MEMO CONTINUED P. 3 July 24, 2017

TO: Dan Hounchell, Steve Curran

FROM: Shawn Stack

DATE: July 24 2017

SUBJECT: CareSource/Ohio Hospital Association/ Large Provider Group Call Notes on outstanding CareSource Issues

 Communication policy: edit changes, policies and medical review audits – Dan to send out an updated list of policy releases to OHA and Large Provider Group. CareSource to publish the release schedule on their website. CareSource is working on building a newsletter distribution list to get updates out to providers along with the redesign of their website. CareSource is looking at engaging a third-party administrator to oversee the process of gathering email distribution lists and having providers sign-up for a mailing list through their new website enhancements. ETA on newsletter: Fall 2017.

 Provide an update of the CareSource Plan to resolve and provide clear and concise policy surrounding the reoccurrence of the LCD/NCD edits and reprocess all impacted claims without provider required appeals – CareSource reports that the 146 NCD/LCD edits have all been reprocessed.

 STI Policy. - CareSource is researching additional updates needed to the STI policy/edit. Dan Hounchell is to report back to OHA and LPG on any outcomes of this research.

 New vs. Established Patients -CareSource to look releasing documentation on their policy on how to bill New vs. Established patients so providers are clear on the edits in the CareSource system. OHA and LPG agrees with the directive published from CMS in 2000 and then the changes in 2008 make this area gray and want to roll out clarification surround the billing of New vs. Established patients to CareSource. MEMO CONTINUED P. 2 July 24, 2017

 Discuss the continuing issues with CareSource recoupments. 1) Payments are taken back in duplicate. 2) Refunds are made to CareSource on behalf of the hospital/provider within the request 60-day period, yet CareSource also recoups – CareSource reports that an audit of recoupments was completed by July 22 and mass adjustments will be made to all impacted claims by the end of July.

 Hospitals are having issues with CareSource’s secondary billing process. Example: Hospital bills CareSource primary, CareSource denies the claim and sends to Permedion to have hospital bill the primary payer. Hospital bills primary and send secondary claim to CareSource to process the copay or deductible… CareSource sends the secondary claim back to Permedion a second time without processing for secondary payment – CareSource is still researching this outstanding issue reported by Large Provider Group.

 The reimbursement levels for outpatients which changed in July 2016 for pediatric hospitals continue to be incorrected. CareSource is paying pediatric claims at level 2 and should be paying at level 1. -CareSource states this issue has been correct and adjustments have been made to claims impacted.

 Three-Day/72 hour Medicaid OP/IP Rule being adopted by CareSource – CareSource states that all claims have been reprocessed. However, CareSource is researching an issue with OP Behavioral Health claims being incorporated into this reprocessing and CareSource may have to correct those scenarios. Dan Hounchell is considering the status of the impacted behavioral health claims.

 Strep throat denials – CareSource states that the reprocessing of strep throat denials has been completed and network notification was released. MEMO CONTINUED P. 3 July 24, 2017

 CareSource has been processing take-backs on infusion therapy claims that providers had authorized. CareSource is rescinding their payments as “services do not meet medical necessity criteria”

– CareSource reports they are conducting an internal audit the last week of July and any potential refunds due to hospitals will be processed within two weeks.

 Thyroid denials – CareSource reports that a new policy has been released to providers, claims have been audited for errors and any impacted claims will be reprocessed and paid on August 5.

 PCR/Lab Testing – CareSource reports that meeting codes in the configuration set-up for payment were resolved by July 12. Mass claim adjustments to correct denials back to Sept. 2016 (policy effective date) will be completed by July 29. CareSource’s clinical review process for the larger clinical concerns on this policy are underway and updates to the policy will follow the formal communication/network notification.