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[Ohio] Avalon Q3 Policy Update - February 2025
Act
by Mar 31, 2025
Effective date
Apr 1, 2025
Identified
May 9, 2026
Summary
CareSource (Ohio Medicaid and Ohio MyCare) is implementing updated laboratory benefit management policies through Avalon Healthcare Solutions effective April 1, 2025. The update affects 40+ laboratory testing policies covering routine testing management (RTM), a post-service pre-payment clinical claim editing program. Providers must ensure all laboratory claims comply with the updated Avalon policies, which are available on Avalon's website.
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What to do
by Mar 31, 2025 · 5 steps
01Billing team and providers must review all 40+ updated laboratory policies on Avalon Healthcare Solutions website (https://www.avalon-healthcare.com or through CareSource Provider Portal).
02Immediately register and test claims using the Trial Claim Advice Tool on the CareSource Provider Portal to simulate compliance with new policies before April 1, 2025.
03Update laboratory ordering procedures and billing workflows to ensure claims for Flow Cytometry, Cervical Cancer Screening, Prostate Biopsy Analysis, Prenatal Screening, Hepatitis Testing, Celiac Disease Testing, Thyroid Testing, Alzheimer biomarkers, Cardiovascular Risk Assessment, Bone Turnover Markers, Breast Cancer Risk Assessment, Fecal Analysis, TB Testing, Chemoresistance Assays, Therapeutic Antibody Monitoring, Hepatic Fibrosis Testing, Oral Cancer Screening, Thiopurine Metabolites, Influenza Diagnostics, IBD Testing, Multiple Sclerosis Biomarkers, Tumor Markers, Pathogen Panels, Cardiac Biomarkers, TBI Testing, Pancreatic Enzymes, Folate Testing, Inflammation Testing, Urine Culture, Vector-Borne Infections, Beta-Hemolytic Streptococcus, Gamma-glutamyl Transferase, Thrombosis Risk Testing, Alpha-1 Antitrypsin, Microorganism Identification, and Nerve Fiber Density Testing comply with Avalon's clinical editing criteria.
04Failure to comply will result in claim denials or payment delays post-service.
05Communicate policy changes to all providers ordering laboratory tests.
Original notice
[Ohio] Avalon Q3 Policy Update - February 2025
caresource.com · Always check the source before changing claims.
Related changes
See all CareSource changes →[Ohio] Avalon Policy UpdatesHighEffective Dec 1, 2026 · Medical Policy[Georgia] Avalon Policy Updates - Q3 2024HighEffective Apr 1, 2025 · Medical Policy[Ohio] Avalon Policy Update - February 2025MediumEffective Apr 1, 2025 · Medical Policy[Georgia] Avalon Policy Updates - November 2025MediumEffective Jan 1, 2026 · Medical PolicyBrowse every CareSource change in the policy list