Routine Hearing Services, Hearing Aids, and Related Services (Coverage Criteria)
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Defines coverage, limits, provider network, and related services for routine hearing services and hearing aids for CareSource Marketplace Ohio members, including administration by TruHearing and age-based benefit limits.
Policy Summary
PayerCareSource Georgia
PolicyRoutine Hearing Services, Hearing Aids, and Related Services (Coverage Criteria)
Policy CodePolicy POLMP-OH(2025) Rev.1
Change TypeAmendment updating hearing aid services administration and requirements
Effective DateApr 3, 2025
Last ReviewApr 3, 2025
Next Review DateN/A
Key ActionUse a TruHearing Network Provider and select hearing aids from the approved hearing aid list to obtain covered hearing aid services.
The Evidence of Coverage language for hearing aid services is updated and administered by TruHearing through the TruHearing Choice Program.
1routine hearing screening per benefit year
1routine hearing exam per benefit year
$2,500max hearing aid benefit per ear (≤21)
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48 months
frequency cap for hearing aid benefit
22+TruHearing discount program age threshold
Coverage Criteria and Benefit Rules
Covered Hearing Aid Benefit and Related Services
Covered when ALL of the following are met
Eligibility & Provider Network: Member uses a TruHearing Network Provider; hearing aids must be listed on the approved hearing aid list to be Covered Services; if a member does not use a TruHearing Network Provider for services in this section, the services will be considered Non-Covered Services and the member is responsible for all costs.
See TruHearing network and product-list requirement
Age-limited hearing aid benefit (children/young adults): For Covered Persons age 21 or younger verified as deaf or hearing impaired by a licensed audiologist, otolaryngologist, or other licensed physician: benefit limited to one hearing aid per hearing-impaired ear up to $2,500 every 48 months; member responsible for costs above $2,500.age <= 21; $2,500 per ear; frequency = 48 months
Verification required from licensed audiologist/physician
Included related services and support: When a hearing aid is a Covered Service, related services necessary to assess, select, fit, and adjust the hearing aid are included at no member cost share and must be provided as specified: first-year follow-up visits, a 60-day trial period, a 3-year extended warranty, 80 batteries per aid for non-rechargeable models, and ear molds ordered by an Ohio-licensed Physician or audiologist.60-day trial; 3-year warranty; 80 batteries per aid
Related services included only for covered hearing aids on the approved list
TruHearing Choice Discount Program (non-benefit): TruHearing also offers a Choice Discount Program for Covered Persons aged 22 and older; purchases under this discounted program are not a Plan Benefit and are paid 100% by the member.age >= 22
Discount program is separate from Plan coverage and not a Covered Service
Limitations and exclusions specific to the program: Hearing aids not considered Medically Necessary per state speech and hearing professionals board standards are not covered; non-routine and medical-based hearing exams, hearing aid accessories except as listed, additional provider visits beyond those included, additional batteries beyond the included amount, replacement batteries for rechargeable hearing aids, hearing aids not in the applicable TruHearing catalog, and costs associated with loss and damage warranty claims are excluded.
See Limitations subsection for full list
Enrollment and Dependent Coverage Criteria
Covered benefits and eligibility are subject to enrollment, payment of premiums, and meeting Marketplace or Plan eligibility rules. Dependent coverage has specific rules.
Member Enrollment and Premiums: Member must be enrolled for coverage under the Plan and must pay any required Premiums; enrollment must follow Plan and Marketplace eligibility requirements.
Enrollment and premium payment required
Residency and Service Area: To be eligible through the Marketplace, the member and dependents must meet Marketplace eligibility (citizen or lawfully present immigrant, not incarcerated, resident of Ohio and within the Plan's Service Area); eligibility determinations are made by the Marketplace (or by CareSource for off-Marketplace enrollment).
Residency and Service Area requirements
Dependent Limiting Age and Disabled Dependent Exception: Dependent child is eligible until the end of the Benefit Year in which the child reaches age 26. A dependent over age 26 who is incapable of self-sustaining employment due to developmental or intellectual disabilities or physical handicap and is primarily dependent on the subscriber may remain eligible with satisfactory proof.limiting age = 26; exception for qualifying disabled dependents
Special Enrollment Periods
Special enrollment periods are provided when ANY of the following qualifying events occur:
Loss of minimum essential coverage (e.g., job loss, quitting, divorce/legal separation, no longer residing in Plan service area, aging out, loss of parent's plan) qualifies for special enrollment.60 calendar days from triggering event
Length of special enrollment period is 60 days unless stated otherwise
Changes in other coverage or plan status: Enrollment in a non-calendar year group plan, violation of material contract by prior plan, QHP decertification, gaining access to new QHPs after a permanent move, or enrollment errors due to Marketplace/provider misconduct qualifies for special enrollment.60 calendar days
Various administrative qualifying events
Life events creating or changing dependent status: Gaining or becoming a dependent through marriage, birth, adoption or placement for adoption, foster care, child support or court order, release from incarceration, death of a member or dependent, or domestic abuse/spousal abandonment qualifies for special enrollment.
Enrollment Effectivity and Confirmation
Coverage effective dates and confirmation
Marketplace vs Plan confirmation: If enrolled through the Marketplace, the Marketplace confirms eligibility and effective date and notifies CareSource; if enrolled outside the Marketplace, CareSource confirms eligibility and effective date in writing.
Effective date determined by enrollment pathway
Effectuation and payment requirement: Coverage becomes effective on or after the coverage effective date once payment sufficient to effectuate coverage (e.g., Binder Payment or required premium) has been received.
Coverage provided on and after effective date when payment received
No refusal for health condition: CareSource may not refuse to enroll you in the Plan because of your health condition.
Eligibility confirmation is not contingent on health status
Dependent Enrollment and Termination
Dependent enrollment and termination protections
Non-discrimination in dependent enrollment: CareSource will not deny enrollment of a child because the child was born out of wedlock, is not claimed on the subscriber's federal tax return, or does not reside in the subscriber's household or service area.
Statutory protections for dependent enrollment
Enrollment by other parent or pursuant to order: If a parent is required by court or administrative order to provide coverage and fails to apply, CareSource will enroll the Dependent upon application from the other parent or pursuant to a child support order as required by state law.
Enrollment may be effectuated by other parent or per court order
Termination protections: Termination of a dependent's coverage will not occur unless CareSource receives satisfactory written evidence that the court or administrative order is no longer in effect or that the child will be enrolled in comparable coverage effective no later than the Plan termination date.
Written evidence required before termination
Medically Necessary and Experimental/Investigational criteria
Covered when services meet the Plan's medical necessity definition and are not Experimental or Investigational, except in narrow life‑threatening exceptions.
Primary Medical Necessity Conditions: Service is a Covered Service under a specific Benefit provision; is not listed as an Exclusion; and is determined to be Medically Necessary per CareSource medical policies and nationally recognized guidelines (consistent with prevailing peer-reviewed literature and accepted clinical guidelines).
Medical Necessity definition requires safety, effectiveness, cost-efficient setting, and consistency with diagnosis
Experimental/Investigational exceptions: A service otherwise deemed Experimental or Investigational may be considered Covered for a life‑threatening condition if CareSource determines it is promising and used in a clinically controlled research protocol meeting standards equivalent to NIH; such exceptions are narrow and require review and authorization.life‑threatening condition criteria
Experimental/Investigational definition and exception process
Non-Network Provider Coverage Conditions
Covered Services from Non-Network Providers are allowed only in specified circumstances and subject to Prior Authorization when required.
Situations where Non-Network Services are Covered: Health Care Services from Non-Network Providers are Covered Services if any of the following apply: Emergency Health Care Services (including Emergency Ambulance Services); Urgent Care Services while temporarily outside the Service Area; specified continuity of care situations; services provided by a Non-Network Provider while you are in a Network Facility (e.g., anesthesiologist, pathologist, ER physician, radiologist); or the needed Covered Services are not available from a Network Provider or Facility and Prior Authorization is obtained.
Except for emergency/urgent and in-facility exceptions, Prior Authorization is required
Prior Authorization requirement for Non-Network: With the exception of Emergency Health Care Services, Emergency Ambulance Services, Urgent Care Services while temporarily outside the Service Area, and services by a Non-Network Provider while in a Network Facility, you or the Non-Network Provider must obtain Prior Authorization before receiving the services; failure to obtain Prior Authorization will result in services being considered Non-Covered Services.
Ohio and federal laws (No Surprises Act) modify balance billing protections for emergency care
Prior Authorization Requirement
When Prior Authorization is required for Non-Network services:
Prior Authorization Rule: You or the Non-Network Provider are required to obtain a Prior Authorization before receiving the services; failure to obtain a Prior Authorization will result in the services being considered Non-Covered Services.
Non-Network services payable only if Prior Authorization obtained (except emergencies/urgent/in-facility)
Payment limits and filing responsibilities: When Covered, Non-Network services will be payable at the Network level and limited to the Maximum Allowable Amount; you are responsible for filing the claim and for payment of any Non-Covered Services, services not Medically Necessary, and any difference between the provider's charge and the Allowed Amount plus applicable deductible/coinsurance/copayment.
Member financial responsibility explained
Payment and Member Responsibility
Financial and claims handling for Non-Network Provider services when covered:
Payment and Member Responsibilities: Non-Network services that are Covered will be paid at the Network level and limited to the Maximum Allowable Amount; the member is responsible for filing claims and paying for Non-Covered Services, services not Medically Necessary, and any amounts in excess of the Allowed Amount plus applicable Deductible/Coinsurance/Copayment.
