MedicaidCoverageMedium impact
[Ohio] Avalon Policy Update - February 2025
CareSource·OH · Gastroenterology, Family Medicine, Internal Medicine +1 more·Medical Policy
Effective date
Apr 1, 2025
We identified it
May 9, 2026
Summary
CareSource is implementing a new Routine Testing Management (RTM) program through Avalon Healthcare Solutions for laboratory benefits management in Ohio Medicaid, effective April 1, 2025. This program includes post-service pre-payment clinical claim editing for routine lab testing based on Avalon's lab policies. Providers must ensure colorectal cancer screening claims (G2181 policy) comply with CareSource laboratory policies or face claim denials.
Action Required
By March 31, 2025: Billing team must review the G2181 Colorectal Cancer Screening policy on Avalon's website and CareSource's laboratory policy guidelines. All providers and billing staff must understand the updated screening requirements and frequency limitations. Implement a process to validate all colorectal cancer screening claims for policy compliance BEFORE submission. Use the CareSource Trial Claim Advice Tool on the Provider Portal to test claims for adherence to laboratory policies before final billing. Update internal claim review procedures to flag any colorectal cancer screening claims that may not meet Avalon/CareSource RTM program requirements. Train billing team on new RTM program requirements. Document all policy changes in billing workflow. Non-compliant claims will be denied or subject to post-service editing, resulting in payment delays and potential recovery actions.