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Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

The beneficiary must swallow a tiny capsule that contains a data transmitter, battery, antenna, disposable light source, and tiny color video camera in order to undergo wireless capsule endoscopy (WCE). The self-contained capsule is constructed from a biocompatible polymer that is resistant to the digestive fluids found in the gastrointestinal (GI) tract and is sealed with careful care. After swallowing the capsule, the GI tract's normal contraction and relaxation forces the capsule forward. The beneficiary wears a data recorder around their waist the whole time, capturing and storing pictures sent by the capsule's camera. Following the surgery, a computer workstation is attached to the beneficiary’s data recorder, allowing the pictures to be downloaded, examined, and interpreted by the physician. The process takes about five minutes to observe the mucosa of the esophagus and about eight hours to observe the mucosa of the intestine. The capsule is excreted naturally from the body and is made to be thrown away.

Unit Value

1 unit= 1 procedure with physician interpretation and report

Exclusions

Medicaid shall not cover capsule system testing or radiography to evaluate GI patency prior to wireless capsule endoscopy. Medicaid shall not cover wireless capsule endoscopy in following situations: a. undiagnosed obscure GI bleeding; b. Known or suspected gastrointestinal obstruction, stricture, fistulae, known bowel disease; c. For a diagnosis of suspected:

• 1. Crohn’s disease or irritable bowel syndrome (IBS);
• 2. esophageal varices;
• 3. Barrett’s esophagus;4. Celiac disease;
• 5. gastric or intestinal neoplasm; or
• 6. intestinal polyps.
• d. Recurrent intussusception;
• e. Duodenal lymphocytosis;
• f. Surveillance of the small intestine for a beneficiary with hereditary polyposis

syndrome;

• g. As a first-line diagnostic tool for diffuse abdominal pain;
• h. As a replacement for colonoscopy for colon cancer screening as part of

United States Preventative Services Task Force (USPSTF) recommendation; Medicaid shall not cover wireless capsule endoscopy when the beneficiary:

• a. is Pregnant; or
• b. has a cardiac pacemaker, defibrillator, spinal cord stimulator, or other

implanted electromagnetic device.

Place of Service

Inpatient hospital, Outpatient hospital

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-31
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

How to Submit

N/A - No authorization is required

General ophthalmological services include a medical examination and evaluation with the initiation or continuation of a diagnostic and treatment program. General ophthalmologic services include the following definitions for the two levels of service:

• a. Intermediate ophthalmological services are an evaluation of a new or existing condition

complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis. This service is used for an acute condition or for a chronic condition which is stable.

• b. Comprehensive ophthalmological services are a general evaluation of the complete visual

system. The comprehensive services constitute a single service entity but do not need to be performed at one session.

Limits

General ophthalmological services are not covered for any one of the following:

• a. screening, preventative or refractive error services (routine eye exams);
• b. prescription of lenses;
• c. monitoring contact lenses for refractive error correction; or
• d. follow-up of a condition that does not require diagnosis or treatment.

Length of Stay

Intermediate and comprehensive ophthalmological services for established

Exclusions

General ophthalmological services are integrated services in which medical decision making is not separate from the examining techniques used. The following service components are included as part of general ophthalmologic services and must not be billed separately:

• 1. slit lamp examination;
• 2. keratometry;
• 3. ophthalmoscopy;
• 4. retinoscopy;
• 5. tonometry; and
• 6. motor evaluation.

Intermediate and comprehensive ophthalmological services for established beneficiaries are each limited to 2 times per year.

Place of Service

Inpatient, Outpatient, Office

Additional Service Specifics

General ophthalmological services are comprised of integrated services and are billed with one unit per complete examination even if performed over more than one session.

How to Submit

N/A - No authorization is required

Resources

• 1T-A General Ophthalmological Services
• Records Management and Documentation Manual