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CareSourceMedicaid · Reimbursement · Medical Policy · OH · Pathology, Internal Medicine, Family Medicine +11 moreHigh impact

[Ohio] Avalon Policy Updates

Act
by Nov 30, 2026
Effective date
Dec 1, 2026
Identified
Oct 1, 2026

Summary

CareSource Ohio Medicaid has partnered with Avalon Healthcare Solutions for laboratory benefits management and is revising 36 laboratory reimbursement policies effective December 1, 2026. These revised policies govern routine lab testing through Avalon's post-service pre-payment clinical claim editing program (RTM). No prior authorization requirement changes are indicated, but billing teams must ensure compliance with updated lab policies on Avalon's website to avoid claim denials.

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What to do

by Nov 30, 2026 · 5 steps
01Billing team must access Avalon Healthcare Solutions' website and review all 36 revised laboratory reimbursement policies (F2019 v7, G2005, G2008, G2011, G2013, G2014, G2022, G2031, G2036, G2044, G2045, G2050, G2056, G2059, G2063, G2098, G2099, G2120, G2124, G2125, G2138, G2143, G2149, G2153, G2154, G2164, G2181, M2041, M2057, M2067, M2112, M2116, M2141, M2172, P2018, R2162, T2015).
02Document any changes to medical necessity requirements, frequency limits, age restrictions, or covered indications for routine lab testing.
03Update billing software and EMR templates to enforce the revised policies.
04Providers should utilize the Trial Claim Advice Tool on the CareSource Provider Portal to validate laboratory claims for compliance before submission.
05Ohio Medicaid lab claims submitted without adherence to Avalon's revised policies will be subject to post-service pre-payment claim editing and potential denials.

Original notice

[Ohio] Avalon Policy Updates
caresource.com · Always check the source before changing claims.
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