Exceptions apply for emergency and in-facility services per policy
Grace Period Impact on Claims
Effects of Premium non-payment on claim processing (Grace Period):
Grace Period with APTC: If receiving Advance Premium Tax Credit (APTC): Grace Period is three consecutive months after a missed premium; the Plan will continue to pay Covered Services during the first month, hold processing of non-prescription drug claims for months two and three (or reserve right to recover amounts paid), reject Prescription Drug Services during months two and three, and notify Network Providers of the possibility of denied claims.3 months
Providers are notified of potential denied claims
Grace Period without APTC: If not receiving APTC: Grace Period is 31 consecutive calendar days after missed premium; the Plan may hold processing of non-prescription drug claims during the Grace Period, reject Prescription Drug Services during the Grace Period, and notify Network Providers of the possibility of denied claims.31 days
Held claims processed if premium paid before Grace Period ends; otherwise denied and coverage terminated retroactively as described
Payment processing and continuity criteria
Rules for payment processing and continuity during Grace Periods and when providers leave the network:
Grace Period processing rules: If a member receiving APTC misses a Premium payment, the Grace Period is three months; Plan continues to pay Covered Services during month one, may hold or reserve recovery of non-prescription claims during months two and three, and will reject prescription drug services during months two and three; if not receiving APTC, the Grace Period is 31 days with similar holding/rejection rules. Payment of the outstanding Premium in full before the Grace Period expires results in processing of held non-prescription claims and notification to providers/HHS; expiration without payment results in termination retroactive to specified dates and denial of held claims.3 months with APTC; 31 days without APTC
See Grace Period provisions for outcomes
Provider leaving Network - notification and temporary payment: When the Plan is aware a PCP or Hospital a member sees on a regular basis is leaving the Network, the Plan will notify the member in writing within 30 days; the Plan will pay for Covered Services received between the provider leaving date and five days after mailing notice at in-network rates and calculate cost-sharing at in-network rates; the PCP/Hospital cannot balance bill beyond allowed member cost share.30 days notification; payment for services up to 5 days after mailing notice
Continuity for existing members (provider removed)
Covered when ALL of the following are met:
Continuity for existing members: Member is enrolled in a QHP on-exchange product AND is undergoing an Active Course of Treatment with a PCP or provider seen on a regular basis AND the provider was removed from the network without cause.
If authorized, coverage may continue up to 90 days from provider leaving or until treatment completion, paid at in-network rates though provider may balance bill in certain circumstances
Continuity for pregnancy
Covered when ALL of the following are met:
Pregnancy continuity: Member is pregnant AND the Network Provider seen in connection with pregnancy leaves the network for reasons other than fraud or quality of care.
If authorized, member may continue to receive Covered Services from that provider through delivery and postpartum; provider must contact Medical Management for Prior Authorization
Continuity for terminal illness
Covered when ALL of the following are met:
Terminal illness continuity: Member has a Terminal Illness AND the provider treating the terminal illness is no longer participating in the Plan (for reasons other than fraud or quality of care).
With Prior Authorization from Medical Management, coverage may continue until care is no longer needed; provider must contact Medical Management
Continuity for new members
Covered when ANY of the following apply:
New member continuity scenarios: For up to 30 days after the coverage effective date if a non-network clinician does not participate in another Marketplace QHP for which the member is eligible OR the clinician is providing an Active Course of Treatment or is the member's PCP; through postpartum if pregnant; or until death if terminally ill.30 days general; through postpartum; until death for terminal illness
Prior Authorization required before continuing care with a Non-Network Provider
Emergency Health Care Services
Stance:
Emergency care coverage stance: Emergency Health Care Services are covered without prior authorization and are covered in the U.S. and abroad; Emergency services rendered by Non-Network Providers are treated as Covered Services with the same member cost-sharing as Network care; follow-up care after stabilization requires Prior Authorization to be covered when provided by Non-Network Providers.
Members should notify PCP/CareSource as soon as reasonably possible and inpatient admissions from ER require notification within 24 hours
Urgent Care outside service area
Covered when ALL of the following are met:
Urgent care outside service area: Member receives urgent care from Non-Network Providers while temporarily outside the Service Area; care should be obtained from the nearest appropriate provider and is limited to the Maximum Allowable Amount; certain care types (foreseeable, routine/preventive, elective procedures that can be delayed, and follow-up care that can wait) are not covered while outside the Service Area.
If hospitalized outside the Service Area after urgent care, member must call PCP and CareSource within 48 hours after admission
Non-network inpatient referral: Hospital services needed are not available from any Network Hospital AND the PCP obtains Prior Authorization for referral to a Non-Network Hospital.
CareSource will comply with No Surprises Act requirements; except for emergency admissions, member should call PCP before going to hospital
Covered Services and Conditions
Covered when services meet Medical Necessity, are not Experimental/Investigational, and follow Plan rules (Network providers, prior authorization when required):
Urgent and Emergency care: Urgent Care Services outside the Service Area and Emergency Health Care Services are Covered when appropriate per definitions; obtain nearest appropriate care; benefits limited to the Maximum Allowable Amount; follow-up care after stabilization requires authorization when provided by Non-Network Providers.
Emergency services do not require Prior Authorization
Inpatient and Hospital services: Except for Emergency Medical Conditions, members should call their PCP before going to a Hospital; referrals to Non-Network Hospitals are allowed only when Network Hospitals cannot provide required services and Prior Authorization is obtained; No Surprises Act protections apply.
Network referral and authorization processes must be followed
Ambulance services: Emergency ambulance to the nearest appropriate ER is covered; non-emergency ambulance is covered only for specified listed reasons (e.g., ordered by authority when member cannot refuse; Non-Network to Network transfers; higher level care; to a more cost-effective facility; acute to sub-acute transfers; hospital to SNF; hospital/SNF to home). Ambulettes, taxis and similar vehicles are not covered.
Diagnostic Services
Covered when ALL of the following are met
Diagnostic Services Coverage: Service is a non-invasive diagnostic service (e.g., x-ray, labs, MRI/MRA/PET/CT, ultrasound, ECG, EMG except surface EMGs, BAER, SSEP, VEP, nerve conduction studies, echocardiogram) and any central supply or pharmacy items necessary to perform the diagnostic service are provided.
Surface EMGs are explicitly excluded
Emergency Health Care Services
Emergency services are covered without prior authorization when presenting symptoms reasonably appear to constitute an Emergency Medical Condition.
Emergency Care Coverage: Services that meet the definition of Emergency Health Care Services including screening, stabilization, and treatment in the ER are covered whether rendered by Network or Non-Network Providers without Prior Authorization; inpatient admissions from the ER require notification within 24 hours and Prior Authorization for the inpatient stay; follow-up care beyond stabilization requires authorization to be covered when provided by Non-Network Providers.
Member should notify PCP/CareSource as soon as reasonably possible
Habilitative Services
Covered when ALL of the following are met
Habilitative Services: Provided on an outpatient basis for Covered Persons with congenital, genetic, or early acquired disorders; administered by appropriately licensed providers; not Experimental or Investigational; services that are solely educational or custodial are not Habilitative Services.Physical, Speech, Occupational Therapy limits = 20 visits each per Benefit Year
Habilitative services must demonstrate progress under a treatment plan
Home Health Care Services
Covered when ALL of the following are met
Home Health Care: Patient is confined to the home for medical reasons and physically unable to obtain needed services on an Outpatient basis; services must be provided by a Home Health Care Agency or approved organization supervised by the agency; included services are intermittent skilled nursing, therapy services (subject to Home Health visit limits), medical/social services, medical supplies, DME, prescription drugs billed by the agency, and private duty nursing as specified.Home Health: 100 visits per Benefit Year; Private duty nursing: up to 100 eight-hour visits per Benefit Year
Therapy rendered in the home counts toward Home Health visit limits
Hospice Care
Covered when ALL of the following are met
Hospice Care: Patient has a Terminal Illness with life expectancy of six months or less as confirmed by attending Physician; covered services include skilled nursing, diagnostic services, therapies if part of plan, medical supplies, counseling, inpatient hospice and respite, prescription drugs given by hospice, and home health aide services; benefits continue if patient lives longer than six months.life expectancy = 6 months (typical)
Eligibility confirmed by attending Physician
Maternity Services
Covered when ALL of the following are met
Maternity Services: Includes inpatient, outpatient, home visits and office services for normal or complicated pregnancy; minimum postpartum inpatient stay of 48 hours for vaginal delivery and 96 hours for cesarean delivery with possible Prior Authorization for longer stays; at-home post-delivery visit by physician or nurse within 72 hours after discharge.48 hours vaginal; 96 hours cesarean; 72-hour home visit
Shorter stays permitted with member consent and clinician determination of stability
Infertility Services
Covered when ALL of the following are met
Infertility Services: Services for diagnosis and treatment of underlying causes of infertility are covered when provided by or under the direction of a Network Provider and are Medically Necessary (examples: endometriosis, tubal blockage, varicocele); not all infertility-related services are covered and refer to exclusions for specifics.
Refer to Section 7: What Is Not Covered for exclusions
Medical Supplies and DME
Covered when ALL of the following are met
DME & Medical Supplies: Medical supplies, Durable Medical Equipment, and appliances are Covered Services only if Medically Necessary; repairs/replacements are covered when the item is a Covered Service, continued use is Medically Necessary, and there is reasonable justification for repair/replacement (warranty expiration alone is not reasonable).
Replacements not covered for misuse, malicious breakage, gross neglect, or lost/stolen items
Repairs or Replacements
Covered when ALL of the following are met
Repair/Replacement of Purchased Items: Equipment, supply or appliance is a Covered Service; continued use is Medically Necessary; and there is reasonable justification for repair, adjustment, or replacement (warranty expiration alone is not reasonable); assessment by a rehabilitation equipment specialist/vendor is recommended when evaluating repair vs replacement costs.
Repairs/replacements due to misuse, malicious breakage, gross neglect, or lost/stolen items are not covered
Replacement Conditions
Replacement may be covered when ANY of the following are met
Replacement Conditions: Replacement is allowed when the item is worn out or no longer functions; repair is not possible or would equal/exceed replacement cost; patient needs have changed due to weight gain, growth, or deterioration; or the item is damaged and cannot be repaired.
Warranty expiration alone is not sufficient justification
Prosthetics and Orthotics
Covered when ALL of the following are met
Prosthetics: Artificial substitutes for body parts/tissues and materials inserted into tissue for functional or therapeutic purposes are covered, including purchase, fitting, adjustments, repairs and replacements when Medically Necessary; prosthetic devices should be purchased rather than rented when Medically Necessary.
Examples include cochlear implants, intraocular lenses, breast prosthesis after mastectomy, LVAD as bridge to transplant
Orthotics: Initial purchase, fitting, and repair of custom made rigid or semi-rigid orthotic devices are covered when Medically Necessary; casting, molding, fittings and adjustments are covered when billed with the orthotic; orthotic appliances may be replaced once per Benefit Year when medically necessary with additional replacements allowed for damage or growth in members under 18.
