REIMBURSEMENT POLICY STATEMENTD-SNP Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-DSNP-PY-1376 IN, GA, 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, regulato ry requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services includ e, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, imp airment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying t his Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the foll owing Marketplace(s): Georgia Indiana Kentucky Ohio Table of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 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-DSNP-PY-1376Effective Dat e: 11/01/2022 The 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 physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary polic ies 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 rec eived for processing. Reimbursement modifiers are two-digit codes 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 accepts the use of modifiers, their 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 po st-payment 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 Medic are 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 situations o r 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 Coding I nitiative (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/surgeries a re 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 Services (CMS) established four HCPCS modifiers 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 bec ause it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.CPT instructions state that modifier 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 spec ific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of 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, u pdated, 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 a bout 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 documentati on 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 the claims submission, this will also result in a claims denial. III. Provider claims b illed 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 mo difier. 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 service 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, separate 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 surgical procedures, non-surgical 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 Procedure to Procedure (PTP) -associated modifiers (i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1 – T9, LC, L D, RC, LM, RI). Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 11/01/2022 The 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 during 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 the same encounter but occur one after another (the first service must be completed befor e 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 performed at separate anatomic sites; or 2. Are performed at separate patient encounters on t he 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 diagnostic procedure is the basis for performing the therapeutic procedure; and 2. It occurs befor e the therapeutic procedure and is not mingled with services the therapeutic intervention requires; and 3. Provides clearly the information needed to decide whether to proceed 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 separately. F. Modifiers XU (or 59, when applicabl e) may be used when 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 after 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 therapeuti c intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (e.g., not separately payable) post – procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separatel y. 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 re fer 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 within the policy, this policy applies to bothparticipating and nonparticipating providers and facilities.Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 11/01/2022 The 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 b e the governing document.F. Related Policies/RulesModifier 25 G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised Date Effective GA, IN, KY: 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. R evised January 1, 2022. Retrieved June 24, 2022 from www.cms.gov. 2. Centers for Medicare & Medicaid Services. (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). MLN1783722 – 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. 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 Information A. 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
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Myoelectric Lower Extremity Prosthetic Technology MP-MM-1327 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a confl ict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 4 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 5 B. State-Specific Information ……………………………………………………………………………………… 5Myoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.A. Subject Myoelectric Lower Extremity Prosthetic Technology B. Background The policy addresses the computerized limb prosthesis that is a nonstandard, external prosthetic device incorporating a microprocessor for movement control. These devices are equipped with a sensor that detects when the knee is in full extension and adjusts the swing phase automatically, permitting a more natural walking pattern of varying speeds . C. Definitions Myoelectric Lower Extremity Prosthetic Technology Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type. Classification Level Rehabilitation potential as described by Centers for Medicare & Medicaid Services : Lev el 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility a. The individual does not have sufficient cognitive ability to safely use a prosthes is with or without assistance. b. The individual requires assistance from equipment or caregiver to transfer and use of a prosthesis does not improve mobility or independence with transfers. c. The individual is wheelchair dependent for mobility and use of a prosthesis does not improve transfer abilities. d. The individual is bedridden and has no need or capacity to ambulate or transfer. Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence, typical of the limited and unlimited household ambulator. a. The individual has sufficient cognitive ability to safely use a prosthesis with or without an assistive device and/or the assistance/supervision of one person. b. The individual is capable of safe but limited ambulation within the home with or without an assistive device and/or with or without the assistance/supervision of one person. c. The individual requires the use of a wheelchair for most activities outside of their residence. d. The individual is not capable of most of the functional activities designated in Level 2. Myoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.Level 2: Has the ability or potential for ambu lation with the ability to transverse low level environmental barriers such as curbs, stairs or uneven surfaces. This level is typical of the limited community ambulator. a. The individual can ambulate with or without an assistive device (which may inc lude one or two handrails) and/or with or without the assistance/supervision of one person: i. Perform the Level 1 tasks designated above ii. Ambulate on a flat, smooth surface iii. Negotiate a curb iv. Access public or private transportation v. Negotiate 1-2 stairs vi. Negotiate a ramp built to ADA specifications. b. The individual may require a wheelchair for distances that are beyond the perimeters of the yard/driveway, apartment building, etc. c. The individual is only able to increase his/her generally observed speed of walking for short distances or with great effort. d. The individual is generally not capable of accomplishing most of the tasks at Level 3 (or does so infrequently with great effort). Level 3: Has the ability or potential for ambulation with variable cadence, typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic, or exercise activity that d emands prosthetic utilization beyond simple locomotion. a. With or without an assistive device (which may include one or two handrails), the individual is independently capable (i.e. requires no personal assistance or supervision) of performing the Level 2 tasks above and can: i. Walk on terrain that varies in texture and level (e.g., grass, gravel, uneven concrete) ii. Negotiate 3-7 consecutive stairs iii. Walk up/down ramps built to ADA specifications iv. Open and close doors v. Ambulate through a crowded area (e.g., grocery store, big box store, restaurant) vi. Cross a controlled intersection within his/her community wi thin the time limit provided (varies by location) vii. Access public or private transportation viii. Perform dual ambulation tasks (e.g. carry an item or meaningfully converse while ambulating) b. The individual does not perform the activities of Level 4. Level 4: Has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress or energy levels typical of the prosthetic demands of the child, active adult, or athlete. With or without an assistiv e device , which may include one or two handrails, this individual is independently capable (i.e. , requires no personal assistance or supervision) of performing high impact domestic, vocational or recreational activities such as: a. Running b. Repetitiv e stair climbing c. Climbing of steep hills d. Being a caregiver for another individualMyoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d.e. Home maintenance (e.g. repairs, cleaning) NOTE: Consideration is given to bilateral amputees who often cannot be strictly bound by the Classification Levels .D. PolicyI. CareSource considers myoelectric lower limb prosthetic technology medically necessary when the following criteria are met: A. The member is 18 years of age or older . B. Has a lower extremity prosthesis( es). C. Documentation submitted supports medical necessity and includes the following: 1. A written order/prescription from a treating practitioner for the additional technology ; 2. Sufficient documentation of the rehabilitation potential including, but not limited to clear documentation supporting the expected potential classification l evel of K3 or above; and 3. Member: a. Is emotionally ready; b. Is able and willing to participate in training; c. Is able and willing to care for the technology; d. Is physically able to use the equipment; and e. Has adequate cardiovascular and pulmonary reserve for ambulation at faster than normal walking speed. NOTE: Documentation for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies is followed E. Conditions of Coverage NA F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 07/20/2022Date Revised Updated references; no changes Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedMyoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.H. References 1. Centers for Medicare & Medicare Services Health Technology Assessment. (2017, September). Lower Limb Prosthetic Workgroup Consensus Document. Retrieved July 5, 2022 from www.cms.gov . 2. Centers for Medicare & Medicare Services. (2020, December 30). Medicare Program Integrity Manual Chapter 5 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations. Retrieved July 5, 2022 from www.cms.gov . 3. Centers for Medicare & Medicare Services . (2 020, January 10. Local Coverage Determination Lower Limb Prosthesis L33787). Retrieved July 5, 2022 from www.cms.gov . 4. MCG.MCG Guidelines. 26th edition (2022). A-0487 (AC). Lower Limb Prosthesis. Retrieved July 5, 2022 from www.careweb.careguidelines.com . 5. Optum 360. EncoderProc.om for Payers Professional. (2005, January 1). HCPCS Code Detail L5856-L5859. Retrieved July 5, 2022 from www.encoderprofp.com .B. State-Specific Information A. Georgia 1. Effective: 11/01/2022 B. Indiana 4. Effectiv e: 11/01/2022 C. Kentucky 1. Effective: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effective: 11/01/2022
