtain ongoing supervision for a minimum of 5% of the hours spent providing behavior-analytic services per month.C. The treatment codes are based on daily total units of service in 15-minute i ncrements. A unit of time is attained when the mid-point is passed.1. Ti me interval examples: Units Number of minutes 1 unit >8 minutes through 22 minutes 2 units >23 minutes through 37 minutes 3 units >38 minutes through 52 minutes 4 units >53 minutes through 67 minutes 1 www.bacb.com Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 4 5 units >68 minutes through 82 minutes 6 units >83 minutes through 97 minutes 7 units >98 minutes through 112 minutes 8 units >113 minutes through 127 minutes E.Conditions of Coverage Payments may be subject to limitations and/or qualifications and will be determi ned w hen the claim is received for processing. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers.Prog ram Integrity will be engaged for an annual review of data. F.Related Policies/Rules Applied Behavior Analysis for Autism Spectrum DisorderEvidence of Coverage and Health Insurance Contract G.Review/Revision History DATES ACTION Date Issued 11/29/2018 Date Revised 04/12/2019 01/27/2020 02/ 02/2021 08/ 31/2021 08/ 17/2022 Removed U3 & U5 modifiers Revised definitions, clarified PA requirements, added ASD diagnosis as primary, added specificity to reimbursement, updated limitations, added MUE, added time intervals, added specificity to concurrent billing Updated definitions, Removed transition ABA therapy, Removed codes. Changed from PY policy. Removed coding portions in policy . Updated MUE table: 97152 MUE went from 8 to 1697154 MUE went from 12 to 180362T MUE went from 8 to 16Added Program Integrity will be engaged for an annual review of data New composite MP template; updated references; no change to MUE table. Date Ef fective 11/01/2022 Date Archived H.References 1. American Medical Association. (2018). Coding Update: Reporting Adaptive BehaviorAssessment and Treatment Services in 2019. CPT Assistant, 28(11).2. Behavior Analyst Certification Board. (2018, October 8). Adaptive BehaviorAssessment and Treatment Code Conversion Table. Retrieved August 3, 2022 fro m w ww.bacb.com . Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 5 3.Behavior Analyst Certification Board. (2019, February). Clarifications Regardi ng A pplied Behavior Analysis Treatment of Autism Spectrum Disorder. (2nd ed.).Retrieved August 3, 2022 from www.bacb.com.4. The Council of Autism Service Providers. (2020). Applied Behavior AnalysisTreatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers. Retrieved on August 3, 2022 from www.caseproviders.org. I.State-S pecific InformationA. Georgia1. Effective: 11/01/2022B. Indiana1. Effective: 11/01/2022C. Kentucky1. Effective: 11/01/2022D. Ohio1. Effective: 12/01/2022E. Wes t Virginia1. Effective: 11/01/2022 Th e Administrative Policy Stateme nt det ailed a bove has r eceived due con side ration as defined in the Administrative Policy Stateme nt Po licy a nd is a pprove d.
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Chiropractic Care-MP-PY-1358 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as t he Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addi ction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy a pplies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 Chiropractic Care-MP-PY-1358Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectChiropractic Care B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guara ntee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processin g. Health care providers and office staff are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.C. Definitions Chiropractor A Doctor of Chiropractic who is duly licensed and qualified to provide chiropractic services. Chiropractic Therapy Therapy that focuses on the joints of the spine and the nervous system, while osteopathic therapy includes equal emphasis on the joints and surrounding muscles, tendons and ligaments. Manipulation Therapy Osteopathic/chiropractic therapy used for treating problems associated with bones, joints and the back. Medically Necessary/Medical Necessity Health care services that a provider would render to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is (i) in accordance with generally accepted standards of medical practice; and (ii) clinically appropriate in terms o f type, frequency, extent, and duration. D. PolicyI A covered chiropractic service that is legally performed will not be denied when such covered service is rendered by a n in-network licensed chiropractor in the state that the covered service is performed. II. All services are subject to members share of cost (deductible, co-insurance and/orco-pays). This varies based on the members plan enrolled at the time of service.III. When manipulation services are provided in addition to an evaluation andmanagement (E/M) office visit, modifier 25 should be appended to the E/M code.This distinguishes a significant , separately identifiable E/M office visit from the additional ma nipulation service. Chiropractic Care-MP-PY-1358Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.IV. Scope of practiceA. Chiropractors must follow their states scope of practice. Any training or certification required by the state must be available to Care Source, upon request . V. Chiropractic patients whose diagnosis is not within the chiropractic scope of practice, shall be referred , by the chiropract or, to a medical doctor or other licensed healthpractitioner for treatment of that condition.VI. Manipulation therapyA. Includes chiropractic manipulation therapy used for treating problems associated with bones, joints and the back. Chiropractors would be limited to subluxations of the articulations of the human spine and its adjacent tissue. B. Annual benefit limits apply. It is the providers responsibility to validate the available remaining quantity before rendering service. Manipula tions performed will be counted toward any maximum for manipulation therapy services as specified in the members Evidence of Coverage (EOC) or Schedule of Benefits regardless if: 1. Billed as the only procedure; or 2. Done in conjunction with an exam and billed as an office visit. C. The members plan does not provide benefits for manipulation therapy services provided in the home as part of Home Health Care Services. D. Modifier AT is required to be appended to any manipulation code. E. Claims should include a pr imary diagnosis of subluxation and a secondary diagnosis that reflects the patients neuromusculoskeletal condition. VII. All codes contained within this policy are not all inclusive but provide a general reference of covered codes based on what chiroprac tors are allowed to perform within their state. Codes contained within this policy that may or may not require a prior authorization should be confirmed by accessing the Provider Look-up Tool on the CareSource website (www.procedurelookup.caresource.com). VIII. The following are a list of c odes that may be covered and do not require a prior authorization: A. Evaluation and management (E/M) codes (99202-99204, 99211-99214) B. 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions C. 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions D. 98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions E. 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regio ns F. X-rays (radiologic examination (RE)) for diagnostic purposes: 1. 72020 RE, spine, single view, specify level 2. 72040 RE, spine, cervical; 2 or 3 views 3. 72050 RE, spine, cervical; 4 or 5 views 4. 72052 RE, spine, cervical; 6 or more views 5. 72070 RE, spin e; thoracic, 2 views 6. 72072 RE, spine; thoracic, 3 views 7. 72074 RE, spine; thoracic, minimum of 4 views 8. 72080 RE, spine; thoracolumbar junction, minimum of 2 views Chiropractic Care-MP-PY-1358Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.9. 72081 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spi ne if performed (e.g., scoliosis evaluation); one view 10. 72082 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 2 or 3 views 11. 72083 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 4 or 5 views 12. 72084 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); minimum of 6 views 13. 72100 RE, spine, lumbosacral; 2 or 3 views 14. 72110 RE, spine, lumbosacral; minimum of 4 views 15. 72114 RE, spine, lumbosacral; complete, including bending views, minimum of 6 views 16. 72120 RE, spine, lumbosacral; bending views only, 2 or 3 views 17. 72170 RE, pelvis; 1 or 2 views 18. 72190 RE, pelvis; complete, minimum of 3 views 19. 72200 RE, sacroiliac joints; less than 3 views 20. 72202 RE, sacroiliac joints; 3 or more views 21. 72220 RE, sacrum and coccyx, minimum of 2 views 22. 73000 RE; clavicle, complete 23. 73010 RE; scapula, complete 24. 73020 RE, shoulder; 1 view 25. 73030 RE, shoulder; complete, minimum of 2 views 26. 73050 RE; acromioclavicular joints, bilateral, with or without weighted distraction 27. 73501 RE, hip, unilateral, with pelvis when performed; 1 view 28. 73502 RE, hip, unilateral, with pelvis when performed; 2-3 views 29. 73503 RE, hip, unilateral, with pel vis when performed; minimum of 4 views 30. 73521 RE, hips, bilateral, with pelvis when performed; 2 views 31. 73522 RE, hips, bilateral, with pelvis when performed; 3-4 views 32. 73523 RE, hips, bilateral, with pelvis when performed; minimum of 5 views 33. 