Applicable taxes, shipping, and handling also covered
Outpatient Rehabilitative Services
Covered when ALL of the following are met
Therapy medical necessity: Therapy services must be expected by a Network Provider to result in a practical improvement in functioning within a reasonable period of time; Prior Authorization may be required for therapy services.
Medical necessity and prior authorization requirements apply
Visit Limits: Physical, Occupational and Speech Therapy each have a Benefit Limit of 20 visits per Benefit Year; Manipulation Therapy 12 visits; Physical Medicine & Rehabilitation 60 visits; Cardiac Rehabilitation 36 visits; Pulmonary Rehabilitation 20 visits; Post Cochlear Implant Aural Therapy 30 visits; Cognitive Rehabilitation 20 visits.PT/OT/Speech = 20 visits; Manipulation = 12; PM&R = 60; Cardiac = 36; Pulmonary = 20; Post-cochlear = 30; Cognitive = 20
Some therapies (chemotherapy, dialysis, radiation, inhalation) have no limits
Outpatient Services
Covered as Outpatient Services
Outpatient Services: Facility, ancillary, facility use, and professional charges when given as an Outpatient at specified facilities (Hospital, Alternative Care Facility, Retail Health Clinic, ambulatory surgical center) are covered; diagnostic or therapy services charged as the only outpatient item as part of outpatient surgery may have no Copayment though Coinsurance may apply.
Professional charges must be billed by a Network Physician/Provider
COVERAGE CRITERIA
Covered when ALL of the following are met
Therapy general medical necessity: A Network Provider expects the therapy services will result in practical improvement in the member's level of functioning within a reasonable period of time; documentation should support expected improvement and intensity of therapy.
Prior Authorization may be required
Service-specific limits and conditions: Services are subject to visit/session limits and program requirements as specified (e.g., PT 20 visits, OT 20 visits, Speech 20 visits, Manipulation 12 sessions, PM&R/Day Rehab 60 visits, Cardiac Rehab 36 visits, Pulmonary Rehab 20 visits, Post‑cochlear implant aural therapy 30 visits).as listed
Day Rehabilitation requires minimum intensity and multidisciplinary approach
Day rehabilitation criteria: Day Rehabilitation is covered for individuals who do not require inpatient care but need structured program 4–8 hours/day, 2+ days/week, with at least two therapy services and a multidisciplinary coordinated team approach.
Covered and limited services (excerpt)
Coverage and limits described in this excerpt (apply when Medically Necessary and authorized):
Live donor procurement: Plan covers Medically Necessary procurement of an organ from a live donor and donor complications up to six (6) weeks from procurement; benefits limited to those not available from other sources.6 weeks
Live donor benefits limited to those not available from other sources
Transplant benefit period: Benefit period for a covered transplant begins one (1) day prior to the covered transplant procedure and continues for the applicable case rate/global time period or to discharge for Non-Network transplant Provider facilities; duration varies by transplant type/network agreement.1 day prior
Contact Case Manager for network-specific details
Transportation and lodging for transplants: If Prior Authorization is obtained and member must travel more than 75 miles to the transplant Facility, Plan may provide transportation and lodging benefits for the patient and one companion (two companions for minors); itemized receipts required and maximum reimbursement limits apply.
General coverage conditions
Covered when ALL of the following apply
Formulary coverage basics: Drug is on the Prescription Drug Formulary or a non-Formulary drug exception has been granted via the drug exception process; Formulary listing is the primary determinant of coverage.
Formulary is available online and by request
Prior Authorization for drugs: If a drug is designated PA on the Formulary, the provider must submit required clinical information electronically or by fax and obtain Prior Authorization before coverage is approved; includes certain controlled substances and opioids for chronic pain.
Provider must provide medical history, prior drugs tried, test results as requested
Step Therapy: If a drug is designated ST on the Formulary, required step(s must be completed (try specified alternative) or a bypass must be approved before the drug will be covered; providers can request a bypass with supporting rationale.
Expedited internal appeal timelines apply for Step Therapy exemption denials
Not Covered / Exclusions
The following services are not covered unless specifically listed elsewhere in the Evidence of Coverage or required by law.
Major exclusion categories: Experimental or Investigational services; services related to employment/workers' compensation; governmental benefits; non-network provider services except authorized; services exceeding benefit limits; services from unrecognized providers; services while incarcerated if government liable; custodial or domiciliary care; maintenance therapy; cosmetic procedures (and related complications); reproductive technologies and related services (ART); bariatric surgery; weight loss programs; hearing aids and related services except as specifically listed as a Covered Service; vision services/equipment except as specified; dental services except as specified; alternative/complementary medicine; many other items enumerated in Section 7.
See Section 7 for detailed itemization of exclusions
Experimental or Investigational Criteria
A service is deemed Experimental or Investigational if ANY of the following apply when rendered:
E/I determination criteria: The service cannot be legally marketed in the U.S. without final FDA approval for the proposed use; FDA has contraindicated the use for the specific purpose; the service is provided as part of a clinical research protocol or ongoing Phase I–III Clinical Trial; is subject to IRB review; or is provided pursuant to informed consent documents describing it as investigational; devices approved under Humanitarian Use Device exemption are not considered Experimental.
Plan evaluates peer-reviewed literature, FDA documents, IRB protocols, expert opinion when determining E/I status
Appeals and External Review Criteria
Internal and External Appeals are governed by specific submission requirements and timelines; include expedited pathways for urgent situations.
Internal Appeal submission requirements: Internal Appeals must be submitted in writing within 180 days of receiving an Adverse Benefit Determination (except Urgent Care appeals may be verbal or electronic). Submissions must include member name and ID, provider name, date of service, reason for disagreement, supporting documentation, and signed consent for representative appeals.180 days
Submit to CareSource Ohio Member Appeals as directed
Internal Appeal timelines: For Pre-Service Review or Step Therapy exemption denials, the Plan must notify within 10 calendar days; for other denials, notify within 30 calendar days. Expedited Internal Appeals will be completed within 48 hours for Pre-Service/Step Therapy and within 72 hours for other expedited appeals.10/30 days; expedited 48/72 hours
Expedited timelines apply when eligibility criteria met
Expedited Internal Appeal criteria:
Hearing aids and related services administered through the TruHearing program are subject to specific coverage limits and vendor requirements. In particular, the Plan does not cover hearing aids that are not considered Medically Necessary per state speech and hearing professionals board standards, nor does it cover hearing aids that are not included in the applicable TruHearing catalog. Related exclusions explicitly include non-routine and medical-based hearing exams, ear molds (unless provided as a covered service elsewhere), hearing aid accessories (except those listed as included), additional provider visits, additional batteries beyond the included supply, replacement batteries for rechargeable models, and costs associated with loss or damage warranty claims. Verification and use of TruHearing network products are required for the hearing aid benefit to be treated as a Covered Service.
Members remain financially responsible for services that exceed Plan limitations or that are not Covered Services. The EOC directs readers to review Section 7: What Is Not Covered for the full exclusions list. Where a service is excluded or exceeds a benefit limit, the member must pay the full cost; this applies even when an item or service is described elsewhere in the document—the contract terms and Schedule of Benefits control member liability.
Certain costs never count toward the Annual Out-of-Pocket Maximum. Charges for services that are not Covered Services, premium payments, balance billed charges, and adult vision benefits (when applicable) are explicitly excluded from application to the out-of-pocket maximum. Additionally, Copayments/Coinsurance tied to optional Riders or Enhancements are excluded unless the Rider/Enhancement states otherwise.
Coverage under the Plan is limited to services that meet the Plan's definition of Covered Services and are determined to be Medically Necessary per CareSource medical policies and nationally recognized guidelines. Services that are Excluded under the Plan or that fail to meet Medical Necessity criteria (including services deemed Experimental/Investigational absent an applicable exception) are not Covered Services; members are responsible for payment of such services. Non-Network services may only be covered in defined circumstances and often require Prior Authorization to avoid designation as Non-Covered Services.
Services categorized as Experimental or Investigational are excluded from coverage unless an exception applies. The policy defines Experimental/Investigational to include interventions not approved by the FDA for the proposed use, services provided in clinical trials primarily for data collection, technologies billed with temporary procedure codes, or services subject to IRB oversight. An exception may be considered for life‑threatening conditions when the Plan determines the intervention is promising and used within a research protocol meeting NIH-equivalent standards. External independent review (IRO) may review Experimental/Investigational determinations unless the requested service is explicitly listed as an exclusion under the Plan.
Except for Emergency Health Care Services, Urgent Care Services and certain services rendered by Non‑Network Providers while the member is in a Network Facility, services provided by Non‑Network Providers require Prior Authorization and are otherwise treated as Non‑Covered Services. Emergency services are covered without prior authorization and are protected from balance billing under applicable rules; Non‑Network ancillary services provided within a Network Facility have special consent and notice requirements before balance billing may occur.
Charges that are not Covered Services—such as Non-Covered Services, certain adult vision benefits, premium payments, and balance-billed charges—do not apply toward the member's Annual Out-of-Pocket Maximum. Members must also pay amounts that exceed Eligible Expenses and any amounts resulting from failure to obtain required authorizations.
When a member is temporarily outside the Plan's Service Area, the Plan will cover reasonable Urgent Care and Emergency Health Care Services from Non‑Network Providers, but will not cover care that could reasonably have been foreseen before travel (including ongoing treatment for chronic conditions), routine or preventive services, elective inpatient stays or outpatient surgery that can be delayed, or follow‑up care that can wait until return. If hospitalized outside the Service Area after urgent care, the member must notify their PCP and CareSource within 48 hours or as soon as reasonably possible.
The Plan excludes foreseeable care prior to leaving the Service Area (including ongoing chronic care), routine and preventive care, elective procedures that can be delayed, and follow-up care that can wait until return. Additional exclusions across the EOC include custodial and domiciliary care, certain clinical trial services (those provided solely for data collection or free of charge), and limits such as the $3,000 cap on accidental dental injury benefits. Claims from Non‑Network laboratories are generally non‑covered unless an exception applies (e.g., emergency or Non‑Network lab work while in a Network Facility).