REIMBURSEMENT POLICY STATEMENTD-SNP Policy Name & Number Date Effective Modifier 25-DSNP-PY-1371 IN, GA, KY: 11/01/2022 OH: 12/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its aff iliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are 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 ag reement, 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 necessary for the diagnosis or tre atment 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 discomfort. These services meet the s tandards 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 cover age 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 Marketplace(s): Geor gia Indiana Kentucky Ohio Table of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 Modifier 25-DSNP-PY-1371Effective 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 25 B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a two-digit code that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by s ome specific circumstance. Modifier -25 is used to report an Evaluation andManagement (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Associati on (AMA) Current Procedural Terminology (CPT) book defines modifier -25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of modifier -25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separatelyidentifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be pr ompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier -25 to the approp riate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier -57. For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their use does not guaranteereimbursement. 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 prepay ment and post-payment edit or 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. CareSource uses published guidelines from CPT Modifier 25-DSNP-PY-1371Effective 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.and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.C. Definitions Current Procedural Terminology (CPT) Codes that are issue d, 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 American Medical Association (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. It is the responsibility of the submitting provider to submit accurate documentation of services performed. Failure may result in prepayment and post-payment audit and unpaid claims. II. Provider claims billed with modifier -25 may be flagged for either a prepayment clinical validation or prepayment medical record coding audit and be selected for a post payment medical re cord review. Once the claim has been clinically validated, it is either released for payment or denied for incorrect use of the modifier. III. Modifier -25 may only be used to indicate that a significant, separately identifiable evaluation and management serv ice [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier -25, the code may be denied. IV. Appending modifier -25 to an E/M service is considered inappropriate in the fol lowingcircumstances:A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. B. The E/M service i s reported by a qualified professional provider other than the qualified professional provider who performed the procedure. C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. Modifier 25-DSNP-PY-1371Effective 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.H. The preventative E/M service is performed at the same time as a preventative care visit (e.g., a preventative E/M service and a r outine gynecological exam performed on the same date of service by the same professional provider). Since both services are preventative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation. 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, CMS guidelines will apply. Please refer to t he 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 within the policy, this policy applies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the g overning document.F. Related Policies/RulesModifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17 /2022 New PolicyDate Revised Date Effective GA, IN, KY: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. American College of Cardiology Foundation. (2022). Appropriate Use of Modifier 25. Retrieved June 17, 2022 from www.acc.org. 2. Centers for Medicare and Medicaid Services. Chapter 1 General Correct Coding Policies for National Correct Coding Init iative Policy Manual for Medicare Services. Revised January 1, 2022. Retrieved June 17, 2022 from www.cms.gov. 3. Centers for Medicare & Medicaid Services. (2022). National Correct Coding Initiative (NCCI) Tool. CPT Modifier 25. Retrieved June 17, 2022 from w ww.palmettogba.com. 4. Centers for Medicare and Medicaid Services. (Rev. 11288, 2022, March 4). Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners. Retrieved June 17, 2022 from www.cms.gov. 5. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag. 2004;11(9):21-22. Retrieved June 17, 2022 from www.aafp.org . Modifier 25-DSNP-PY-1371Effective 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.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
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Three-Day Window Payment-MP-AD-1227 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literatu re based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy guidelines. Medically necessary services include, but a re not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the memb er or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 Three-Day Window Payment-MP-AD-1227 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectThree-Day Window Payment B. BackgroundCareSource follows the three-day window payment policy as established by the Centers for Medicare & Medicaid Services (CMS). According to the three-day rule, if an admitting hospital (or w holly owned or who lly operated physician practice ) provides diagnostic or nondiagnostic services three days prior to and including the date of the members inpatient admission, the services are considered inpatient services and are included in the inpatient payment (e.g., b undled service). This includes services performed as pre – admission or preoperative procedures when occurring within three days of the inpatient admission. T he three-day window payment will apply to diagnostic and nondiagnostic services clinically related t o the reason for the members inpatient admission regardless of whether the inpatient and outpatient diagnoses are identical. Hospitals (or wholly owned or wholly operated physician practices) are allowed to bill services separately from the inpatient admi ssion if the outpatient services are unrelated to the inpatient admission. C. Definitions Inpatient Member who is admitted to