MedicaidAdministrativeMedium impact
[Ohio] Policy Updates November 2025
CareSource·OH·Medical Policy
Effective date
Jan 1, 2026
We identified it
May 9, 2026
Summary
CareSource Ohio Medicaid released 14 policy updates effective January 1, 2026, including revisions to clinical trial coverage, continuity of care, hospice billing, laboratory testing, overpayment recovery, modifier usage, EDI transactions, and new guidance on venipuncture in outpatient settings. One new policy (Venipuncture PY-1704) was added; the remaining 13 are revisions to existing policies. The billing team must review each updated policy on the CareSource provider portal to identify specific operational changes.
Action Required
By December 15, 2025: Billing team must access all 14 revised/new policies via CareSource.com > Providers > Tools & Resources > Provider Policies, select 'Ohio Medicaid', and review the full text of each policy. Specifically: (1) Compare the NEW venipuncture policy (PY-1704) against current billing practices to identify any code or modifier changes; (2) Review reimbursement policy revisions (PY-1545, PY-1115, PY-1474, PY-1704) for rate or coding changes and update billing system rules; (3) Review administrative policies (AD-0742, AD-1065, AD-0086, AD-1059, AD-1116, AD-1109) for documentation, submission, or process changes; (4) Review medical policies (MM-0798, MM-1046, MM-1716, MM-1444) for coverage changes that may affect claim denials or prior authorization requirements. Update billing software, encounter forms, prior auth workflows, and staff training by December 31, 2025. Failure to comply with January 1, 2026 policy requirements will result in claim denials and compliance violations.