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CareSourceMedicaid · Coverage · Medical Policy · OH · Gastroenterology, Family Medicine, Internal Medicine +1 moreMedium impact

[Ohio] Avalon Policy Update - February 2025

Act
by Mar 31, 2025
Effective date
Apr 1, 2025
Identified
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.

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What to do

by Mar 31, 2025 · 8 steps
01Billing team must review the G2181 Colorectal Cancer Screening policy on Avalon's website and CareSource's laboratory policy guidelines.
02All providers and billing staff must understand the updated screening requirements and frequency limitations.
03Implement a process to validate all colorectal cancer screening claims for policy compliance BEFORE submission.
04Use the CareSource Trial Claim Advice Tool on the Provider Portal to test claims for adherence to laboratory policies before final billing.
05Update internal claim review procedures to flag any colorectal cancer screening claims that may not meet Avalon/CareSource RTM program requirements.
06Train billing team on new RTM program requirements.
07Document all policy changes in billing workflow.
08Non-compliant claims will be denied or subject to post-service editing, resulting in payment delays and potential recovery actions.

Original notice

[Ohio] Avalon Policy Update - February 2025
caresource.com · Always check the source before changing claims.
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Related changes

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CareSource policiesOH policy changesGastroenterologyFamily MedicineInternal MedicineGeneral Practice

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