73551 RE, femur; 1 view 34. 73552 RE, femur; minimum 2 views IX. Codes that may be covered but require a prior authorization:A. 97 010 hot or cold packs B. 97012 traction C. 97014 electrical stimulation D. 97035 ultrasound E. 97139 unlisted therapeutic procedure F. 97140 manual therapy technique Chiropractic Care-MP-PY-1358Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.X. Exclusions/services not covered for Chiropractors:A. 20560 needle insertion(s) without injection(s); 1 or 2 muscle(s) -dry needling B. 20561 needle insertion(s) without injection(s); 3 or more muscles-dry n eedling 1. CareSource follows the Center for Medicare and Medicaid (CMS) analysis stating that acupuncture includes dry needling. 2. Acupuncture is not a covered benefit. E. Conditions of CoverageNA F. Related Policies/RulesModifier 25 Reimbursement policy G. Review/Revision HistoryDATE ACTIONDate Issued 08/03/2022 New policy. Replace s individual marketplace policies. Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Use of the AT modifier for Chiropractic Billing (May 7, 2019). Retrieved 07/25/2022 from www.cms.gov. 2. Department of Health and Human Services. Centers for Medicare & Medicai d Services. Local Coverage Determination (LCD L37254). Chiropractic Services (February 3,2022). Retrieved 0 7/25/2022 from www.cms.gov. 3. National Coverage Analysis for Acupuncture for Chronic Low Back Pain CAG – 00452N. January 21, 2020. Retrieved 0 7/25/2022 f rom www.cms.gov. 4. The Association of Chiropractic Colleges. (n.d.). Chiropractic Paradigm/Scope & Practice. Retrieved 0 7/25/2022 from www.chirocolleges.org. I. State-Specific Information A. Georgia 1. References a. 2020 Georgia Code. Title 43 – Professions and Business es. Chapter 9 Chiropractors. 43-9-1. Definitions. Retrieved 07/25/2022 from www.law.justia.com. b. 2020 Georgia Code. Title 43 – Professions and Businesses. Chapter 9 Chiropractors. 43-9-16. Scope of Practice; Injury From Want of Reasonable Degree of Care Is a Tort. Retrieved 07/25/2022 from www.law.justia.com. c. MARKETPLACE PLAN Georgia Evidence of C overage 2022. www.caresource.com/documents/marketplace-2022-ga-basic-eoc . Chiropractic Care-MP-PY-1358Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2. Effective: 11/01/2022B. Indiana 1. References a. 2020 Indiana Code. Title 25 ARTICLE 10. Chapter 1. Regulation of Chiropractors IC 25-10-1-1. Definitions. Retrieved 07/25/2022 from www.iga.in.gov . b. 2020 Indiana Code. Title 25 ARTICLE 10. Chapter 1. Regulation of Chiropractors IC 25-10-1-17. Authority to diagnose and treat injuries, conditions, and disorders. Retrieved 07/25/2022 from www.iga.in.g ov . c. MARKETPLACE PLAN Indiana Evidence of Coverage 2022. 2. Effective: 11/01/2022 C. Kentucky 1. References a. Kentucky Administrative Regulations. Title 907 | Chapter 003 | Regulation 125. 907 KAR 3:125. Chiropractic services and reimbursement. Retrieved 07/25/2022 f rom www.apps.legislature.ky.gov. b. MARKETPLACE PLAN Kentucky Evidence of Coverage 2022. www.caresource.com/documents/marketplace-2022-ky-basic-eoc . 2. Effective: 11/01/2022 D. Ohio 1. References a. Ohio Revised Code/Title 47 Occupations-Professions/Chapter 4734 Chiropractors. Section 4734.01 | Practice of chiropractic defined. Retrieved 07/25/2022 from www.codes.ohio.gov. b. Ohio Revised Code/Title 47 Occupations-Professions/Chapter 4734 Chiropractors. Section 4734.15 | Scope of practice of chiropractic. Retrieved 07/25/2022 from www.codes.ohio.gov. c. MARKETPLACE PLAN Ohio Evidence of Coverage 2022. www.caresource.com/documents/marketplace-2022-oh-basic-eoc . 2. Effective: 12/ 01/2022 E. West Virginia 1. References a. WEST VIRGINIA CODE CHAPTER 30. PROFESSIONS AND OCCUPATIONS. ARTICLE 16. CHIROPRACTORS. 30-16-18. Scope of practice; chiropractic assistants; expert testimony. Retrieved 07/25/2022 from www.code.wvlegislature.gov . b. WEST VIRGINIA CODE CHAPTER 30. PROFESSIONS AND OCCUPATIONS. ARTICLE 16. CHIROPRACTORS. 30-16-20. Use of physiotherapeutic devices; electrodiagnostic devices; specialty practice. Retrieved 07/25/2022 from www.code.wvlegislature.gov . c. MARKETPLACE PLAN West Virginia Evidence of Coverage 2022. www.car esource.com/documents/marketplace-2022-wv-basic-eoc/ 2. Effective: 11/01/2022
ADMINISTRATIVE POLICY STATEMENTIndiana D-SNP Policy Name & Number Date Effective Benef its Coordination-IN D-SNP-AD-0887 11/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 2F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 2G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 2 H. Review/Revision History ………………………….. ………………………….. ………………………….. … 2 I. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 2 Ben efits Co o rd ination-IN D-SNP-AD-0887 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.A. Subject Benefits Coordination B. Background Indiana Medicare Dual Advantage, also known as Dual Eligible Special Needs Plan (D – SNP), is a program designed f or members in Indiana who receive both Medicaid and Medicare benef its. Care Source administers the members Medicare benefits. The purpos e of this policy is to direct providers to the appropriate CareSource policies to f ollow f or the D-SNP program. C. Def initions Dual-Eligible Special Needs Plan (D-SNP) – A member who has one health plan that administers their Medicare benefits and another health plan or f ee f or service Medicaid that manages their Medicaid benef its . Caresource administers the members Medicare benef its. D. PolicyI. D-SNP members will f ollow the CareSource Indiana Medicare Dual Special Needs policies. E. Conditions of Coverage N/A F. Related Policies/Rules N/A G. Review/Revision History DATES ACTIONDate Issued 10/14/2020Date Revised 7/20/2022 Annual review. Ref erences updated. Date Effective 11/01/2022 Date Archived H. Ref erences 1. Centers f or Medicare and Medicaid Services.(December 1, 2021). Dual Eligible SpecialNeeds Plans (D-SNPs). Retrieved July 1, 2022 f rom www.cms.go v 2. Medicare.gov . (n.d.) How Medicare Special Needs Plans (SNPs) work. Retrieved September 23, 2020 f rom www.medicare.gov
MEDICAL POLICY STATEMENT Marketplace Policy Name & Number Date Effective Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliate s 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 neces sary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as c overed under this policy. This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A.Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 7 F. Related Policies/Rules ………………………………………………………………………………………….. 7 H. References …………………………………………………………………………………………………………. 9 I. State-Specific Information ……………………………………………………………………………………… 9 Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 2 A.Subj ect Applied Behavior Analysis Therapy for Autism Spectrum Disorder B.Background Autism Spectrum Disorder (ASD) can vary widely in severity and symptoms, depending on the developmental level and chronological age of the patient. ASD is often defined by specific impairments that affect socialization, communication, and stereoty ped ( repe titive) 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.I ndividuals 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 me mbers and their families/ caregivers. ABA services may be provided in centers or at home. Research supports the equivalent effectiveness at both treatment sites . C.Definitions Autism Spectrum Disorder (ASD) – A neurological condition as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of t he A merican Psychiatric Association.A pplied Behavior Analysis (ABA) – A treatment for ASD. Caregiver/Family Training-The goal of caregiver/family training is to maximiz e t he childs outcomes. Caregiver/Family training helps the child generalize their skills taking the skills they are learning in the one to one therapy to the community.Caregiver/Family training sessions focus on providing parents and caregiver with knowledge and skills on behavioral concepts and strategies to maximize a nd r einforce the childs learning and to support the maintenance and generalization of the skills and treatments they are teaching. Caregiver/family are expected t o par ticipate in ABA treatment and if unable to, the provider will assist them i n ac quiring skills to participate. Standardized diagnostic assessment tools-o Autism Diagnostic Observation Schedule (ADOS); or o Autism Diagnostic Int erview Revised (ADI-R).Other known evidence-based diagnostic tools may be used, but only in addition t o t he tools listed above.If submitting standardized instruments that are over one year old, an independent provider must submit recent clinical notes describing behaviors which demonstrat e t he member still has ASD and would benefit from ABA therapy services. SMART goals-Specific, measurable, attainable, relevant, and time-bound. Qualified practitioner-To make a definitive diagnosis of ASDo Pediatric psychiatrist;o Psychologist;o Pediatric neurologist; or o Developmental pediatrician. Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 3 Independent practitioner-To provide ABA therapy :All services provided must be provided by a Behavior Analyst Certification Boar d ( BACB) certified behavior professional/paraprofessional:o Registered Behavioral technician ( RBT);o Behavioral Analyst Certification Board (BACB) certified assistant behavior analyst undergraduate level (BCaBA);o BACB certified behavior analyst graduate level ( BCBA); or o BACB certified behavior analyst doctoral leve ( BCBA-D). 