Numerous routine living‑and-convenience items and services are not Covered Services, including food, housing, homemaker services, home-delivered meals, services provided by non‑contracted individuals or family members, and a range of consumable supplies. Transportation and lodging reimbursements are subject to plan limits and prior authorization and expressly exclude childcare, local mileage within a facility's city, rental cars/taxis except when approved, frequent flyer miles, and similar nonessential travel charges.
Common consumable items and over‑the‑counter convenience supplies are excluded from coverage (examples include adhesive tape, Band‑Aids, cotton tipped applicators, arch supports, donut cushions, hot/cold packs, and most vitamins unless covered under the Formulary as a Preventive Service). Other routinely excluded durable or environmental items include air conditioners, raised toilet seats, and non‑covered assistive devices not meeting the Plan's DME criteria.
Exclusions also include maintenance therapy and repetitive or general exercise programs that are intended only to preserve current function rather than produce practical improvement. Specific therapy modalities excluded include diathermy and ultrasound for pulmonary conditions, and services that are diversional or vocational in nature. Manipulation therapy provided in the home as part of Home Health Care Services is not covered. For hearing-related benefits, non‑routine medical exams, ear molds, hearing aid accessories beyond what is included, additional batteries beyond the included supply, and hearing aids outside the TruHearing catalog are excluded.
Manipulation therapy provided in the home as part of Home Health Care Services is explicitly not covered under the Plan; manipulation benefits apply only as specified in outpatient settings and are subject to the stated session limits.
The Plan lists numerous additional non‑covered items and services (e.g., childcare, certain travel expenses, mileage within a facility city, rental cars/taxis except when authorized, frequent flyer miles, prepayments and deposits, telephone calls, laundry, and entertainment). Vision exclusions are also extensive — services outside the EyeMed network, experimental vision services, replacement of lost/stolen eyewear, non-prescription lenses, visual therapy, and services not listed as Covered Services are examples. Alternative and complementary medicine therapies are similarly excluded unless explicitly covered.
Prescription drugs and devices are subject to Formulary and coverage rules. The Plan excludes drugs and devices that are not on the Formulary and lack required clinical appropriateness, are not FDA‑approved for the proposed use, are dispensed outside coverage eligibility dates, are payable by other programs (e.g., Medicare or workers' compensation), or are dispensed by a Non‑Network Pharmacy. Compounded drugs with non‑FDA-approved ingredients or drugs typically administered in an outpatient setting that the Plan excludes are also not covered unless an exception is obtained.
The exclusions list includes a broad set of services and procedures that are not Covered Services unless specifically listed elsewhere or required by law. Notable exclusions are cosmetic procedures and related complications, assisted reproductive technologies (ART), most hearing aids and associated services unless specified in Section 5, routine vision services outside the EyeMed program, bariatric surgery and related care, and many alternative/complementary therapies. The hearing aid program itself defines the limited covered components and enumerates the items that are not covered.
Experimental or Investigational services are excluded unless CareSource makes an exception. When a Final Adverse Benefit Determination involves a medical judgment or an Experimental/Investigational finding, the member may pursue an External Review by an accredited Independent Review Organization (IRO) unless the requested service is explicitly listed as an exclusion under the Plan. For life‑threatening illnesses, CareSource may consider Experimental/Investigational services if they are promising and provided within a research protocol that meets NIH‑equivalent standards.
Codes, Limits, and Quick Reference Values
Covered Diagnostic ServicesmixedCovered
mixed
X-ray and other radiology services; laboratory and pathology services; advanced imaging (MRI, MRA, PET, SPECT, CT); allergy testing; bone density testing; cardiographic, encephalographic, and radioisotope tests; nuclear cardiology; ultrasound; electrocardiograms; electromyograms (surface EMGs not covered); echocardiograms; diagnostic tests for transplant evaluation; echography; Doppler studies; BAER; SSEP; VEP; nerve conduction studies; muscle testing; electrocorticograms; central supply or pharmacy items necessary to perform diagnostic services.
Medical and Surgical SuppliesmixedCovered
NDC/PriorAuth
Therapeutic foods, formulas, supplements, and low-protein modified food products for inborn errors of metabolism or genetic conditions (Prior Authorization required; coverage limited to conditions required by law).
HCPCS/CPT (examples)
Ostomy supplies; syringes; needles; oxygen; surgical dressings; splints; allergy serum extracts; diabetic testing supplies (limited list on Prescription Drug Formulary); contraceptive devices (diaphragms, IUDs, implants); durable medical equipment examples include hemodialysis equipment, crutches, infusion pumps, glucometers (select brands), tracheotomy tubes, monitors, augmentative communication devices (when approved), wheelchairs, hospital beds, oxygen equipment.
inv-73: Special enrollment period length — 60 calendar days
Special enrollment period length60 calendar days from the date of the triggering event unless otherwise stated
ScopeApplies to individuals enrolling through the Marketplace and directly with the Plan
Examples of triggering eventsLoss of minimum essential coverage, gaining a dependent (birth, adoption), release from incarceration, changes in APTC/CSR eligibility
inv-74: Visit/day limits and stay limits
Home Health visit limit100 visits per Benefit Year
Skilled Nursing Facility (SNF) stay limit
Provider Requirements, Authorizations, and Billing Alerts
Prior Authorization
Use TruHearing Network provider and approved product list
Members must use a TruHearing Network Provider to receive hearing services under this section; hearing aids will only be Covered Services if they are listed on the approved hearing aid list (TruHearing catalog). If a member does not use a TruHearing Network Provider for services under this section, the services will be considered Non‑Covered Services and the member is responsible for all costs.
Hearing aids must be on the approved hearing aid list to be Covered Services.
Call TruHearing at 1-866-202-2561 (or TruHearing number in Section) to locate Network Providers and view the approved list.
Prior Authorization
Obtain Prior Authorization when required
Obtain Prior Authorization for any service listed on the Plan's Prior Authorization list before rendering the service; providers should check the Prior Authorization list on CareSource.com or call Member Services and secure approval to avoid denial of reimbursement.
Prior Authorization list available via CareSource Member Services or the payer website (Prior Authorization List).
Background and Policy Scope
Background: This section governs routine hearing services and hearing aids administered through an outsourced vendor. The benefit covers routine hearing screenings (one pass/fail per Benefit Year) and one comprehensive routine hearing exam per Benefit Year, and defines the TruHearing administration and product requirements (including use of TruHearing network providers and approved hearing aid catalogs). The Program also describes included follow‑up services, trial periods, warranty coverage, and battery allowances for covered hearing aids.
Routine hearing screeningOne (1) pass/fail screening per Benefit Year (series of beeps/tones) to determine normal hearing
Routine hearing examOne (1) comprehensive exam per Benefit Year by a licensed audiologist or hearing instrument specialist including history, testing, counseling, and recommendations
Hearing aid related services includedFirst-year follow-up visits, 60-day trial, 3-year warranty, 80 batteries per aid (non-rechargeable), and Ohio-ordered ear molds are included at no member cost share when hearing aid is a Covered Service
inv-147: Defined Terms
Defined terms locationCapitalized terms used in the EOC are defined in Section 2: Definitions and should be consulted for precise meanings
Usage guidance
Policy Changes and Revision History
2025-04-03AmendmentLatest
Amendment updates Evidence of Coverage language for hearing aid services to reflect changes in Ohio insurance law and specifies that amendment provisions govern in case of conflict with prior EOC.
2025-04-03Administration update
Routine Hearing Services, Hearing Aids, and Related Services are administered by TruHearing through the TruHearing Choice Program, with TruHearing managing the approved Hearing Aid List and network providers.
Policy Summary
PayerCareSource Georgia
PolicyRoutine Hearing Services, Hearing Aids, and Related Services (Coverage Criteria)
Policy CodePolicy POLMP-OH(2025) Rev.1
Change TypeAmendment updating hearing aid services administration and requirements
Effective DateApr 3, 2025
Last ReviewApr 3, 2025
Next Review DateN/A
Key ActionUse a TruHearing Network Provider and select hearing aids from the approved hearing aid list to obtain covered hearing aid services.
Newborn and Newly Adopted Child Temporary Coverage: Newborns and newly adopted children receive coverage from birth or moment of adoption for 31 days without premium; to continue coverage, the member must request addition within 60 days and pay applicable premiums; coverage effective dates follow Marketplace or CareSource processes.31 days temporary coverage; add within 60 days to continue
Submit required proof and premium payment to continue beyond initial 31 days
Dependent Enrollment Protections: CareSource will not deny enrollment because the child was born out of wedlock, not claimed on tax return, or not residing in the household/service area; if court/administrative order requires coverage and subscriber fails to apply, CareSource will enroll the dependent upon application from the other parent or pursuant to the order; termination of dependent coverage requires satisfactory written evidence that the order is no longer in effect or that the child will be enrolled in comparable coverage effective no later than the termination date.
Protections tied to court/administrative orders and lawful enrollment
60 calendar days
Includes birth/adoption placement rules
Changes in public program eligibility or tax credits: Becoming newly eligible or ineligible for Medicaid/CHIP, changes in Advance Premium Tax Credit or cost-sharing reduction eligibility, gaining new immigration status, or gaining/maintaining status as an Indian qualify for special enrollment.60 calendar days
Includes other program-based qualifying events
Other exceptional circumstances: Exceptional circumstances demonstrated to the Marketplace, access to an HRA or QSEHRA, or other Marketplace-determined circumstances may qualify for a special enrollment period.60 calendar days unless otherwise stated
Marketplace may allow additional special enrollment scenarios
Contact Plan if billed for amounts beyond copay/coinsurance/deductible
Continuity for on-exchange QHP active treatment: If enrolled in an on-exchange QHP and undergoing an Active Course of Treatment when a provider is removed without cause, the Plan will offer continuing coverage with that provider for up to 90 days from the date the provider left or until treatment completion (whichever is shorter), paying as if the provider is in-network and calculating cost-sharing at in-network rates, unless member has transitioned, benefit limits reached, or treatment not Medically Necessary.90 days
Provider may balance bill for difference between charges and CareSource allowed amounts; Prior Authorization may be required for continuation in special cases (e.g., pregnancy, terminal illness)
Transport must be to closest appropriate facility
Behavioral health and autism services: Medically necessary behavioral health services (inpatient, residential, partial hospitalization, intensive outpatient, outpatient) and Autism Spectrum Disorder services (including ABA/adaptive behavioral treatment) are covered per described limits; many behavioral health services have no benefit limits, while some therapies have visit limits (e.g., speech and occupational therapy 20 visits each).speech therapy = 20 visits; OT = 20 visits
ABA must be provided by or under supervision of appropriately licensed/certified professionals
Clinical trials routine care: Routine patient health care services that are part of an approved Clinical Trial are covered if they are otherwise Covered Services; purely investigational items, sponsor-paid services, or travel/lodging are not covered.
