CurrentCareSourcePolicy PY-PHARM-0126- AR-MCD

Standard Medical Billing Guidance, Reimbursement Policy Statement - Arkansas PASSE

Governs billing, coding, documentation, and reimbursement criteria for drugs and biologicals for CareSource members in the Arkansas PASSE program; applies to providers submitting claims and to coverage determinations tied to member benefits and medical necessity.

Policy Summary

PayerCareSource

PolicyStandard Medical Billing Guidance, Reimbursement Policy Statement - Arkansas PASSE

Policy CodePolicy PY-PHARM-0126- AR-MCD

Change TypeNo material changes

Effective DateFeb 1, 2023

Next Review Date

Key ActionEnsure claims include member eligibility, medical necessity documentation and required coding (11-digit NDC, HCPCS/CPT, correct units) when submitting for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS1500 / UB04Claim forms covered

11-digitRequired NDC format

DAW reviewMulti-source brand products

Compendia listAuthoritative compendia

Coverage and Medical Necessity Criteria

Coverage criteria for drugs and biologics

Covered when ALL of the following are met:

ALL of the following

FDA- or compendia-supported use
- FDA-approved labeled indication (drug marketed by FDA and used for indications specified on the labeling); reimbursement may be provided if administered on or after the FDA approval date, is reasonable and necessary for the individual, and all other coverage requirements are met.
- Off-label use supported as a medically accepted indication by one or more authoritative compendia (AHFS-DI, NCCN Drugs & Biologics Compendium, Micromedex DrugDex, Clinical Pharmacology, LexiDrugs) or by peer-reviewed medical literature or CMS LCDs.

ALL of the following

Excluded categories (not covered)

Policy Summary

PayerCareSource

PolicyStandard Medical Billing Guidance, Reimbursement Policy Statement - Arkansas PASSE

Policy CodePolicy PY-PHARM-0126- AR-MCD

Change TypeNo material changes

Effective DateFeb 1, 2023

Next Review Date

Key ActionEnsure claims include member eligibility, medical necessity documentation and required coding (11-digit NDC, HCPCS/CPT, correct units) when submitting for reimbursement.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization, Eligibility, and Provider Responsibilities

Prior Authorization

Authorization and prerequisites — verify eligibility, medical necessity, and required authorizations

Reimbursement is contingent on member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, provider contractual terms, and any applicable referral, authorization, notification, or utilization management requirements. This Policy does not guarantee an authorization or payment; providers must follow the plan contract (Evidence of Coverage) and any utilization management or referral/authorization processes to avoid denial or nonpayment.

Confirm member eligibility and benefits for the date of service prior to providing and billing for the drug or biological.
Ensure the service meets medical necessity and is consistent with plan policies, provider contract, and accepted standards of medical practice.
Obtain any required referrals, prior authorizations, notifications, or meet utilization management requirements before administration.
Note that this policy does not ensure authorization or reimbursement; the plan contract (Evidence of Coverage) controls in case of conflict.

Terms and Reference Definitions

Indication

DefinitionIndication: a diagnosis, illness, injury, syndrome, condition, or other clinical parameter for which a drug may be given.

PurposeUsed to identify the clinical reason a medication is prescribed or administered.

Role in coverageDetermines whether a drug use aligns with FDA-approved or medically-accepted indications for reimbursement decisions.

Off-label / Unlabeled use

Off-label/Unlabeled use — definitionUse of a drug for a non‑FDA approved indication (not listed on the official label) or use that deviates significantly from labeled prescribing information (dosage, route, duration, frequency, or population).

Off-label specificsIncludes giving the drug in a way that differs from the label for a particular indication (e.g., different dose, route, duration, frequency, or patient population).

Unlabeled useFDA‑approved drugs used for indications other than what is indicated on the official label as approved by the FDA.

Drug compendia (authoritative sources)

PurposeDrug compendia are expert‑compiled summaries of drug information used to determine medically‑accepted indications.

Authoritative compendia recognized by CMSAmerican Medical Association Drug Evaluations (AMA‑DE); United States Pharmacopoeia‑Drug Information (USP‑DI) or its successor; American Hospital Formulary Service‑Drug Information (AHFS‑DI).

USP‑DI noteUSP‑DI is a database developed by the U.S. Pharmacopeia and maintained by Micromedex, containing medically accepted uses for generic and brand name products.

NDC (11-digit)	National Drug Code required on claims
HCPCS/CPT	HCPCS or CPT code required
HCPCS units	Correct HCPCS units must be reported (not NDC units)

OpenPayer

Standard Medical Billing Guidance, Reimbursement Policy Statement - Arkansas PASSE

Coverage and Medical Necessity Criteria

Claim Coding and Billing Requirements

Authorization, Eligibility, and Provider Responsibilities

Terms and Reference Definitions