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 an RBT or a BCaBA must be supervised by a BCBA,BCBA-Dor a licensed/ registered psychologist certified by the American Board ofProfessional Psychology in Behavioral and Cognitive Psychology who has test ed i n ABA. o A certified RBT, or BCaBA may provide ABA under the supervision of a n i ndependent practitioner (supervisor) must be enrolled in the Marketplac e pr ogram and affiliate with the organization under which they are employed or contracted. o For Ohio see Section I. State-Specific Information D. Policy I.Medical necessity review is required for all ABA services :A. Baseline then every 6 months thereafter or sooner if clinically necessary.B. Medical review documentation must be submitted with appropriate documentation as indicated in section III.I I. CareSource supports medical evidence that suggests ABA therapy should begi n ear ly in life, ideally by the age of 2, typically lasting up to 4 years, and is subject t o t he patients response to intervention. Individuals under the age of 21 years will be assessed and treatment goals and intensity will be based on the individuals needs and progress in treatment to remediate symptoms of the disorder.I II.ABA G eneral Guidelines :A. An independent practitioner will perform a behavior identification assessment and develop a treatment plan before services are provided. Behavioral assessments are generally not to exceed 8 hours every 6 months unless addi tional justification is provided.B. For initiation of ABA services, documentation needs to show medical necessit y t hrough the following criteria:1. Definitive primary diagnos is should be made by a qualified practitioner who has a clinical relationship with the member and is independent of the ABAprovider.2. ABA will be provided by an independent practitioner .3. Behavioral, psychological, developmental, and medical history a.ABA provided as part of the school/home program shoul d be c oordinated to assure medical necessity; and the goals are not to be education related, but will focus on targeted symptoms, behaviors, and functional impairments . The hours spent in a school/home school setting should be included. If submitted, an individualized educational program(IEP) will be included in the review. Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 4 b.Includes a history with symptom intensity and symptom duration; as well as demonstrate how the symptoms affect the members ability to function in various settings such as with family members , peers, and in school01. Includes evidence of previous therapy such as ABA, speech therapy,and occupational therapy if applicable02. Includes type, duration, results of therapy and how the results will influence the proposed treatment c. Includes evidence of coordination with other disciplines involved in t he as sessment such as occupational therapy and speech therapy.4. Treatment plan for child and caregiver/family training must include ALL of the following:a. The treatment plan developed will describe treatment activities and goals and documentation of active participation by the recipient's caregiver/family in the implementation of the treatment program.b. Includes baseline objectives that are clearly related to target behaviors.Measurable SMART goals that define how member improvement will benot ed. Outcome oriented interventions, frequency of treatment (i.e.number of hours per week), and duration of treatment.c. Includes outcome performance-based individualized goals based onbehav ioral assessment and a standardized developmental and/or functional skills assessment/curriculum such as Verbal BehaviorMilestones Assessment and Placement Program (VB-MAPP) orAssessment of Basic Language and Learning Skills (ABLLS-R).d. Includes prescription with number of ABA hours requested per week andm ust be based on the members specific needs and not on a general program structure as evidenced by all of the following:01. Treatment is provided at the lowest level of intensity appropriate to t he m embers clinical needs and goals;02. Detailed description of problems, goals and interventions support the need for requested intensity of treatment; and03.Number of hours requested reflects actual number of hours inten ded t o be provided.e. Includes a plan to modify intensity and duration over time based on the childs progress. Discharge plan should be individualized and specific to each childs treatment needs.f. Caregiver/Family Training (as described above in the definitions) also includes the following:01. Will be individualized to the caregiver/family needs, values, priorities,and circumstances.02. Will be performance-based and based on childs assessment and treatment needs such as teaching parents to implement behavioral techniques in the home; or work on adaptive living skills in the home environment.03. Will be include d in the treatment plan with a focus on target ed s ymptoms, behaviors, and functional impairments.g. ABA services must include documentation of parent/family training. I V. Initial Authorization for ABA Evaluation and Treatment Plan CreationA. A licensed ABA practitioner will perform a behavior identification assessment and develop a treatment plan before services are provided. Behavioral Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 5 assessments are generally not to exceed 8 hours every 6 months unless additional justification is provided. B. For initiation of ABA services, documentation needs to show medical necessity through the following criteria:1. Diagnosis should be made and confirmed in early childhood by a qualifi ed heal thcare provider as outlined above.2. Completion of a comprehensive diagnostic evaluation should include a referral for ABA Therapy services, using one of the following standardiz ed di agnostic assessment tools as described above in the definitions.3. The final diagnosis must be made by a licensed psychologist, physician or other licensed practitioner acting within their scope of practice under state law. V. A uthorization for Initial Course of TreatmentA. PA requests must document the following:1.Once ABA evaluation is authorized and completed, treatment plan goals a nd hour s must be submitted for approval.2. Individual treatment plan submitted by the treating BCBA,including:a.The patients behavioral, psychological, medical and family concerns.b. Previous ABA Therapy services including:01.Durati on 02.Ty pe of therapy received03. Results c. When previous ABA Therapy information is unknown, provi de doc umentation regarding why the information is not accessible and how this will affect treatment.d. Quantitative goals based on standardized assessments addressi ng behav iors the treatment plan is designed to treat, i ncluding:01. Base line measurements02. Progress reports03. Timelines to reach treatment goals according to the initial assessment and period assessments over the course of treatment.e. The specific number of hours a week requested for treatment based o n t he members needs. Benefit has been shown at various intensities of service.01. CareSource will approve a range of hours depending on the following:(1)Members needs;(2) Clinical-based evidence models supporting treatment efficacy and efficiency;(3) Clear clinical documentation of target behaviors;(4) Members response to treatment;(5) Parental participation; an d ( 6)Utilization of prior approved hours.f. Regular review and adjustment of hours per week is required t o addr essbehavioral goals. When original authorized treatment plan hours vary, documentation regarding must be provided.3. Parent/guardian training individualized for each members needs, including:a.Documented plans for the training;b. Parent/guardians ability to and willingness to learn and use therapy techniques in the home setting;4. School transition plans: Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 6 a.Attendance at school if age appropriate;b. Plans to transition to school if not currently attending; and c. plans to be able to attend school without additional ABA therapy outsi de t he school setting.5. Documentation that a licensed or certified behavior analyst will be providi ng t he ABA therapy services. VI.Fo r continuation of ABA services, documentation needs to show ALL of the followi ng c riteria :A. Definitive diagnosis of autism persists, and member continues to demonstrat e A SD symptoms that will benefit from treatment.B. Treatment plan as noted in I II.5. plu s the following updates:1. An updated progress report including treatment plan and assessment scores that notes improvement/members response to treatment from baseline targeted symptoms, behaviors, and functional impairments.2. There is a reasonable expectation based upon a CareSource medical necessity determination that the member would benefit from continued ABAtherapy. VII. D iscontinuation of ABA TherapyA. Generally accepted medical research and practice indicates that ABA therapy is not intended to be a lifelong treatment, and when treatment isnt maki ng s ignificant meaningful progress , it should be titrated and discontinued.B. A ny of the following criteria may result in a discontinuation of ABA therapy (this list is not all inclusive):1. M ember is unable to demonstrate meaningful progress in members behavior for two successive authorization periods as demonstrated through standardized assessments;2. A BA therapy is making symptoms