Follow clinical trial coverage rules
Diagnostic services: Non-invasive diagnostic services (imaging, labs, electrophysiologic tests, BAER, SSEP, VEP, nerve conduction studies, EMG except surface EMGs, etc.) and necessary central supply/pharmacy items are covered when Medically Necessary.
Non-Network lab claims are Non-Covered except for emergency/urgent/in-facility exceptions
Minimum of two therapy services required
Appliance therapy for TMJ: Reversible appliance therapy for TMJ that does not permanently alter tooth or jaw position is covered based on a single appliance maximum allowable fee and includes related diagnostic and adjustment services.
Includes allowance for diagnostic services, visits, adjustments, repair, replacement
Transplant services: Human organ and stem cell/bone marrow transplants and related acquisition, harvest, storage, and preparatory myeloablative therapy are covered when ordered by a provider and determined Medically Necessary; donor costs and live donor procurement covered as specified.
Transplant benefit periods and authorizations apply
>75 miles; max reimbursement $10,000
Unrelated donor search reimbursement up to $30,000 with authorization
Pediatric vision services: Covered pediatric vision services include one comprehensive eye exam with dilation per Benefit Year, contact lens fitting once per Benefit Year (cost share applies), eyewear once per Benefit Year (lenses and frame), retinal imaging once per Benefit Year at no member cost share, and low vision testing/aids one per Benefit Year; administered via EyeMed network.1 per Benefit Year for listed items
Use EyeMed network providers to receive benefits
Prescription drug formulary mechanics: Drugs on the Formulary may carry Prior Authorization (PA), Step Therapy (ST), or Quantity Limits (QL); PA requires submission of clinical information; ST requires trying a specified alternative first or an approved bypass; QL limits how much may be dispensed; Specialty drugs typically require specialty pharmacy fill and are limited to a 30-day supply.30 days for specialty drugs
Formulary rules determine coverage mechanics
Quantity and age limits: Coverage is limited by Quantity Limits and Age Limits listed on the Formulary; provider may request bypass of QL with justification and prior approval is required for override.
Quantity limits align with FDA dosing
Specialty drug fulfillment: Specialty drugs require specialty pharmacy fill and are typically limited to a 30-day supply; cost-sharing and supply limits are plan-specific per Schedule of Benefits.30 days
Refer to Schedule of Benefits for cost-sharing details
Expedited review is available when delaying care could seriously jeopardize life, health, or ability to regain maximum function, cause severe unmanaged pain, or when a physician determines the request is urgent; Urgent Care appeals may be requested verbally or electronically.
Prudent layperson or physician determination may apply
External Review initiation: External Review may be requested within 180 days of a Final Adverse Benefit Determination; requests must be in writing (expedited may be verbal/electronic) and require authorization to release medical records; generally internal appeals must be exhausted unless exceptions apply.180 days
Plan will forward documents to assigned IRO or Ohio Department of Insurance per process
External Review scope and assignment: External Reviews are assigned to an IRO or the Ohio Department of Insurance depending on the issue; IROs review medical judgment or Experimental/Investigational determinations and must be accredited and free of conflicts; reviewers are clinicians in the relevant specialty.
Department may also determine eligibility for External Review
90 days per Benefit Year
Inpatient Rehabilitation Facility stay limit60 days per Benefit Year
inv-75: Rental vs Purchase
Rental vs purchase ruleDurable medical equipment must be rented only up to the cost that does not exceed purchase price; equipment must be purchased when rental costs exceed purchase price
Plan optionPlan may choose to purchase rather than rent when purchase is more economical
Related costs coveredDelivery and installation costs are Covered Services when equipment is provided
inv-76: Distance threshold for travel assistance
Distance threshold for travel and lodging benefits (transplant)> 75 miles from member residence to Facility (Prior Authorization required)
Companion allowanceOne companion reimbursed (two companions for minor patients)
Documentation requiredItemized receipts for transportation and lodging must be submitted in form satisfactory to the plan
Network Provider is responsible for obtaining Prior Authorization; failure to obtain PA may make the Network Provider financially responsible for the service costs.
Documentation Required
Report eligibility or personal information changes within 60 days
Members and providers must notify CareSource and the Marketplace in writing within sixty (60) days of life‑change events (e.g., pregnancy, birth, address, immigration status, income, marital status, Medicare entitlement, or other coverage) that may affect eligibility or premiums.
Notices must be in writing on approved forms or as required by the Marketplace or CareSource.
Failure to notify may affect coverage and member financial responsibility.
Prior Authorization
Secure prior authorization before performing listed services
Prior Authorization is required for Health Care Services that the Plan lists as needing PA; obtain approval from CareSource before the service is performed, received, or dispensed to ensure coverage.
PA is used to determine Medical Necessity per evidence‑based criteria before services are provided.
Approval does not guarantee payment — member eligibility, benefit limits, and exclusions still must be met.
Prior Authorization
Obtain PA for Non‑Network provider services (except emergencies)
Prior Authorization must be obtained for health care services provided by Non‑Network Providers except for Emergency Health Care Services, Emergency Ambulance Services, and certain services rendered by a Non‑Network Provider while in a Network Facility; if PA is not obtained, services will be considered Non‑Covered Services.
When non‑network services are covered only with PA, the member or Non‑Network Provider must obtain PA prior to services.
Non‑network covered services with PA will be payable at the Network level and limited to the Maximum Allowable Amount; the member is responsible for filing claims and any non‑covered amounts.
Prior Authorization
Request Prior Authorization for continuity of care with non‑network providers
For continuity of care situations (e.g., pregnancy continuation, terminal illness, active course of treatment), contact Medical Management to request Prior Authorization to continue coverage with a non‑network provider; authorization is required to maintain coverage with that provider.
Pregnant members whose provider leaves the network: provider should contact Medical Management for PA to continue through delivery and postpartum.
Terminal illness: provider must contact Medical Management to obtain PA to continue care until no longer needed.
Prior Authorization
Follow the payer's Prior Authorization list and submission processes
Obtain Prior Authorization for any service listed on the payer's Prior Authorization list prior to providing the service; providers can call Member Services or view the payer website for the PA list and must supply requested clinical information to support the request.
The ordering Network Provider will contact CareSource to request PA or Predetermination.
You are entitled to reasonable access to documents relevant to PA requests free of charge.
Prior Authorization
Obtain PA for hospital referrals to Non‑Network hospitals
Prior Authorization is required for certain hospital referrals to Non‑Network Providers; when required, the PCP must obtain PA before referring to a Non‑Network Hospital to ensure coverage and compliance with No Surprises Act protections.
In rare instances where required services are unavailable from any Network Hospital, PCP may refer after obtaining PA.
CareSource will comply with statutory No Surprises Act requirements for non‑network services.
Prior Authorization
Get PA for certain inpatient, postpartum, and supply services
Obtain Prior Authorization for inpatient stays following an ER admission and for postpartum stays that exceed the plan's minimums; certain therapeutic foods and supplies also require PA as noted in the policy.
Notify the plan or verify physician has notified the plan of an inpatient admission within 24 hours or as soon as reasonably possible.
Postpartum stays beyond 48 hours (vaginal) or 96 hours (cesarean) may require PA.
Prior Authorization
Confirm PA before delivering therapy or DME
Secure Prior Authorization for therapy services and specified DME (including augmentative communication devices) when required; confirm authorization prior to rendering therapy to avoid denial.
Therapy prior authorization may be required; check with Provider/Plan before delivering therapy.
DME approvals and augmentative communication devices require Plan approval when listed.
Prior Authorization
Verify authorization for therapy services before delivery
Confirm whether therapy services require prior authorization before providing services; lack of PA may result in services not being covered.
Check with the PCP or Network Specialist to ensure required PA has been obtained before visiting a Network Specialist.
Prior Authorization may be included on the Plan's PA list — verify via Member Services or website.
Documentation Required
Submit clinical documentation for PA on transplants and PA drugs
Obtain Prior Authorization for transplants and for Formulary drugs marked 'PA'; submit requested clinical information electronically or by fax (medical history, prior drugs tried, test results) to demonstrate medical necessity.
Provider must call Utilization Management before evaluation/work‑up for a transplant; PA for HLA testing/donor search does not guarantee transplant approval.
For PA drugs, use forms on the payer website and provide clinical documentation to support the request.
Documentation Required
Provide required clinical details for Formulary PA drug requests
When a drug is designated 'PA' on the Formulary, the provider must submit clinical information (medical history, prior drugs tried, test results) electronically or by fax using the payer's forms; opioid analgesics for chronic pain and other controlled substances may also require PA.
Providers can view required information via the Formulary Search Tool on the Provider page of CareSource.com.
Opioid prescriptions for chronic pain require PA.
Prior Authorization
Obtain PA for Experimental/Investigational or nonstandard services
Services determined to be Experimental or Investigational require PA as applicable; such services are generally excluded unless approved under narrow life‑threatening exceptions and may be subject to IRO review.
Any service meeting Experimental/Investigational criteria is not covered unless CareSource approves under specific life‑threatening exception.
Providers should secure PA and supporting evidence if seeking coverage for an investigational or nonstandard service.
Note
Follow pre‑service and Step Therapy appeal timelines and requirements
Pre‑Service Review denials and Step Therapy exemption denials are subject to Internal Appeal timelines and may be eligible for expedited internal appeal; follow appeal submission requirements and timelines when contesting denials.
Internal Appeal for Pre‑Service/Step Therapy denials: decision within 10 calendar days; expedited internal appeals for Pre‑Service/Step Therapy: 48 hours.
Include member name/ID, provider name, date of service, reason for disagreement, supporting documentation, and signed consent for representative appeals.
Step Therapy
When Formulary drugs show 'ST', follow step therapy or request bypass
No Step Therapy clinical steps are specified in this excerpt; if a drug is marked 'ST' on the Formulary, the member must try the specified alternative first or the provider can request a bypass electronically or by fax with justification.
