MedicaidCoverageMedium impact
[Ohio] Avalon Policy Updates - Q4 2024
CareSource·OH · Endocrinology, Family Medicine, General Practice +8 more·Medical Policy
Effective date
Jun 1, 2025
We identified it
May 9, 2026
Summary
CareSource/Avalon is updating 14 laboratory testing policies effective June 1, 2025, for Ohio Medicaid and Ohio MyCare plans. These policy changes will be enforced through the Routine Testing Management (RTM) post-service pre-payment clinical claim editing program. Billing teams must review the updated policies on Avalon's website and ensure claims comply with new requirements to avoid denials.
Action Required
By May 31, 2025: Billing team must access Avalon Healthcare Solutions website and review all 14 updated laboratory policies (G2005, G2006, G2011, G2013, G2014, G2056, G2098, G2149, G2154, G2174, M2067, M2141, M2176, P2018, R2162) for Ohio Medicaid and Ohio MyCare plans. Providers and clinical staff should be notified of policy changes to ensure documentation and testing orders comply with new requirements. Implement use of the CareSource Trial Claim Advice Tool on the provider portal to validate laboratory claims before submission. Train billing staff on any new medical necessity criteria, frequency limits, or documentation requirements outlined in the updated policies. Failure to comply will result in claim denials through the RTM post-service editing program.