worsen; or3. Members symptoms have stabilized to where the member can be dischar ged t o a less intensive type of treatment to manage their symptoms VIII. Tel ehealthA. Caregiver/Family Training and supervision may be provided by telehealth ; how ever, ABA 1:1 therapy will not be reimbursed. IX .E xclusionsA. Only evidence-based interventions based in behavior analysis will ber eimbursed.B. Reimbursement is not permitted under any of the following situations:1.Services or activities not stated in the treatment plan;2. Services or activities based on experimental behavior methods or mode3. Education and related services or activities as described for the individual under the Individuals with Disabilities Education Improvement Act of 2004,20 U.S.C. 1400 et seq. (IDEA);4. Services or activities that are vocational in nature and otherwise available t o t he recipient through a program funded under Section 110 of t he R ehabilitation Act of 1973; or5. Services or activities that are a component of adult day care programs.C. When solely based on the benefit of the family, caregiver or therapist;D. When solely focused on recreational or educational outcomes;E. When making symptoms worse or when member is showing regression; Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 7 F.For symptoms and/or behaviors that are not part of core symptoms of AS D ( e.g., impulsivity due to ADHD, reading difficulties due to learning disabilities, or excessive worry due to an anxiety disorder). Other treatments will bec onsidered to treat symptoms not associated with autism;G. If academic or adaptive deficits are included in the treatment plan, the focus should be on addressing autistic symptoms that are impeding these deficits i n t he home environment (i.e. reduce frequency of self-stimulatory behavior t o al low child to be able to follow through with toilet training or complete a m athematic sorting task) rather than on any academic targets;H. When ABA therapy services are not expected to bring measurable functional improvement or measurable functional improvement is not documented;I. When therapy services are duplicative in addressing the same behavioral goals using the same techniques as the treatment plan, including services perform ed under an IEP;J. For more than one program manager/lead behavioral therapist for a member at any one ti me;K. For more than one agency/organization providing ABA therapy services for a member at any one time;L. Services provided by family or household members are not covered.M. Treatment will not be covered if the care is primarily custodial in nature (that do not require the special attention of trained/professional ABA staff), shadow, para-professional, or companion services in any setting.N. Personal training or life coaching.O. Services that are more costly than an alternative service or services, which are at least as likely to produce equivalent diagnostic or therapeutic results for th e pat ients disorder.P. Any program or service performed in nonconventional settings (even if t h e se rvices are primarily performed by a licensed provider), including: spas/resorts;vocational or recreational settings; Outward Bound; and wilderness, camp or ranch programs. NO TE : Compliance with the provisions in this policy may be monitored and addr essed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E.C onditions of CoverageNA F. Related Policies/Rules Applied Behavior Analysis for Autism Spectrum Disorder Administrative policiesMedical Records Documentation for Practitioners policyMedical Necessity policy Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 8 G.Review /Revision History DATE ACTION Date Issued 10/04/2018 Date Revised 01/27/2020 01/ 25/2021 08/ 31/2021 08/ 17/2022 Added program attributes, definitions of provider types and of ABA, title changed, clarified services needing a PA, changed NP to health care provider trained in ASD, added IV, added willingness to participate in program, added description of plan of care, added ages, clarified provider requirements, added must have ASD diagnosis, added home school and IEP, added documentation requirements, added must include type of ASD treatment program with PA, revised continuation of AGA therapy requirements, Added AFLS, ESDM and PEAK-DT assessments, revised discontinuation criteria, added section on transitioning ABA therapy to school environment, revised exclusions, and removed PA checklist. Clarified telehealth coverage, moved documentation requirements to Medical Records Documentation for Practitioners policy, and removed transition to school section/updated school section. Updated definitions. Updated ABA criteria. Updated RBT supervision. Background added ABA services may be provided in centers or at home. To sec. DIII 5.g. ABA services must include parent/family training or may be subject to denial. Edited Sec. V. Removed VII. A Used combined template. Updated references. Removed Sec. III.B.2. stating that an ABA order/recommendation from a provider other than one who has a financial relationship with the ABA entity that is planning to provide these services; Called out the distinct s eparate steps for Initial Authorization for ABA Evaluation and Treatment Plan Creation, Authorization for Initial Course of Treatment, and Continuation of ABA Services; Combined telehealth. Added VIII. A. Only evidence-based interventions based in behavior analysis will be reimbursed . In VIII. P, we state that for program or service performed in nonconventional settings (even if the services are primarily performed by a licensed provider ). Date Effective 11/01/2022 Date Archived Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 9 H.References1.American Academy of Pediatrics (n.d.). Autism Initiatives. Retrieved August 4, 2022from www.aap.org.2. The Behavior Analyst Certification Board. (2020. November). BCBA HandbookRetrieved on August 4, 2022 from www.bacb.com . 3.The B ehavior Analyst Certification Board. (2020, November). Registered BehavioralTechnician Handbook. Retrieved August 4, 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 4, 2022 from www.casproviders.org.5. Crockett, J. L., & Fleming, R. K. (2007). Parent training: Acquisiti on and gener alization. Research in Developmental Disabilities, 28, 23-36.6. Dixon, Mark. (n.d.). PEAK Relational training system Evidence-based autism assessment and treatment.7. Gresham, F. M., Beebe-Frankenberger, M. E., & MacMillan, D. L. (1999). A selectiv e r eview of treatments for children with autism: Description and methodological considerations. School Psychology review, 559-575.8. Lord C, Rutter M, Goode S, et al. (1989). Autism diagnostic observation schedule: as tandardized observation of communicative and social behavior . JAutism De v Dis ord 19 (2): 185 212 9.P artington, J. & Mueller, M. (n.d.). AFLS – The Assessment of Functional Livi ng S kills. Retrieved July 20, 2022 from www.partingtonbehavioranalysts.com10. Partingon, J. (2006). (ABLLS-R) Assessment of Basic Language and Learning Skills,Revised.11. Rogers, S. & Dawson, G. (2010). Early Start Denver Model for Young Children withAutism Checklist.12. Rutter, M., LeCouteur A. et al. (2003). AIDTM-R Autism Diagnostic interview, Revised 13. S undberg, M. (n.d.). Verbal Behavioral Milestones Assessment and PlacementProgram. Retrieved August 4, 2022 from www.vbmappapp.com .14. Susan L. Hyman, Susan E. Levy, Scott M. Myers and Council on children wit h di sabilities, section on developmental and behavioral pediatrics. Pediatrics January2020, 145 (1) e20193447; DOI: https://doi.org/10.1542/peds.2019-3447.15. Volkmar, F, et al. (2014) . Practice Parameter for the Assessment and Treatment ofChildren and Adolescents With Autism Spectrum Disorders . Retrieved August 4,2022 from www.aacap.org.16. Weissman, L. (2018, June 28). Autism Spectrum Disorders in Children an d A dolescents: Behavioral and Educational Interventions. Retrieved August 4, 2022from www.uptodate.com I. S tate-Specific InformationA. Georgia1. References a.GA-Evidence of Coverage and Health Insurance Contract Georgia2. Effective: 11/01/2022B. Indi ana 1. R eferences a. Evidence of Coverage and Health Insurance Contract Indiana Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 10 b.Indiana Department of Insurance. (2015, June 17). Payment of UndisputedABA Treatment During Appeals Process. Bulletin 216. Retrieved July 20,2022 from https://www.in.gov c. Indiana Department of Insurance. (2006, March 30). Insurance Coverage forPervasive Development Disorders Bulletin 136. Retrieved July 20, 2022 from www.in.gov d. Indiana Department of Insurance. (2010, April 27). Pervasive DevelopmentalDisorders Coverage Clarification Bulletin 179. Retrieved July 20, 2022 from www.in.gov2. Effective: 11/01/2022 b. K entuckyEvidence of Coverage and Health Insurance Contract Kentucky1. Effective: 11/01/2022 c.O hioEvidence of Coverage and Health Insurance Contract Ohio I n Ohio, in order to independently practice and supervise others in ABA, one must also be certified under the Ohio Board of Psychology in one of the following areas: o BCBA (Certified Ohio Behavioral Analyst-COBA) o BCBA-D (COBA) 1. Effective: 12/01/2022 d.W est VirginiaEvidence of Coverage and Health Insurance Contract West Virginia i. Effective: 11/01/2022 The Med ical Policy Stateme nt det ailed a bo ve has received due con side ration as defined in the Medical Policy Stateme nt Po licy a nd is a pprove d.