If a bypass is requested, supporting clinical rationale must be provided; the plan will not cover the ST drug until bypass approved.
Expedited internal appeals for Step Therapy exemption denials will be completed within 48 hours.
Documentation Required
Document verification and use approved hearing aid products
Verify hearing impairment for members age 21 and younger with documentation from a licensed audiologist, otolaryngologist, or other licensed physician; use items from the approved hearing aid list and ensure Ohio‑licensed ordering providers for ear molds when applicable.
Hearing aid benefit for members ≤21 is limited to one aid per hearing‑impaired ear up to $2,500 every 48 months when verified by licensed clinician.
Ear molds must be ordered by a Physician or audiologist licensed in Ohio to be included as related services.
Documentation Required
Provide eligibility documentation on request
Providers and applicants may be asked to furnish proof of eligibility (age, residence, income, marital status, employment) when requested by CareSource or the Marketplace; satisfactory proof is required to continue dependent coverage.
Proof of eligibility may be requested to confirm continued Dependent coverage.
Failure to submit satisfactory proof may result in termination of Dependent's coverage beyond last date of eligibility.
Documentation Required
Verify eligibility and submit required notices in writing
Verify and document eligibility changes and send notices in writing on approved forms as required by the Marketplace or CareSource; failure to notify will not obligate payment for persons no longer eligible.
Notify CareSource/Marketplace within 60 days of events like pregnancy, birth, address change, income change, Medicare entitlement, or gaining other coverage.
Acceptance of premium payments for persons no longer eligible does not obligate CareSource to pay for services.
Documentation Required
Document medical necessity with guideline‑based evidence
When requesting Prior Authorization to support Medical Necessity, submit documentation consistent with prevailing peer‑reviewed medical literature and nationally recognized guidelines demonstrating safety, effectiveness, and consistency with the diagnosis and standard of care.
Medical Necessity determinations are based on clinical coverage guidelines reflecting standards of practice and peer‑reviewed evidence.
Provide clinical records, test results, prior treatments, and rationale linking the requested service to expected benefit.
Documentation Required
Keep and provide medical records to support requests and appeals
Maintain medical records — any written, printed, or electronically recorded material maintained by a Provider concerning the patient and services provided — to support claims, Prior Authorization requests, and appeals.
Records include confidential communications made by a patient in connection with care.
Upon request, providers and members are entitled to reasonable access to documents relevant to PA requests and appeals.
Documentation Required
Follow provider departure notification and apply in‑network cost‑sharing during transition
When a PCP or Hospital leaves the Network, the Plan will notify affected members in writing within 30 days; during the transition period the Plan will calculate copayments, coinsurance and deductibles at in‑network rates and pay for Covered Services received from that provider for the defined transition period.
Plan pays for Covered Services between provider leaving date and five days after mailing notice as if provider were in‑network.
Members should call the Plan for help choosing another PCP or provider.
Documentation Required
Use formal request channels and provide access to supporting documents
Providers may request Prior Authorization, Predetermination, or Retrospective Medical Review and members are entitled to reasonable access to documents relevant to these requests free of charge; designate an authorized representative if needed.
Ordering Network Providers should contact CareSource for PA requests; Network Providers typically know which services require PA.
You may designate an Authorized Representative to act on your behalf for specific requests.
Documentation Required
Notify PCP and CareSource within 48 hours after out‑of‑area admission
If hospitalized outside the Service Area after urgent care, the member (or provider) must call the PCP and CareSource within forty‑eight (48) hours after admission or as soon as reasonably possible to notify the plan.
Post‑admission notification requirement applies after urgent care resulting in hospitalization outside the Service Area.
Failure to notify may affect continuity processing of claims.
Billing Rule
Verify lab/network status before ordering tests
Confirm Network status of laboratories and other ancillary providers before ordering tests; claims from Non‑Network laboratories will be considered Non‑Covered Services except for Emergency Health Care Services, Urgent Care, or services performed by a Non‑Network Laboratory while the member is in a Network Facility.
Providers should ensure the lab they use is a Network Provider to avoid claims denial.
For services performed in a Network Facility, certain non‑network ancillary services may still be covered subject to PA and notice requirements.
Documentation Required
Provide admission notification within 24 hours
Notify the plan or verify that the Physician has notified the plan of an inpatient admission within 24 hours or as soon as reasonably possible to comply with admission notification requirements.
For inpatient stays following Emergency Health Care Services, Prior Authorization is required; providers must notify within 24 hours.
Notification supports timely processing and PA follow‑up.
Documentation Required
Prescribe and document DME/orthotic medical necessity and assessments
DME and orthotic services require a physician prescription and documentation that the equipment is Medically Necessary; assessments by a rehabilitation equipment specialist or vendor are recommended when determining repair vs replacement costs.
Rental costs must not exceed purchase price; equipment must be purchased when costlier to rent than buy.
Repair/replacement coverage requires reasonable justification; warranty expiration alone is not sufficient.
Documentation Required
Document Day Rehabilitation program intensity and services
Day rehabilitation programs must document that the program provides a minimum of two therapy services, is of sufficient intensity requiring a multidisciplinary coordinated team approach, and is expected to result in practical improvement within a reasonable period.
Documentation should support intensity and multidisciplinary need for Day Rehabilitation coverage.
Program must meet defined hours and therapy composition to qualify as Covered Service.
Billing Rule
Collect and submit itemized receipts for travel/lodging reimbursement
Members must submit itemized receipts in a form satisfactory to the plan to be reimbursed for authorized transportation and lodging expenses (e.g., for transplant travel) when Prior Authorization has been obtained.
Travel/lodging benefits require PA and travel threshold (>75 miles) to apply.
Maximum reimbursement caps apply (e.g., $10,000 for transportation/lodging; up to $30,000 for unrelated donor search) and require itemized receipts.
Documentation Required
Submit clinical documentation for PA of prescription drugs
Provide clinical documentation for Prior Authorization of prescription drugs (medical history, prior drugs tried, relevant test results) using the forms and electronic/fax channels available on the payer website to demonstrate Medical Necessity.
Use the Formulary Search Tool on the Provider page to see required information.
When PA is required for a drug, submit documentation electronically or by fax using payer forms.
Documentation Required
Provide required info for PA drug approvals and non‑Formulary exception requests
When a drug has a Prior Authorization limit, submit required clinical information (medical history, prior drugs tried, test results) electronically or by fax to demonstrate medical necessity before the drug will be covered.
If a non‑Formulary drug exception is denied, the denial notice will explain the next level review and external review rights.
Providers may submit drug exception requests on behalf of the member with consent.
Documentation Required
Confirm benefit limits and document medical necessity
Ensure services are within Benefit limits listed in the Schedule of Benefits and document medical necessity and coverage category; services exceeding Benefit limits will not be paid.
Benefit limits are enforced per Schedule of Benefits; providers should verify remaining available benefits.
When services exceed benefit limits, provider/member financial responsibility applies.
Documentation Required
Provide required information when submitting appeals or external reviews
Include the member name and ID, provider name, date of service, reason for disagreement, supporting documentation, and signed consent for authorized representatives when filing Internal Appeals or External Review requests.
Internal Appeal must be submitted within 180 days of the Adverse Benefit Determination (expedited appeals may be verbal/electronic for urgent cases).
External Review requests must also include authorization to release medical records and adhere to 180‑day timelines.
Denial Risk
Non‑coverage if TruHearing network or approved product not used
Services will be considered Non‑Covered Services and the member responsible for all costs if the member does not use a TruHearing Network Provider or uses hearing aids not in the approved TruHearing catalog; ensure Network and product list compliance to avoid denial.
Hearing aids not in the TruHearing catalog are not covered; related exclusions include additional batteries beyond included amount and costs associated with loss/damage warranty claims.
Use the TruHearing catalog and Network providers to receive Covered Services and avoid member financial liability.
Denial Risk
Risk of denial if Prior Authorization not obtained
Services that require Prior Authorization may be denied reimbursement if Prior Authorization is not obtained; providers must check PA requirements before providing services to prevent denials and financial responsibility.
Network Provider responsibility to secure PA; Network Provider may be held financially responsible if PA not obtained.
For Non‑Network Provider services, member or Non‑Network Provider is responsible for full payment if PA not obtained.
Documentation Required
Dependent termination requires written evidence
Termination of a dependent's coverage will not occur unless CareSource receives satisfactory written evidence that the court or administrative order is no longer in effect or that the child will be enrolled in comparable coverage effective no later than the Plan termination date; providers should ensure documentation is submitted when relevant.
If required by court/administrative order to provide coverage, CareSource will enroll the dependent upon application from the other parent or pursuant to the child support order.
Termination requires satisfactory written evidence as specified.
Denial Risk
Notify plan of ineligible persons to avoid coverage gaps
Failure to notify the Marketplace or CareSource of persons no longer eligible will not obligate CareSource to provide coverage; acceptance of premium payments for ineligible persons will not obligate payment for health care services.
Providers and members should verify eligibility status and ensure timely notification of changes.
CareSource will not pay for services for persons no longer eligible even if premiums were accepted.
Denial Risk
Medical necessity determinations affect coverage
Services not determined to be Medically Necessary per CareSource medical policies and nationally recognized guidelines may be excluded and denied; providers must document guideline‑based justification when requesting coverage.
Medical Necessity requires consistency with prevailing peer‑reviewed literature and national guideline standards.
Denials for lack of medical necessity are appealable as Adverse Benefit Determinations.
Denial Risk
E/I services are denial risks unless narrow exceptions met
Services defined as Experimental or Investigational (e.g., unapproved FDA uses, services in Phase I–III trials, procedures billed with temporary codes) are subject to denial unless an exception for a life‑threatening condition applies and CareSource approves; request PA and supporting evidence if pursuing coverage.
Experimental/Investigational services are excluded by policy unless CareSource determines a life‑threatening exception applies and the service is promising under an NIH‑equivalent research protocol.
Providers may pursue External Review via an IRO for Experimental/Investigational determinations where applicable.
Denial Risk
PA required for Non‑Network services to avoid non‑coverage
Failure to obtain Prior Authorization for Non‑Network services (except Emergency Health Care Services, Emergency Ambulance Services, and certain in‑facility services) will render those services Non‑Covered Services; ensure PA is obtained before referral or non‑network care.