a hospital based upon the written orders of a physician or dentist and whose inpatient stay continues beyond midnight of the day of admission. Outpatient Services Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a physician or dentist which are furnished to an outpatient by a hospital. Outpatient services do not include direct – care services provid ed by physicians, podiatrists, and dentists. Inpatient Services All covered services provided to members during the course of an inpatient hospital stay except for direct-care services provided by physicians, podiatrists, and dentists. Emergency room (ER ) services are covered as an inpatient service when member is admitted from the ER. D. PolicyI. Three-Day Payment Rule. A. Claims submitted for outpatient services, including emergency room and observation services, provided within the three calendar days prior t o the inpatient admission for the same member for the same hospital may be denied, because the inpatient and outpatient services must be combined when they are related . 1. The outpatient services and inpatient admission must be submitted on one inpatient clai m. 2. The dates of the claims should begin with the outpatient service through the inpatient discharge. B. If the hospital submits the outpatient claim separately before the inpatient claim, the inpatient claim may be deemed as a duplicate claim and may be denie d payment. The hospital will need to void the paid claim for the outpatient service Three-Day Window Payment-MP-AD-1227 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.and resubmit the inpatient claim so that it includes inpatient and outpatient services. C. Physician practices and entities should use modifier PD (diagnostic or related non-diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days or 1 day) to identify services subject to the payment window. D. It is recommended that ICD-10 diagnosis code Z01.81X be used to indicate an encounter for preprocedural examinations to flag the outpatient claim as related to an inpatient service/procedure. II. Outpatient hospital behavioral health services provided in the outpatient hospital setting within three calendar days prior to the inpatient admission are exempt from the three-day window policy. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. Centers for Medicare & Medicaid Services (CMS). (2021 December 1). Three Day Payment Window Implementation of New Statutory Provision pertaining to Medicare 3-Day (1-Day) Payment Window Policy Outpatient Services Treated As Inpatient. Retrieved August 1, 2022 from www.cms.gov . 2. Centers for Medicare & Medicaid Services (CMS). (2020 December 3). FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients. MLN Matters SE20024. Retrieved August 12, 2022 from www .cms.gov. 3. Centers for Medicare & Medicaid Services (CMS). (2012 June 14). Frequently Asked Questions CR 7502. Retrieved August 1, 2022 from www.cms.gov. 4. Centers for Medicare & Medicaid Services (CMS). (2011, December 21). Pub 100-04 Medicare Claims Processing, Transmittal 2373. Retrieved July 29, 2022 from www.cms.gov . I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 Three-Day Window Payment-MP-AD-1227 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.B. Indiana1. Effectiv e: 11/01/2022 C. Kentucky 1. Effect ive: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effective: 11/01/2022
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
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Three-Day Window Payment-MP-AD-1227 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literatu re based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy guidelines. Medically necessary services include, but a re not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the memb er or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 Three-Day Window Payment-MP-AD-1227 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectThree-Day Window Payment B. BackgroundCareSource follows the three-day window payment policy as established by the Centers for Medicare & Medicaid Services (CMS). According to the three-day rule, if an admitting hospital (or w holly owned or who lly operated physician practice ) provides diagnostic or nondiagnostic services three days prior to and including the date of the members inpatient admission, the services are considered inpatient services and are included in the inpatient payment (e.g., b undled service). This includes services performed as pre – admission or preoperative procedures when occurring within three days of the inpatient admission. T he three-day window payment will apply to diagnostic and nondiagnostic services clinically related t o the reason for the members inpatient admission regardless of whether the inpatient and outpatient diagnoses are identical. Hospitals (or wholly owned or wholly operated physician practices) are allowed to bill services separately from the inpatient admi ssion if the outpatient services are unrelated to the inpatient admission. C. Definitions Inpatient Member who is admitted to a hospital based upon the written orders of a physician or dentist and whose inpatient stay continues beyond midnight of the day of admission. Outpatient Services Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a physician or dentist which are furnished to an outpatient by a hospital. Outpatient services do not include direct – care services provid ed by physicians, podiatrists, and dentists. Inpatient Services All covered services provided to members during the course of an inpatient hospital stay except for direct-care services provided by physicians, podiatrists, and dentists. Emergency room (ER ) services are covered as an inpatient service when member is admitted from the ER. D. PolicyI. Three-Day Payment Rule. A. Claims submitted for outpatient services, including emergency room and observation services, provided within the three calendar days prior t o the inpatient admission for the same member for the same hospital may be denied, because the inpatient and outpatient services must be combined when they are related . 