MedicaidCoverageHigh impact
[Ohio] Avalon Q2 2025 Quarterly Policy Updates
CareSource·OH · Family Medicine, Internal Medicine, General Practice +12 more·Medical Policy
Effective date
Jan 1, 2026
We identified it
May 9, 2026
Summary
CareSource has partnered with Avalon Healthcare Solutions to implement routine testing management (RTM), a post-service pre-payment clinical claim editing program for laboratory services in Ohio Medicaid. Effective January 1, 2026, 20 laboratory policies will be updated and enforced through Avalon's website, affecting routine lab testing authorization and compliance requirements.
Action Required
Before January 1, 2026: (1) Billing and clinical teams must review all 20 updated Avalon laboratory policies on Avalon's website, specifically policies F2019, G2008, G2022, G2031, G2035, G2044, G2045, G2099, G2120, G2125, G2138, G2143, G2149, G2164, G2181, M2041, M2057, M2116, M2172, and T2015. (2) Update internal billing workflows and EMR/practice management system templates to ensure all laboratory orders comply with the new Avalon policies prior to claim submission. (3) Train billing staff and providers on the new requirements for each test type listed. (4) Implement use of the CareSource Trial Claim Advice Tool (available on CareSource Provider Portal) to simulate and validate laboratory claims for policy adherence before submission. (5) Establish a process to monitor Avalon's website for any policy clarifications or updates. Failure to comply with these policies will result in claim denials during RTM post-service review.