ADMINISTRATIVE POLICY STATEMENT Indiana D-SNP Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-IN DSNP-AD-1228 11/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management 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 neces sary 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 discomfor t. 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 Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Pro gram In teg rity Pro vid er Prep aymen t Review-IN DSNP-AD-1228 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. SubjectProgram Integrity Provider Prepayment ReviewB. BackgroundThis policy applies to participating (PAR) providers only.CareSource Program Integrity (PI) operates a provider prepayment review program to detect, prevent and correct fraud, waste and abuse and to f acilitate accurate claim payments. Physicians and other healthcare profession als may have the right to appeal results of reviews. C. Def initionsProvider prepayment review-reviews medical record documentation and compares it to billed services.Program Integrity (PI) – Program integrity ref ers to the proper management and f unction of the health insurance program to ensure it is providing quality and ef f icient care while using f unds taxpayer dollars appropriately and with minimal waste.Certified Professional Coder (CPC) – The certified professional coder credential is of f er ed through the American Academy of Prof essional Coders (AAPC). Professional coding is medical coding that is conducted in a prof essional environment such as a physician’s of f ice, outpatient setting, or hospital.Registered Health Information Administrator (RHIA) – A registered health inf ormation administrator (RHIA) is a prof essional who handles patient health inf ormation. The RHIA role requires certification and must adhere to standards such as the Health Insurance Portability and Accountability Act and ot her privacy and security rules.Registered Health Information Technician (RHIT) – An RHIT is a certif ied prof essional who stores and verif ies the accuracy and completeness of electronic health records. An RHIT also analyzes patient data with the goal of co ntrolling healthcare costs and improving patient care.D. PolicyI. A provider prepay review involves reviewing medical records compared to services billed prior to claim adjudication.A. Providers are placed on prepay review to monitor f or improper billing of me dical claims including but not limited to the f ollowing reasons:1. Overutilization of services2. Billing f or items or services not rendered3. Selection of wrong CPT/HCPCS code or supplies4. Lack of medical necessity5. Billing/dispensing unnecessary services6. Procedure repetition7. Upcoding8. Billing f or services outside of provider specialty Pro gram In teg rity Pro vid er Prep aymen t Review-IN DSNP-AD-1228 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. II. Placement on prepayment review will require the provider to submit medical records with each claim allowing CareSource to review the medical records in comparison to the bill ed services.A. CareSource will provide a written 30-day notice to the provider/provider group advising them of the ef fective date of prepayment review.1. Prepayment review will be implemented f or a period of 6 months.2. The 6 month period begins upon the f irst successful adjudication of a claim submission under prepayment review.3. All claims must be submitted with medical records.4. Medical records may be submitted in one of the f ollowing ways :a. Electronically with a claim.b. Submitted via the provider portal.Note: CareSource will not accept medical records via f ax. 5. Failure to submit medical records to CareSource in accordance with this provision will result in claim denial.6. Failure to meet minima l documentation standards such as member name and date of service on each page of the medical record, a signed dated order and a valid provider signature will result in claim denial.7. Providers must bill timely and accurate claims during the prepayment revi ew period.III. CareSource utilizes our published decision hierarchy to conduct our reviews, in addition we may use:A. Centers f or Medicare and Medicaid Services (CMS) guidelines as stated inMedicare manuals.B. Medicare local coverage determinations and national coverage determination.C. All CareSource published policies (Administrative, Medical and Reimbursement),code-editing policies and CareSource provider manuals.D. National Unif orm Billing Guidelines f rom the National Billing Committee.E. American Medical Associat ion Current Procedural Terminology (CPT) guidelines.F. American Medical Association Healthcare current Common Procedure CodingSystem (HCPCS) Level II.G. ICD 10-CM of ficial guidelines f or coding and reporting.H. American Association of Medical Audit Specialists national healthcare billing audit guidelines.I. Industry-standard utilization management criteria and/or care guidelines such asMCG guidelines (current edition on date of service).J. Food and Drug Administration guidance.K. National prof essional med ical societys guidelines and consensus statements.L. Publication f rom specialty societies, such as the American Society f or Parenteral and Enteral Nutrition, Substance Abuse and Mental Health ServiceAdministration, andAmerican Association of Neuromuscular & Mental HealthServices Administration.M. Nationally recognized, evidence-based published literature including, but not limited to, sources such as Medscape, the American Academy of Pediatrics(AAP) and the American College of Obstetricians and Gynecologist s (ACOG).IV. The Program Integrity Provider Prepayment Review Team is made up of clinical review and coding specialists who maintain CPC, RHIA, or RHIT designation. Pro gram In teg rity Pro vid er Prep aymen t Review-IN DSNP-AD-1228 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. The team reviews provider documentation to determine whether the claim is appropriate f or payment based on criteria including, but not limited to, provider documentation which establishes that:1. Services were provided according to CareSource policy require ments.2. Billed services were medically necessary and appropriate, and not in excess of the members need.3. Members were benefit eligible on the date the services were provided.4. Prior authorization was obtained if required by policy.5. Providers and their staf f were qualif ied as required by state or f ederal law.6. The provider possessed the proper license, certification, or other accreditation requirements specific to the providers scope of practice at the time the service was provided to the member.V. Prov iders whose claims are determined not payable may send in new corrected claims, a dispute or an appeal, whichever is appropriate, within timely f iling limitations as outlined in their provider manual.A. Providers and/or billing managers may reach out direct ly to the program integrity prepayment review team to discuss specif ic claim denials.VI. Providers are prohibited f rom billing covered individuals f or services CareSource has determined not payable as a result of the prepayment review process, whether due to f raud, abuse, waste or any other billing issue, or f or f ailure to submit medical records as set f orth above.VII. On completion of the 6 month review periodA. CareSource will determine if the provider is eligible f or release f rom prepayment review if :1. The provider has achieved an 85% or more approval rate on claim submissions f or 3 consecutive months and2. The volume of its claims submissions remained within 10% of the volume bef ore prepayment reviewB. If the provider successfully completes both requirements un der A above bef ore the month deadline the provider may be removed f rom the prepayment review process at the discretion of CareSource.C. If the provider f ails to satisf y the requirements above they may be placed under an additional 6 month prepayment review period and be required to submit a corrective action plan.1. If af ter the second 6 month interval prescribed under subsection Cthe provider f ails to satisf y the requirements under subsections A1 and A2,CareSource may do the f ollowing:a. Deny payment f or m edical assistance services rendered during a specif ied period of time b. Terminate the provider agreement c. Require a corrective action plan2. Providers who are able to demonstrate accurate billing practices and have been removed f rom prepayment review may be subject to f uture follow up reviews to ensure continued compliance with billing practices.3. If a provider has been on a prepayment review f or 12 months CareSource ma y terminate the provider agreement if :a. There has been no billing activity f or 6 months; or Pro gram In teg rity Pro vid er Prep aymen t Review-IN DSNP-AD-1228 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. b. The volume of claim submissions during review period is not within 10% of its volume bef ore prepayment review.4. Upon completion of the prepayment review period, the provider/provider group will receive notif ication in writings as to the ef fective end date of the review.E. Conditions of CoverageN/AF. Related Policies/RulesN/AG. Review/Revision HistoryDATES ACTION Date Issued 08/17/2022 New Policy Date Revised Date Effective 11/01/2022 H. Ref erences1. Centers f or Medicare and Medicaid Services. Medicare Program Integrity Manual(April 21, 2022). Retrieved July 11, 2022 f rom www.cms.gov