1. The outpatient services and inpatient admission must be submitted on one inpatient clai m. 2. The dates of the claims should begin with the outpatient service through the inpatient discharge. B. If the hospital submits the outpatient claim separately before the inpatient claim, the inpatient claim may be deemed as a duplicate claim and may be denie d payment. The hospital will need to void the paid claim for the outpatient service Three-Day Window Payment-MP-AD-1227 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.and resubmit the inpatient claim so that it includes inpatient and outpatient services. C. Physician practices and entities should use modifier PD (diagnostic or related non-diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days or 1 day) to identify services subject to the payment window. D. It is recommended that ICD-10 diagnosis code Z01.81X be used to indicate an encounter for preprocedural examinations to flag the outpatient claim as related to an inpatient service/procedure. II. Outpatient hospital behavioral health services provided in the outpatient hospital setting within three calendar days prior to the inpatient admission are exempt from the three-day window policy. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. Centers for Medicare & Medicaid Services (CMS). (2021 December 1). Three Day Payment Window Implementation of New Statutory Provision pertaining to Medicare 3-Day (1-Day) Payment Window Policy Outpatient Services Treated As Inpatient. Retrieved August 1, 2022 from www.cms.gov . 2. Centers for Medicare & Medicaid Services (CMS). (2020 December 3). FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients. MLN Matters SE20024. Retrieved August 12, 2022 from www .cms.gov. 3. Centers for Medicare & Medicaid Services (CMS). (2012 June 14). Frequently Asked Questions CR 7502. Retrieved August 1, 2022 from www.cms.gov. 4. Centers for Medicare & Medicaid Services (CMS). (2011, December 21). Pub 100-04 Medicare Claims Processing, Transmittal 2373. Retrieved July 29, 2022 from www.cms.gov . I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 Three-Day Window Payment-MP-AD-1227 Effective Dat e: 11/01/2022 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.B. Indiana1. Effectiv e: 11/01/2022 C. Kentucky 1. Effect ive: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effective: 11/01/2022
ADMINISTRATIVE POLICY STATEMENT Marketplace Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-MP-AD-1222 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited t o, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. Th ese services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of se rvices. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in th e Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatm ent of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………… 2 B. Background ………………………….. ………………………….. ………………………….. ……………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ……………………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. … 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. . 5 H . References ………………………….. ………………………….. ………………………….. ………………… 5 I. State-Specif ic Inf ormation ………………………….. ………………………….. …………………………. 5 Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. SubjectProgram Integrity Provider Prepayment ReviewB. BackgroundThis policy applies to participating (PAR) providers only.CareSource Program Integrity (PI) operates a provider prepayment review program to detect, prevent and correct fraud, waste and abuse and to f acilitate accurate claim payments. Physicians and other healthcare professionals may have the right to appeal resu lts of reviews. C. Def initionsProvider prepayment review-reviews medical record documentation and compares it to billed services.Program Integrity (PI) – Program integrity ref ers to the proper management and f unction of the health insurance program to ensure it is providing quality and ef f icient care while using f unds taxpayer dollars appropriately and with minimal waste.Certified Professional Coder (CPC) – The certified professional coder credential is of f ered through the American Academy of Prof essional Coders (AAPC).Prof essional coding is medical coding that is conducted in a prof essional environment such as a physician’s of f ice, outpatient setting, or hospital.Registered Health Information Administrator (RHIA) – A registered health inf orm ation administrator (RHIA) is a prof essional who handles patient health inf ormation. The RHIA role requires certification and must adhere to standards such as the Health Insurance Portability and Accountability Act and other privacy and security rules.Reg istered Health Information Technician (RHIT) – An RHIT is a certif ied prof essional who stores and verif ies the accuracy and completeness of electronic health records. An RHIT also analyzes patient data with the goal of controlling healthcare costs and impr oving patient care.D. PolicyI. A p rovider prepay review involves reviewing medical records compared to services billed prior to claim adjudication.A. Providers are placed on prepay review to monitor f or improper billing of medical claims including but not limited to the f ollowing reasons:1. Overutilization of services .2. Billing f or items or services not rendered .3. Selection of wrong CPT/HCPCS code or supplies .4. Lack of medical necessity .5. Billing/dispensing unnecessary services .6 . Procedure repetition .7. Upcoding . Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 8. Billing f or services outside of provider specialty .II. Placement on prepayment review will require the provider to submit medical records with each claim allowing CareSource to review the medical records in comparis on to the billed services.A. CareSource will provide a written 30 day notice to the provider/provider group advising them of the ef fective date of prepayment review.1. Prepayment review will be implemented f or a period of 6 months2. The 6 month period b egins upon the f irst successful adjudication of a claim submission under prepayment review.3 . All claims must be submitted with medical records.4. Medical records may be sub m itted in one of the f ollowing ways:a. Electronically with a claim .b. Submitted via the provider portal.Note: CareSource will not accept medical records via f ax. 5 . Failure to submit medical records to CareSource in accordance with this provisionwill result in claim denial.6 . Failure to meet minimal documentation sta ndards such as member name and date of service on each page of the medical record, a signed dated order and a valid provider signature will result in claim denial.7 . Providers must bill timely and accurate claims during the prepayment review period.III. CareSource utilizes our published decision hierarchy to conduct our reviews, in addition we may use:A. Centers f or Medicare and Medicaid Services guidelines as stated in Medicare manuals.B. Medicare local coverage determinations and national coverage determination s .C. All CareSource published policies (Administrative, Medical and Reimbursement),c ode-editing policies and CareSource provider manuals.D. National Unif orm Billing Guidelines f rom the National Billing Committee.E. American Medica l Association Current Procedural Terminology (CPT) guidelines.F. American Medical Association Healthcare current Common Procedure CodingSystem (HCPCS) Level II.G. ICD 10-CM of ficial guidelines for coding and reporting.H. American Association of Medical Audit Specialists national healthcare billing audit guidelines.I. Industry-standard utilization management criteria and/or care guidelines such asMCG guidelines (current edition on date of service).J. Food and Drug Administration guidance.K. National prof essional medical societys guidelines and consensus statements.L. Publication f rom specialty societies, such as the American Society f or Parenteral and Enteral Nutrition, the Substance Abuse and Mental Health ServiceAdministration, and the A merican Association of Neuromuscular & Mental HealthServices Administration .M. Nationally recognized, evidence-based published literature including, but not limited to, sources such as: Medscape, the American Academy of Pediatrics(AAP), and the American College of Obstetricians and Gynecologists (ACOG). Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. IV. The PI Provider Prepayment Review Team is made up of clinical review and coding specialists who maintain CPC, RHIA, or RHIT designation.A. The team reviews provider documentation to determine whethe r the claim is appropriate f or payment based on criteria including, but not limited to, provider documentation which establishes that:1. Services were provided according to CareSource policy requirements.2. Billed services were medically necessary and ap propriate, and not in excess of the member s need.3. Members were benefit eligible on the date the services were provided.4. Prior authorization was obtained if required by policy.5. Providers and their staf f were qualif ied as required by state or f ederal law.6. The providers possessed the proper license, certifications, or other accreditation requirements specific to the providers scope of practice at the time the service was provided to the member.V. Providers whose claims are determined not pa yable may send in new corrected claims, a dispute or an appeal, whichever is appropriate, within timely f iling limitations as outlined in their provider manual.A. Providers and/or billing managers may reach out directly to the PI prepayment review team to discuss specif ic claim denials.VI. Providers are prohibited from billing covered individuals f or services we have determined not payable as a result of the prepayment review process, whether due to f raud, abuse, waste of any other billing issue, or f or f ailure to submit medical records as set f orth above.VII. On completion of the six month review periodA. CareSource will determine if the provider is eligible f or release f rom prepayment review if :1. The provider has achieved an 85% or more approval rate on claim submissions f or 3 consecutive months and2. The volume of its claims submissions remained within 10% of the volume bef ore prepayment reviewB. If the provider successfully completes both requirements under A above bef ore the six month deadline th e provider may be removed f rom the prepayment review process at the discretion of CareSource.C. If the provider fails to satisf y the requirements above they may be placed under an additional 6 month prepayment review period and be required to submit a cor rective action plan.1. If af ter the second 6 month interval prescribed under sub section Cthe provider f ails to satisf y the requirements under sub section A1 and A2,CareSource may do the f ollowing :a. Deny payment f or medical assistance services rendered during a specif ied period of time b. Terminate the provider agreement c. Require a corrective action plan Pro gram In teg rity Pro vid er Prep aymen t Review-MP-A D-1222 Effective Date: 11/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 2. Providers who are able to demonstrate accurate billing practices and have been removed f ro m prepayment review may be subject to f uture f ollow up reviews to ensure continued compliance with billing practices.3. If a provider has been on a prepayment review f or 12 monthsCareSource may terminate the provider agreement if :a. There has been no bi lling activity f or 6 months; or b. The volume of claim submissions during the review period is not within10% of its volume bef ore prepayment review.4. Upon completion of the prepayment review period, the provider/provider group will receive notif ication in writings as to the ef fective end date of review.E. Conditions of CoverageN/AF. Related Policies/RulesN/AG. Review/Revision HistoryDATE ACTION Date Issued 08/17/2022 New Policy Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date Archived H . Ref erences1, Centers f or Medicare and Medicaid Services. Medicare Program Integrity Manual(April 21, 2022). Retrieved July 11, 2022 f rom www.cms.govI.State-Specific Information a. Georgia1. Effective: 11/01/2022b. Indiana1. Effective: 11/01/2022c. Kentucky1. Effective: 11/01/2022d. Ohio1. Effective: 12/01/2022e. West Virginia Pro g ram In teg rity Pro vid er Prep aymen t Review-MP-AD-1222 Effective Dat e: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n th e ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. i. Effective: 11/01/2022 I nd e pe n de nt med i ca l r e v iew
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