Non‑Network services that are covered only with PA will be payable at Network level and limited to Maximum Allowable Amount when PA obtained.
Without PA, member or Non‑Network Provider is responsible for full payment.
Denial Risk
Claims may be held or rejected during Grace Period
Claims for services provided during Grace Period months may be held for processing or denied; prescription drug services rendered during the second and third months of the Grace Period (when receiving APTC) or during the Grace Period (when not receiving APTC) will be rejected and providers will be notified of possible denials.
If receiving APTC: three‑month Grace Period — covered services paid in first month, non‑prescription claims held in months two and three, prescription drugs rejected in months two and three.
If not receiving APTC: 31‑day Grace Period — non‑prescription claims may be held and prescription drugs rejected during the Grace Period.
Note
Financial liability if Prior Authorization not obtained
Failure of a Network Provider to obtain required Prior Authorization makes the Network Provider responsible for the costs of services rendered without PA; if a Non‑Network Provider or member fails to obtain PA for services on the PA list, the member is responsible for full payment.
Network Providers should confirm PA has been obtained prior to rendering listed services.
Non‑Network Provider or member responsibility applies if PA not obtained for non‑network services.
Note
Network provider bears cost if PA not obtained
If a Network Provider fails to obtain Prior Authorization when required, the Network Provider shall be financially responsible for the costs and neither CareSource nor the member will be required to pay for those services.
Network Provider responsibility underscores the importance of pre‑service PA checks.
Providers should use payer resources (website, Member Services) to verify PA requirements.
Prior Authorization
Obtain PA for non‑network hospital referrals when network care unavailable
In rare instances when required hospital services are not available from any Network Hospital, obtain Prior Authorization before referring the member to a Non‑Network Hospital to ensure coverage and compliance with No Surprises Act requirements.
PCP must obtain PA before referring to a Non‑Network Hospital when Network hospitals cannot provide required services.
CareSource will process such referrals in line with statutory requirements; contact Medical Management for PA.
Denial Risk
Non‑Network laboratory claims are generally non‑covered
Claims from laboratories that are Non‑Network Providers will be considered Non‑Covered Services except in Emergency Health Care Services, Urgent Care, and services performed by a Non‑Network Laboratory while the member is in a Network Facility; confirm lab network status before ordering.
Providers should use Network laboratories to ensure claim payment.
When a Non‑Network lab performs testing outside allowed exceptions, the claim may be denied as Non‑Covered.
Denial Risk
Repair/replacement requests need reasonable justification
Repairs and replacements of purchased equipment may be denied if there is no reasonable justification (warranty expiration alone is not reasonable) or if loss/stolen/misuse/malicious breakage/gross neglect are the cause; document medical necessity and reasonable justification when requesting repair or replacement.
Replacement covered when item is worn out, irreparable, or patient needs have changed (growth, weight gain, deterioration).
Assessment by rehabilitation equipment specialist/vendor recommended to estimate repair cost vs replacement.
Billing Rule
DME rental may be denied when purchase is more economical
Rental reimbursement for DME may be limited or denied if rental costs exceed purchase price or if rental duration would cost more than purchase; rental is not paid when member is in a facility expected to provide the equipment.
Durable Medical Equipment must be purchased when costlier to rent than to buy.
Rental reimbursement limitations apply; verify rental vs purchase economics before authorizing rental.
Prior Authorization
Confirm PA for therapy services before treatment
Prior Authorization may be required for Therapy Services; confirm authorization prior to rendering therapy services to avoid non‑coverage.
Therapy services have defined benefit limits (e.g., PT/OT/Speech 20 visits each) and may require PA.
Providers should check PA requirements before scheduling therapy sessions.
Denial Risk
TruHearing network required for TruHearing‑administered services
Use of non‑TruHearing Network Providers for TruHearing‑administered hearing services will result in services being considered Non‑Covered and the member being responsible for all costs; providers must use the TruHearing network and approved products for hearing aid benefits.
TruHearing Choice Program administers hearing aid benefits and maintains the Network and approved hearing aid list.
Non‑network use or non‑catalog devices lead to non‑coverage and member financial liability.
Prior Authorization
Obtain PA before transplant evaluation/work‑up; separate transplant determination required
Prior Authorization is required before evaluation and/or work‑up for a transplant; the Provider must contact Utilization Management to obtain PA and be aware that approvals for HLA testing/donor search/harvest/storage do not constitute approval for the transplant itself — a separate medical necessity determination is required for the transplant procedure.
Provider must obtain PA before evaluation/work‑up and prior to the transplant to determine inpatient vs outpatient setting.
Approvals for HLA testing/donor search/harvest/storage are reviewed separately and do not guarantee transplant approval.
Billing Rule
Obtain authorization for transportation and lodging reimbursements
Authorization is required to obtain transportation and lodging benefits (e.g., for transplant travel reimbursement); failure to obtain authorization may leave the member responsible for those expenses and providers must ensure PA and submission of itemized receipts.
Transportation/lodging benefits require PA and travel >75 miles to the Facility to apply.
Submit itemized receipts in a form satisfactory to the plan; maximum reimbursement limits apply (e.g., $10,000 for travel/lodging).
Documentation Required
Appeal denied non‑Formulary drug exceptions and pursue external review
Denial of a drug exception (non‑Formulary) may be appealed through the Plan's internal process and pursued via an independent external review; denials will be communicated in writing with instructions for next‑level review and external review rights.
If a drug exception is granted, the drug will be treated as an Essential Health Benefit and cost sharing applies.
If denied, written notification explains how to request next level review and external review procedures.
Denial Risk
Exclusions will cause denials — verify coverage and medical necessity
Services, treatments, items, or supplies listed in Exclusions will not be paid; services that do not meet Medical Necessity or policy criteria may be denied — verify coverage, exclusions, and medical necessity before providing services.
Refer to Section 7: Exclusions for a comprehensive list of non‑covered services (e.g., experimental services, many cosmetic and reproductive technologies, hearing aids outside specified coverage).
Providers should confirm coverage and Medical Necessity to avoid denials.
Denial Risk
Adverse Benefit Determinations may be appealed — document thoroughly
Adverse Benefit Determinations include denials for services that do not meet Medical Necessity, appropriateness, required health care setting, level of care, effectiveness, or that are Experimental/Investigational; providers should document reasoned clinical rationale and follow appeal rights when contesting denials.
Adverse Benefit Determinations are appealable via Internal Appeal (submit within 180 days) and may proceed to External Review if eligible.
Provide comprehensive supporting documentation to improve chances on appeal.
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Refer to Section 2 often to understand capitalized words in the EOC
Pronoun definitionsIn this EOC, 'we/us/our' refers to CareSource and 'you/your' refers to the Covered Person or Responsible Party
inv-148: Active Course of Treatment
Active Course of Treatment definitionAn ongoing course of treatment for life‑threatening or serious acute conditions, pregnancy (through postpartum), or treatment where discontinuation would worsen the condition (examples: chemotherapy, radiation, post-operative visits)
Includes pregnancyPregnancy through the postpartum period is considered an Active Course of Treatment
Provider attestationAlso includes treatment where the treating provider attests that discontinuing care would worsen the condition or interfere with outcomes
inv-149: Continuing Care Patient
Continuing Care Patient descriptionAn individual undergoing treatment for a Serious and Complex Condition, institutional/inpatient care, scheduled nonelective surgery (including postoperative care), pregnancy treatment, or terminal illness treatment with a provider or facility
ContextUsed to determine continuity of care when a provider leaves the network or for continuity protections
ExamplesIncludes patients receiving institutional care, scheduled nonelective surgery, pregnancy, or terminal illness care
inv-150: CareSource24
CareSource24 serviceCareSource24 is CareSource's 24/7 nurse advice line for non-emergency health situations
FunctionMembers speak with a registered nurse who assesses the situation and provides action guidance
Care coordinationThe nurse will send a fax to the member's PCP to help coordinate care
inv-151: Annual Out-of-Pocket Maximum
Annual Out-of-Pocket Maximum definitionThe maximum amount a member pays in a Benefit Year for covered services; when reached, Benefits pay at 100% of Eligible Expenses for the remainder of the Benefit Year subject to plan terms
What countsPayments toward the Annual Deductible, Copayments, and Coinsurance for Covered Services apply toward the Out-of-Pocket Maximum unless otherwise noted
Non-applicable chargesCharges for Non-Covered Services and certain Rider/Enhancement copays/coinsurance never apply to the Out-of-Pocket Maximum
inv-152: Active Course of Treatment
Clinical trial Active Course criteriaA trial intended to improve health (not merely test toxicity) treating cancer or life‑threatening disease, testing responses, comparing effectiveness, or studying new uses, approved by NIH-equivalent agencies qualifies as an Active Course of Treatment
Approval bodiesIncludes NIH, CDC, AHRQ, CMS, FDA, DoD, and VA cooperative groups/centers for trial approval
Life‑threatening exceptionUnproven or Experimental services may be considered where life‑threatening and research protocol meets NIH-equivalent standards
inv-153: Medically Necessary / Medical Necessity
Medically Necessary / Medical NecessityServices appropriate per CareSource medical policies and nationally recognized guidelines; not Experimental or Investigational; necessary to meet basic health needs and rendered in the most cost-efficient appropriate setting
Evidence standardDetermination requires consistency with prevailing peer‑reviewed medical literature and national guidelines
ExclusionsServices deemed Experimental/Investigational or not meeting medical necessity are excluded unless narrow exceptions apply
inv-154: Experimental or Investigational Services
Experimental or Investigational definitionServices not FDA‑approved for the proposed use, subject to IRB review, part of Phase I–III clinical trials, billed with temporary procedure codes, or otherwise lacking regulatory approval are considered Experimental or Investigational
Life‑threatening exceptionMay be considered Covered for life‑threatening conditions if determined promising and used in a clinically controlled research protocol meeting NIH-equivalent standards
Determination factorsPlan will consider scientific evidence, peer-reviewed literature, and regulatory status when making EI determinations
inv-155: Ambulatory Surgical Facility
Ambulatory Surgical FacilityA facility with organized physician staff, licensed where required, permanent facilities and equipment primarily for outpatient surgical procedures, providing physician-supervised treatment and nursing services while patient is present
