Claim Reimbursement Hierarchy
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Defines CareSource Georgia's hierarchy and methods for reimbursing claims across products, indicating which reimbursement sources are used when contracts or Medicare rates do not apply; affects providers submitting claims to CareSource Georgia for Marketplace and related services.
No material clinical or coverage changes in this revision.
Claim Reimbursement Decision Hierarchy
Claim reimbursement decision hierarchy
Payment is determined using the following hierarchy; when a service-level policy exists it supersedes this policy. Approved authorization or a rate on the market fee schedule does not guarantee payment.
Payment hierarchy (apply in order)
- Provider's contracted rate/reimbursement method is the primary determinant when the contract specifies reimbursement terms.
- If the contract does not specify reimbursement terms for a covered service, CareSource pays using the Medicare maximum allowable for the specific procedure or service.
- Codes not covered on Medicare fee schedules but that have RVU values will be reimbursed using RVU values and/or the Essential RVU gap fill fee schedule; in the absence of Medicare guidance, State guidelines will be consulted.
- Provider-administered medical drugs provided through the medical benefit not addressed above will be reimbursed at Average Wholesale Price (AWP) minus 15%.
- CareSource Market Fee Schedule rates (developed from external/third-party national or regional fee schedules) are used where applicable; existence of a rate does not guarantee payment. Rates undergo at least annual review.
Reimbursement Calculation & Coding Details
| RVU | Services not covered on Medicare fee schedules but with RVU values will be reimbursed using RVU values and/or Essential RVU gap fill fee schedule. |
| AWP | Provider-administered medical drugs via medical benefit reimbursed at Average Wholesale Price minus 15%. |
Authorization, Documentation, and Billing Requirements
Authorization and Payment Risk — Authorization ≠ Payment
Approved authorizations and pre-authorizations do not guarantee payment. Providers must verify member eligibility and understand that payment is determined upon claim receipt and subject to contractual, regulatory, and claims-editing rules; the plan contract (Evidence of Coverage) controls when in conflict. Pre-authorization does not ensure payment and the existence of a rate on the CareSource Market Fee Schedule does not guarantee payment.
- Verify member eligibility and benefits on the date of service prior to rendering services.
- Confirm applicable authorizations and ensure claims reflect the actual services provided for review at claim processing.
DME Invoice Requirement — Invoice Required When No Medicare Rate
For Durable Medical Equipment (DME) items that do not have Medicare rates, providers must submit a supporting invoice to receive reimbursement.
- Submit a detailed invoice when billing DME services lacking Medicare fee schedule rates.
- Refer to the DME-specific policies and related administrative guidance for additional billing requirements.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.