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Nutritional Supplements-MP-MM-1330 IN, GA, WV, KY : 11/01/2022 OH: 12/01/2022 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body o rgan or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessar y services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Sta tement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), co verage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 8 Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.A. SubjectNutritional Supplements B. BackgroundNutrition may be delivered through oral intake or through a tube into the stomach or small intestine. Enteral nutrition may be medically necessary to maintain optimal health status for individuals with diseas es or structural defects of the gastrointestinal ( GI ) tract that interfere with transport, digestion, or absorption of nutrients. Such conditions may include anatomic obstructions due to cancer motility disorders such as gastroparesis or metabolic absorpti ve disorders such as PKU. Considerations are given to medical condition, nutrition and physical assessment, metabolic abnormalities, gastrointestinal function, and expected outcome. Enteral nutrition may be either for total enteral nutrition or for supplem ental enteral nutrition. C. Definitions Chronological Age The time elapsed after birth, usually described in days, weeks, months, and/or years. Corrected Age A term most appropriately used to describe children up to 3 years of age who were born preterm or before gestational age of 37 weeks. This term represents the age of the child from the expected date of delivery (mothers due date). Corrected age is calcula ted by subtracting the number of weeks born before 40 weeks of gestation from the chronological age. Donor Human Milk Breast milk that is expressed by a mother and processed by a human milk bank for use by a recipient that is not the donor mothers own i nfant. Enteral Nutrition Nutritional support given via the gastrointestinal (GI) tract, either directly or through any of a variety of tubes used in specific medical conditions. This includes oral feeding, as well as feeding using tubes such as orogastri c, nasogastric, gastrostomy, and jejunostomy tubes. Human Milk Bank A service which recruits human breast milk donors, collects, pasteurizes, and stores donor human milk, tests the donor milk for bacterial contamination, and distributes donor human milk to recipient infants in need. Inborn Errors of Metabolism (IEM) Inherited biochemical disorders resulting in enzyme defects that interfere with normal metabolism of protein, fat, or carbohydrate. Medical Food Specially formulated and processed for indi viduals who are seriously ill or who require the product as a major treatment modality. This term does not pertain to all foods fed to ill individuals. Medical foods are intended solely to meet the nutritional needs of individuals who have specific metabol ic or physiological limitations restricting their ability to digest regular food. This can include specially formulated infant formulas. According to the Food and Drug Administrations (FDA), a product must meet all the following minimum criteria to be cons idered a medical food: o The product must be a food for oral or tube feeding. o The product must be labeled for the dietary management of a specific medical disorder, disease, or condition for which there are distinctive nutritional requirements. o The product m ust be used under the supervision of a physician. Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved. Oral Nutrition (oral feeding) Nutritional support given via the oral route. RELiZORB The only FDA-approved product indicated to hydrolyze (break down) fats in enteral feeding. RELiZORB is indicated for use in pediatric patients (ages 5 years and older) and adult patients. Standard Food Regular grocery products including typical, not specially formulated, infant formulas. Supplemental Nutrition Fewer than 50% of daily calories are supplied by enteral nutrition products. Therapeutic Oral Non-Medical Nutrition : o Food Modification Some conditions may require adjustment of carbohydrate, fat, protein, and micronutrient intake or avoidance of specific allergens (e.g., diabetes mellitus, celiac disease). o Fortified Food Food products that have additives to increase energy or nutrient density. o Functional Food Food that is fortified to produce specific beneficial health effects. o Texture Modified Food and Thickened Fluids Liquidized/thin puree , thick puree, finely minces, or modified normal. o Modified Normal Eating normal foods by avoiding particulate foods that are a choking hazard. Total Enteral Nutrition (TEN) More than 50% of daily calories are supplied by enteral nutrition products. D. Po licyI. Oral Nutrition : Prior authorization is required except for inborn error of metabolism conditions. A. Total oral nutrition is considered medically necessary when ALL the following criteria are met: 1. The product must be a medical food for oral feeding; 2. The product must be used under medical supervision; 3. The member has the ability to swallow without increased risk of aspiration; 4. The product is documented to make up more than 50% of the members daily intake, which, by definition, is the members primary source of nutrition; 5. The product must be labeled and used for nutritional management of a members specific medical condition without which serious morbidities (physical or mental) may develop OR the product is used to promote normal development or function for the member; 6. The member must have one of the following medical conditions: a. A condition caused by an inborn error of metabolism, including but not limited to the following: Phenylketonuria; Homocystinuria; Methylmalonic academia; Galactosemia; OR b. A condition that interferes with nutrient absorption and digestion, including, but not limited to: Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.01. Current diagnosis of non-IgE-mediated cows milk allergy (CMA) as defined by any of the following: (1). Abnormal stools, defined as hemoccult positive, mucous – containing, foam-containing, or diarrheal; (2). Poor weight gain trajectory for age (e.g., failure to thrive); (3). Atopic dermatitis: age of onset less than 3 months, severe eczema, exacerbation of eczema noted with introduction of cows milk, cow s milk formula, or maternal ingestion of cows milk (if breastfed); 02. Allergy to specific foods, including food-induced anaphylaxis, or severe food allergy indicating a sensitivity to intact protein product, as diagnosed through a formal food challenge; 03. All ergic eosinophilic enteritis (colitis/proctitis, esophagitis, gastroenteritis); 04. Cystic fibrosis with malabsorption ; 05. Diarrhea or vomiting resulting in clinically significant dehydration requiring treatment by a medical provider; 06. Malabsorption unresponsive t o standard age-appropriate interventions when associated with failure to gain weight or meet established growth expectations; 07. Failure to thrive unresponsive to standard age-appropriate interventions (e.g., nutritionally complete liquid meal supplements) wh en associated with weight loss, failure to gain weight, or to meet established growth expectations, including but not limited to: (1). Premature infants who have not achieved the 25 th percentile for weight based on their corrected gestational age; (2). Individuals w ith end-stage renal disease and hypoalbuminemia (albumin less than 4gm/dl); 7. The product must be used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care pro vider authorized to prescribe dietary treatments; 8. Approval duration can be up to 12 months for all oral nutrition products. B. Oral supplemental nutrition is considered medically necessary when ALL the following apply: 1. The members diet consists of less than 50% enteral nutrition and more than 50% standard diet for age; 2. The product is used as part of a defined and limited plan of care for a member transitioning from total enteral nutrition to standard diet for age; 3. Documentation of a medical basis for the members inability to maintain appropriate body weight and nutritional status (initial and ongoing) with normal or therapeutic oral nutrition; 4. The product must be used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authorized to prescribe dietary treatments; 5. The primary reason is not for convenience of the member or caregiver; Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6. All avenues of coverage available must be exhausted first. For example,members eligible for their county Women, Infant, and Children (WIC) program must apply for an eligibility evaluation before supplemental nutrition coverage will be considered; 7. Approval duration can be up to 12 months for all oral suppl emental nutrition products. Documentation of ongoing evidence of members positive response to the oral nutrition is required for future approvals. II. Enteral Nutrition via Tube : Prior authorization is required except for inborn error of metabolism condition s and for low-profile gastrostomy/jejunostomy/gastrojejunostomy tubes. A. Total enteral nutrition via tube feeing is considered medically necessary when the member has a functioning, accessible gastrointestinal tract, and ALL the following: 1. Enteral nutrition comprises the majority (greater than 50%) of the members diet; 2. The product is used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authorized to prescribe dietary treatments; 3. There is documentation that the member cannot ingest nutrients orally dur to a medical condition (physical or mental) which: a. Interferes with swallowing (e.g., dysphagia from a neurological condition, severe chronic anorexia nervosa or serious cases of oral aversion in children, which render member unable to maintain weight and nutritional status with oral nutrition alone); OR b. Puts member at risk for aspiration if nutrition is given by oral route; OR c. Is associated with anatomical abnormality of the proximal GI tract (e.g., tumor of the esophagus causing obstruction); 4. Approval duration can be up to 12 months for all enteral nutrition products. B. Enteral supplemental nutrition via tube is considered medically necessary when ALL the following are met: 1. The members diet consists of less than 50% enteral nutrition and more than 50% standard diet for age; 2. The enteral product is used as part of a defined and limited plan of care for a member transitioning from total enteral nutrition to standard diet for age; 3. Documentation of a medical basis for the inability of the member to maintain appropriate body weight and nutritional status (initial and ongoing) with normal or therapeutic enteral nutrition; 4. Documentation of ongoing evi dence of members positive response to the enteral nutrition; 5. The product must be used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authoriz ed to prescribe dietary treatments; 6. The primary reason is not for convenience of the member or caregiver; 7. All avenues of coverage available must be exhausted first (e.g., members eligible for their county Women, Infant, and Children (WIC) program must appl y for an eligibility evaluation before supplemental nutrition coverage will be considered); Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8. Approval duration can be up to 12 months for all supplemental enteral nutrition products.III. Donor breast milk : p rior authorization is required. See Section I for add itional criteria for Kentucky and Georgia. A. CareSource considers human milk medically necessary when ALL the following criteria are met: 1. Provider must be in good standing with the Human Milk Banking Association of North America; 2. Documentation support s medical necessity; 3. Documentation support s that the provider has attested to educating the member in the donation process and about human milk; and 4. Documentation supports that the provider discussed the risks and benefits with the member . B. Per the Food & Dr ug Administration, only human milk banks that screen their milk donors and take precautions to ensure the safety of its milk should be utilized. IV. CareSource does NOT consider the following medically necessary:A. Nutritional formulas and dietary supplements that can be purchased over the counter, which by law do not require either a written prescription or dispensing by a licensed pharmacist. B. Use of a nutritional product for the convenience or preference of the mem ber or caregiver. C. Therapeutic diets where non-medical foods are tolerated , including any of the following: 1. Food modification . 