No inpatient accommodationsDoes not provide inpatient accommodations and is not used incidentally as a private office or clinic
Staffing and licensingMust be licensed where required and have organized physician staff
inv-156: Home Health Care Agency
Home Health Care AgencyA state-licensed agency that provides skilled nursing and other services on a visiting basis in the covered person's home and supervises delivery of such services under a written plan prescribed and approved by the attending physician
Service requirementsPatient must be confined to home for medical reasons and physically unable to obtain needed outpatient services to qualify
Visit countingEach authorized representative visit counts as one Home Health Care visit; visit equals at least four hours for home health aide
inv-157: Telehealth Services
Telehealth ServicesHealth care services provided through information and communication technology by a health care professional located at a different site than the patient, within the professional's scope of practice
ScopeIncludes consultative services between providers as appropriate within scope of practice
Network considerationsTelehealth providers are subject to network and availability limitations; services may vary by partner
inv-158: Unproven Service
Unproven Service definitionHealth care services, including medications, not consistent with prevailing medical research demonstrating beneficial effects on health outcomes and lacking well-conducted randomized trials or cohort studies
Exception for life‑threateningMay be considered if life‑threatening and used in a protocol meeting NIH-equivalent standards
Coverage decision basisPlan decisions based on prevailing medical research and trial design quality
inv-159: Serious and Complex Condition
Serious and Complex ConditionFor acute illness: requires specialized medical treatment to avoid death or permanent harm; for chronic illness: life‑threatening, degenerative, potentially disabling or congenital and requires specialized care over prolonged period
Clinical implicationUsed to determine eligibility for continuity of care and special protections
ExamplesIncludes conditions requiring specialized ongoing care such as complex chronic diseases
inv-160: Annual Deductible
Annual DeductibleThe amount a member must pay in a Benefit Year before the plan provides benefits for some services (refer to Schedule of Benefits for specifics)
AccumulationAmounts paid toward the Annual Deductible accumulate during the Benefit Year
Preventive servicesNetwork preventive health care services are not subject to the Annual Deductible
inv-161: Coinsurance
CoinsuranceA fixed percentage of Eligible Expenses that the member is responsible for paying for certain Covered Services
ApplicationApplies after Annual Deductible is satisfied and until Out-of-Pocket Maximum reached, per Schedule of Benefits
Counts toward OOPMCoinsurance payments for Covered Services apply toward the Annual Out-of-Pocket Maximum unless noted otherwise
inv-162: Copayment
CopaymentA fixed dollar amount required for certain Covered Services, usually paid when services are received
VariabilityCopayments may vary based on the type of service received and as shown in the Schedule of Benefits
Effect on deductibleCopayments generally do not count toward the Annual Deductible unless specified
inv-163: Emergency Health Care Services
Emergency Health Care Services coverage stanceEmergency services are covered without prior authorization in the U.S. and abroad; stabilization care covered and non-network emergency care treated as Covered Services
Follow-up careFollow-up care after stabilization is not automatically covered from non-network providers unless Prior Authorization is obtained and it is Medically Necessary
Notification requirementIf admitted as an inpatient from ER, CareSource must be notified within 24 hours or as soon as reasonably possible
inv-164: Urgent Review / Urgent Care Services
Urgent Review definitionRequests where delay could jeopardize life/health/safety, cause severe unmanaged pain, or as determined urgent by a physician; includes opioid use treatment
Submission channelsUrgent Review requests may be submitted electronically or via other secure transmission methods per plan process
Decision timeframesExpedited internal appeal timelines apply for urgent/urgent care related determinations
inv-165: Urgent Care Services outside Service Area
Urgent Care Services outside Service AreaCovered when member is temporarily outside the Service Area and requires urgent or emergency care from Non-Network Providers; payable at Network level limited to Maximum Allowable Amount
Member responsibilityMember may be responsible for amounts in excess of the Maximum Allowable Amount; notify PCP when able
ExclusionsForeseeable, routine, elective or follow-up care while outside the Service Area is excluded
inv-166: Adaptive Behavioral Treatment / ABA
Adaptive Behavioral Treatment / ABABehavioral therapy for Autism Spectrum Disorders that must be provided by or under supervision of appropriately licensed/certified professionals in accordance with a treatment plan
Coverage scopeIncludes inpatient services, diagnostic evaluation, screening/testing, outpatient services, and ABA per treatment plan
Visit limitsSpeech and occupational therapy limits may apply (e.g., 20 visits each) though ABA may have none
inv-167: Hospice Care Program
Hospice Care ProgramMedical, social, and psychological services for persons with a Terminal Illness and life expectancy of six months or less as confirmed by attending Physician
Covered servicesIncludes routine home care, continuous home care, inpatient hospice, inpatient respite, skilled nursing, diagnostics, therapies as part of plan, supplies, counseling, prescription drugs given by hospice, and home health aide services
Benefit continuationBenefits continue if the patient lives longer than six months
inv-168: Habilitative Services
Habilitative Services definitionServices and devices that help keep, learn, or improve skills and functioning for daily living (e.g., therapy for developmental delays) when provided by licensed practitioners and not experimental
Example servicesPhysical, occupational, and speech therapy for congenital/genetic/early acquired disorders
Visit limitsTypically limited to 20 visits per therapy type per Benefit Year unless otherwise noted
inv-169: Durable Medical Equipment / Prosthetic / Orthotic
Durable Medical Equipment / Prosthetic / OrthoticDME: rental or purchase of equipment prescribed by a physician; Prosthetic: artificial substitutes for body parts/tissues including purchase, fitting, adjustments and repairs; Orthotic: custom rigid/semi-rigid supportive devices
Purchase vs rentalProsthetic devices should be purchased not rented and must be Medically Necessary; orthotics may be replaced once per Benefit Year when medically necessary
Included servicesCasting, molding, fittings, adjustments, and applicable taxes/shipping/handling are covered when billed appropriately
inv-170: Day Rehabilitation program
Day Rehabilitation programA program provided through a Day Hospital for individuals who do not require inpatient care but require rehabilitation therapy four to eight hours per day, two or more days per week, with at least two therapy services provided
Multidisciplinary approachRequires a coordinated team approach (physical therapy, occupational therapy, speech therapy, nursing, neuropsych services)
Coverage conditionMust be medically necessary and expected to result in practical improvement within a reasonable period
inv-171: Manipulation therapy
Manipulation therapy definitionOsteopathic/chiropractic manipulation therapy used for treating problems associated with bones, joints, and the back; counted toward manipulation therapy maximum whether billed alone or with an exam/office visit
LimitCovered up to twelve (12) manipulation therapy sessions; services provided in the home as part of Home Health Care are not covered
Billing noteManipulations billed alone or with an exam/office visit count toward the same maximum
inv-172: Examination (pediatric vision)
Examination (pediatric vision)Comprehensive eye exam of the complete visual system including case history, patient observation, clinical/diagnostic testing, evaluation and refraction; pupillary dilation required for Members with diabetes
Limits for pediatric visionOne comprehensive pediatric eye exam per Benefit Year; pediatric vision benefits administered by EyeMed and EyeMed network providers must be used to receive benefits
Related pediatric vision itemsRetinal imaging covered once per Benefit Year at no member cost share; contact lens fitting and eyewear subject to Benefit Year limits
inv-173: Low Vision
Low VisionSignificant loss of vision but not total blindness; supplemental testing and low vision aids are limited to one per Benefit Year
Covered aidsIncludes spectacle-mounted magnifiers, telescopes, hand-held and stand magnifiers, and video magnification when medically necessary
Testing limitSupplemental diagnostic/low vision testing limited to one per Benefit Year
inv-174: Specialty drug
Specialty drug definitionA drug that has extra safety monitoring or storage requirements or must be administered in a specific way; typically limited to a 30-day supply and filled by a specialty pharmacy
Formulary tiersFormulary uses multiple tiers (e.g., Tier 0–4) to determine cost-sharing and controls such as PA, ST, and QL
Coverage implicationsSpecialty drugs require specialty pharmacy fulfillment and have higher cost-sharing; refer to Schedule of Benefits for plan-specific details
inv-175: Drug exception (non-Formulary drug)
Drug exception (non-Formulary) processProcess allowing access to clinically appropriate drugs not on the Formulary; if granted, the drug is treated as an Essential Health Benefit subject to applicable cost-sharing and counts toward Out-of-Pocket Maximum
Submission optionsRequests may be submitted by member, authorized representative, or prescribing provider; written determination provided
Contraceptive noteFor contraceptives, the Plan will follow attending provider's recommendation and provide contraceptive service or FDA-approved item without cost sharing upon request
inv-176: Experimental or Investigational
Experimental or Investigational (E/I)Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply used in or directly related to diagnosis or treatment that meets criteria such as lacking FDA approval for the use, being provided in a clinical trial, requiring IRB review, or described as investigational in consent/protocol documents
Life‑threatening exceptionMay be considered for coverage in life‑threatening situations if promising and part of an approved research protocol meeting NIH-equivalent standards
inv-177: Adverse Benefit Determination
Adverse Benefit DeterminationA decision to deny, reduce, or terminate a requested health care service or benefit in whole or in part, including determinations about eligibility, covered services, imposition of exclusions, failure to meet Medical Necessity, or rescission of coverage
AppealabilityAdverse Benefit Determinations are subject to Internal Appeal and External Review processes per EOC timelines
Examples includedDeterminations that a service is not Medically Necessary, is Experimental/Investigational, or not a Covered Service are Adverse Benefit Determinations
inv-178: External Review
External ReviewA review of an Adverse Benefit Determination (including a Final Adverse Benefit Determination) conducted pursuant to state or federal law
Initiation timeframeExternal Review generally must be requested within 180 days of a Final Adverse Benefit Determination (see Appeals section)
IRE roleIndependent Review Entities (IREs/IROs) conduct External Reviews and must be accredited and free of conflicts; reviewers are clinicians in relevant specialty
inv-179: Independent Review Entity (IRE) / IRO
Independent Review Entity (IRE) / IROAn entity that conducts independent external reviews of Adverse Benefit Determinations; accredited and free of conflicts of interest for the assigned matter
Reviewer qualificationsReviewers are clinicians with specialty expertise relevant to the case
ScopeIROs review medical judgment, Experimental/Investigational determinations, and other appealable issues under External Review rules