2. Texture modified food . 3. Thickened fluids . 4. Fortified food . 5. Functional food . 6. Modified normal . 7. Flavorings . D. Relizorb ( insufficient publ ished evidence). E. Oral nutrition products for meal replacements or snack alternatives. F. Feeding tubes for individuals with a dvanced dementia . G. Products administered in an outpatient provider setting. These items are not separately reimbursable. E. Conditions of CoverageNA F. Related Policies/RulesNA Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. American Geriatric Society Committee and Clinical Practice and Models of Care Committee. (2014). American Geriatrics Society feeding Tubes in Advanced Dementia Position Statement. JAmerican Geriatric Society. 2014;62(8):1590-1593. Retrieved July 26, 2022 from www.agsjournals.onlinelibrary.wiley.com . 2. Burris A, Burris J, Jarvinen. Cows Milk Protein Allergy in Term and Preterm Infants: Clinical Manifestations, Immunologic Pathophysiology, and Management Strategies. NeoReviews. 2020 December; 21(12):e795-e80 8. 3. Cederholm T, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clinical Nutrition. 2017;36(1):49-64. Doi:10.1016/j.clnu.2016.09.004. 4. Dipasquale V, Ventimiglia M, Gramaglia SMC, et al. Health-related quality of life and home enteral nutrition in children with neurological impairment: report from a multicenter survey. Nutrients. 2019;11(12):2968. 5. Druyan ME, Compher C, Boullata JI, et al. Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pedia tric Patients: applying the GRADE system to development of A.S.P.E.N. clinical guidelines. JParenter Enteral Nutr. 2012;36(1):77-80. 6. Klek S, Hemanowicz A, Dziwiszek G, et al. Home enteral nutrition reduces complications, length of stay, and health care co sts: results from a multicenter study. Am JClin Nutr. 2014;100(2):609-615. 7. Marchand V, Motil KJ. NASPGHAN Committee on Nutrition. Nutrition support for neurologically impaired children: a clinical report of the North American Society for Pediatric Gastroe nterology, Hepatology, and Nutrition. JPediatr Gastroenterol Nutr. 2006;43(1):123-135. 8. Moro GE, Billeaud C, Rachel B, et al. Processing of donor human milk: update and recommendations from the European Milk Bank Association (EMBA). Front Pediatr. 2019;7(4 9):1-10. 9. Robinson D, et al. (2018, May). American Society for Parenteral and Enteral Nutrition (ASPEN) Definition of Terms, Style, and Conventions Used in ASPEN Board of Directors-Approved Documents. Retrieved July 26, 2022 from www.nutritioncare.org . 10. U.S. Food and Drug Administration (FDA). Center for Food Safety and Applied Nutrition. Office of Nutritional Products, Labeling, and Dietary Supplements. May 2016: Frequently Asked Questions about Medical Foods. Retrieved July 26, 2022 from www.fda.gov . 11. U.S. F ood and Drug Administrations (FDA). (2017, December 6). Medical Foods Guidance Documents & Regulatory Information. Retrieved July 26, 2022 from www.fda.gov . Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.12. U.S. Food and Drug Administrations (FDA). Regulatory Information. Section 5 of Orphan Drug Act. Ret rieved July 26, 2022 from www.fda.gov .13. U.S. Social Security Administration (SSA). Disability Evaluation under Social Security. 105.08 Digestive System Childhood. Retrieved July 26 , 2022 from www.ssa.gov . 14. U.S. Social Security Administration (SSA). P rogram Operations Manual System (POMS). DI 24598.002. Failure to Thrive. March 2017. Retrieved 2022 from www.secure.ssa.gov . 15. Wanden-Berghe C, et al. Complications associated with enteral nutrition: CAFANE study. Nutrients. 2019;11(9):2041. 16. Worthington P, e t al. When is Parenteral Nutrition Appropriate? JParent er Enteral Nutr . 2017;41(3):324-377. doi:10.1177/0148607117695251. I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 2. Additional donor milk cover age criteria: As per the evidence of coverage, a benefit is provided for 100% human diet, if the 100% human diet and supplemented milk fortifier products are prescribed for the prevention of necrotizing enterocolitis and associated co-morbidities and admi nistered under the direction of a physician. 100% human diet means the supplementation of a mothers expressed breast milk or donor milk with a milk fortifier. 3. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Georgia (2022). Retrieved July 26, 2022 from www.caresource.com. B. Indiana 1. Effective: 11/01/2022 2. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Indiana (2022). Retrieved July 26, 2022 from www.caresource.com. C. Kentucky 1. Effective: 11/01/2022 2. Additional donor milk coverage criteria: As per the evidence of coverage, a benefit is provided for 100% human diet, if the 100% human diet and supplemented milk fortifier products are prescribed for the prevention of necrotizing enterocolitis and associated co-morbidities and administered under the direction of a physician. 100% human diet means the supplementation of a mothers expressed breast milk or dono r milk with a milk fortifier. 3. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Kentucky (2022). Retrieved July 26, 2022 from www.caresource.com. D. Ohio 1. Effective: 12/01/2022 2. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Oh io (2022). Retrieved July 26, 2022 from www.caresource.com. E. West Virginia 1. Effective: 11/01/2022 2. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, West Virginia (2022). Retrieved July 26, 2 022 from www.caresource.com.
ADMINISTRATIVE POLICY STATEMENT Marketplace Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-MP-AD-1222 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited t o, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. Th ese services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of se rvices. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in th e Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatm ent of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………… 2 B. Background ………………………….. ………………………….. ………………………….. ……………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ……………………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. … 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. . 5 H . References ………………………….. ………………………….. ………………………….. ………………… 5 I. State-Specif ic Inf ormation ………………………….. ………………………….. …………………………. 5 Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. SubjectProgram Integrity Provider Prepayment ReviewB. BackgroundThis policy applies to participating (PAR) providers only.CareSource Program Integrity (PI) operates a provider prepayment review program to detect, prevent and correct fraud, waste and abuse and to f acilitate accurate claim payments. Physicians and other healthcare professionals may have the right to appeal resu lts of reviews. C. Def initionsProvider prepayment review-reviews medical record documentation and compares it to billed services.Program Integrity (PI) – Program integrity ref ers to the proper management and f unction of the health insurance program to ensure it is providing quality and ef f icient care while using f unds taxpayer dollars appropriately and with minimal waste.Certified Professional Coder (CPC) – The certified professional coder credential is of f ered through the American Academy of Prof essional Coders (AAPC).Prof essional coding is medical coding that is conducted in a prof essional environment such as a physician’s of f ice, outpatient setting, or hospital.Registered Health Information Administrator (RHIA) – A registered health inf orm ation administrator (RHIA) is a prof essional who handles patient health inf ormation. The RHIA role requires certification and must adhere to standards such as the Health Insurance Portability and Accountability Act and other privacy and security rules.Reg istered Health Information Technician (RHIT) – An RHIT is a certif ied prof essional who stores and verif ies the accuracy and completeness of electronic health records. An RHIT also analyzes patient data with the goal of controlling healthcare costs and impr oving patient care.D. PolicyI. A p rovider prepay review involves reviewing medical records compared to services billed prior to claim adjudication.A. Providers are placed on prepay review to monitor f or improper billing of medical claims including but not limited to the f ollowing reasons:1. Overutilization of services .2. Billing f or items or services not rendered .3. Selection of wrong CPT/HCPCS code or supplies .4. Lack of medical necessity .5. Billing/dispensing unnecessary services .6 . Procedure repetition .7. Upcoding . Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 8. Billing f or services outside of provider specialty .II. Placement on prepayment review will require the provider to submit medical records with each claim allowing CareSource to review the medical records in comparis on to the billed services.A. CareSource will provide a written 30 day notice to the provider/provider group advising them of the ef fective date of prepayment review.1. Prepayment review will be implemented f or a period of 6 months2. The 6 month period b egins upon the f irst successful adjudication of a claim submission under prepayment review.3 . All claims must be submitted with medical records.4. Medical records may be sub m itted in one of the f ollowing ways:a. Electronically with a claim .b. Submitted via the provider portal.Note: CareSource will not accept medical records via f ax. 5 . Failure to submit medical records to CareSource in accordance with this provisionwill result in claim denial.6 . Failure to meet minimal documentation sta ndards such as member name and date of service on each page of the medical record, a signed dated order and a valid provider signature will result in claim denial.7 . Providers must bill timely and accurate claims during the prepayment review period.III. CareSource utilizes our published decision hierarchy to conduct our reviews, in addition we may use:A. Centers f or Medicare and Medicaid Services guidelines as stated in Medicare manuals.B. Medicare local coverage determinations and national coverage determination s .C. All CareSource published policies (Administrative, Medical and Reimbursement),c ode-editing policies and CareSource provider manuals.D. National Unif orm Billing Guidelines f rom the National Billing Committee.E. American Medica l Association Current Procedural Terminology (CPT) guidelines.F. American Medical Association Healthcare current Common Procedure CodingSystem (HCPCS) Level II.G. ICD 10-CM of ficial guidelines for coding and reporting.H. American Association of Medical Audit Specialists national healthcare billing audit guidelines.I. Industry-standard utilization management criteria and/or care guidelines such asMCG guidelines (current edition on date of service).J. Food and Drug Administration guidance.K. National prof essional medical societys guidelines and consensus statements.L. Publication f rom specialty societies, such as the American Society f or Parenteral and Enteral Nutrition, the Substance Abuse and Mental Health ServiceAdministration, and the A merican Association of Neuromuscular & Mental HealthServices Administration .M. Nationally recognized, evidence-based published literature including, but not limited to, sources such as: Medscape, the American Academy of Pediatrics(AAP), and the American College of Obstetricians and Gynecologists (ACOG). Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. IV. The PI Provider Prepayment Review Team is made up of clinical review and coding specialists who maintain CPC, RHIA, or RHIT designation.A. The team reviews provider documentation to determine whethe r the claim is appropriate f or payment based on criteria including, but not limited to, provider documentation which establishes that:1. Services were provided according to CareSource policy requirements.2. Billed services were medically necessary and ap propriate, and not in excess of the member s need.3. Members were benefit eligible on the date the services were provided.4. Prior authorization was obtained if required by policy.5. Providers and their staf f were qualif ied as required by state or f ederal law.6. The providers possessed the proper license, certifications, or other accreditation requirements specific to the providers scope of practice at the time the service was provided to the member.V. Providers whose claims are determined not pa yable may send in new corrected claims, a dispute or an appeal, whichever is appropriate, within timely f iling limitations as outlined in their provider manual.A. Providers and/or billing managers may reach out directly to the PI prepayment review team to discuss specif ic claim denials.VI. Providers are prohibited from billing covered individuals f or services we have determined not payable as a result of the prepayment review process, whether due to f raud, abuse, waste of any other billing issue, or f or f ailure to submit medical records as set f orth above.VII. On completion of the six month review periodA. CareSource will determine if the provider is eligible f or release f rom prepayment review if :1. The provider has achieved an 85% or more approval rate on claim submissions f or 3 consecutive months and2. The volume of its claims submissions remained within 10% of the volume bef ore prepayment reviewB. If the provider successfully completes both requirements under A above bef ore the six month deadline th e provider may be removed f rom the prepayment review process at the discretion of CareSource.C. If the provider fails to satisf y the requirements above they may be placed under an additional 6 month prepayment review period and be required to submit a cor rective action plan.1. If af ter the second 6 month interval prescribed under sub section Cthe provider f ails to satisf y the requirements under sub section A1 and A2,CareSource may do the f ollowing :a. Deny payment f or medical assistance services rendered during a specif ied period of time b. Terminate the provider agreement c. Require a corrective action plan Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 2. Providers who are able to demonstrate accurate billing practices and have been removed f ro m prepayment review may be subject to f uture f ollow up reviews to ensure continued compliance with billing practices.3. If a provider has been on a prepayment review f or 12 monthsCareSource may terminate the provider agreement if :a. There has been no bi lling activity f or 6 months; or b. The volume of claim submissions during the review period is not within10% of its volume bef ore prepayment review.4. Upon completion of the prepayment review period, the provider/provider group will receive notif ication in writings as to the ef fective end date of review.E. Conditions of CoverageN/AF. Related Policies/RulesN/AG. Review/Revision HistoryDATE ACTION Date Issued 08/17/2022 New Policy Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date Archived H . Ref erences1, Centers f or Medicare and Medicaid Services. Medicare Program Integrity Manual(April 21, 2022). Retrieved July 11, 2022 f rom www.cms.govI.State-Specific Information a. Georgia1. Effective: 11/01/2022b. Indiana1. Effective: 11/01/2022c. Kentucky1. Effective: 11/01/2022d. Ohio1. Effective: 12/01/2022e. West Virginia Pro g ram In teg rity Pro vid er Prep aymen t Review-MP-AD-1222 Effective Dat e: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. i. Effective: 11/01/2022 I nd e pe n de nt med i ca l r e v iew
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-MP-PY-1367 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies pr epared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other facto rs 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 editin g logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or supplies that are proper and ne cessary 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 functi on, dysfunction of a body organ or part, or significant pain and discom fort. 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 defin ed in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy t o services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplac e(s): Georgia Indiana Kentucky Ohio West VirginiaTable of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Po licy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective 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. SubjectModifier 59, XE, XP, XS, XU B. BackgroundReimbursement policies are designed to assist p roviders when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary polici es are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is rece ived for processing. Reimbursement modifiers are two-digit code s that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource a ccepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-paym ent audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when two Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together, either in all situat ions or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management ( E/M ) services, that are not usually reported together but are appropriate under the patients specific circumstance. National Correct Cod ing Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because two different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the two procedures/surger ies are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Serv ices (CMS) established four HCPCSmodifiers to define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective 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.CPT instructions state that m odifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions o f modifier 59. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to audit any submission at any time to ensure correct coding standards and guidelines are met. II. It is the responsibility of the submitting provider to submit accurate documentation of services performed when requested from CareSource. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support t he claims submission, this will also result in a claims denial. III. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding audit. Once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. IV. Modifiers X {EPSU} should be used prior to using modifier 59.V. Modifier X {EPSU} (or 59 , when applicable) may only be used to indicate that a distinct procedural ser vice was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available . Documentation should support a different session, different procedure or surgery, different site or organ system, sep arate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty . A. Modifier XS (or 59, when applicable) is for sur gical procedures, non-surgi cal therapeutic procedures, or diagnostic procedures that: 1. Are performed at different anatomic sites; and 2. Are not ordinarily performed or encountered on the same day; and 3. Cannot be described by one of the more specific anatomic NCCI P rocedure to Procedure (P TP )-associated modifiers (i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI). Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective 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.B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are performed d uring different patient encounters ; and 2. Cannot be described by one of the more specific NCCI PTP-associated modifiers (i.e., 24, 25, 27, 57, 58, 78, 79, 91). C. Modifier XE (or 59, when applicable) may also be used when two timed procedures are performed during th e same encounter but occur one after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are perf ormed at separate anatomic sites ; or 2. Are performed at separate patient encounters on the same date of service . E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when: 1. The diagnost ic procedure is the basis for performing the therapeutic procedure; and 2. It occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires; and 3. Provides clearly the information needed to decide whether to proc eed with the therapeutic procedure; and 4. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separat ely. F. Modifiers XU (or 59, when applicable) may be used for a diagnostic procedure is performed after a therapeutic procedure only when: 1. The diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure; and 2. It occurs a fter the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires; and 3. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (e.g., not separately payable) post – procedure service of th e surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted wi thin the policy, this policy applies to bothparticipating and nonparticipating providers and facilities.Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective 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.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/RulesModifier 25 Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued Not SetDate Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. Centers for Medicare & Medicaid Services. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. Revised January 1, 2022. Retrieved June 24, 2022 from www.cms.gov . 2. Centers for Medicare & Medicaid Service s. (2022 March). Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Rev. 11288 . Retrieved June 24, 2022 from www.cms.gov . 3. Centers for Medicare & Medicaid Services (2022 March). M LN1783722 – Proper Use of Modifiers 59 & -X{EPSU}. Retrieved July 12, 2022 from www.cms.gov. 4. Centers for Medicare & Medicaid Services. (2022). National Correct Coding Initiative (NCCI) Tool. Retrieved August 2, 2022 from www.cms.gov. 5. Centers for Medicare & Medicaid Services (2014 August). Transmittal R1422OTN – Publication 100-20 – MM8863 – Specific Modifiers for Distinct Procedural Services. Retrieved July 12, 2022 from www.cms.gov . I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 B. Indiana 1. Effective: 11/01/2022 C. Kentucky 1. Effective: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effectiv e: 11/01/2022
© Copyright CareSource 2024. Todos los derechos reservados.
Detalles del sistema