Community Plan. Pennsylvania Physician, Health Care Professional, Facility and Ancillary Provider Manual. UHCCommunityPlan.

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1 Community Plan Pennsylvania 2013 Physician, Health Care Professional, Facility and Ancillary Provider Manual UHCCommunityPlan.com

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3 Table of Contents Welcome to UnitedHealthcare Community Plan How to Contact us Covered and Non-Covered Services Prior Authorizations Claims Policies and Procedures Primary Care Physician Hospital and Hospitalizations Special Needs Pharmacy Member Information Participating Providers Primary Care Physician Standards and Policies Specialist Preventive Health and Clinical Practice Guidelines Provider Appeals Quality Management Program Ethical Business Practices and Compliance Appendix A. Forms B. UnitedHealthcare Community Plan Medical Record Documentation Standards C. PA Medical Assistance Manual D. Medicaid and CHIP Complaints and Department of Welfare Medicaid Fair Hearings E. Legal/Advocacy Help i

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5 Welcome to UnitedHealthcare (UnitedHealthcare Community Plan) UnitedHealthcare (UnitedHealthcare Community Plan) is a business unit of UnitedHealth Group, a diversified health and well-being company dedicated to making health care work better. UnitedHealthcare Community Plan manages UnitedHealth Group s Medicaid health plans and management service organization contracts in 25 states and the District of Columbia. Several factors distinguish UnitedHealthcare Community Plan: UnitedHealthcare Community Plan emphasizes service to all our customers regulators, providers and members. UnitedHealthcare Community Plan understands the unique needs of the populations we serve, and our health plans are designed specifically to meet those needs. UnitedHealthcare Community Plan has a private-sector focus on cost accounting, data analysis and fiscal discipline, coupled with sensitivity to the imperatives of public sector accountability. UnitedHealthcare Community Plan invests in the systems and personnel required to successfully manage our business. Moreover, UnitedHealthcare Community Plan understands that compassion and respect are essential components of success in health care. UnitedHealthcare Community Plan employs a diverse workforce, rooted in the communities we serve, with varied backgrounds and extensive practical experience that gives us a better understanding of our members and their needs. UnitedHealthcare Community Plan is delighted to present this latest edition of the Provider Manual. There have been significant changes for the improvement of services and delivery of our products to our provider network. We value you as one of our participating providers, and welcome you to utilizing the resources available to you in this manual, the UnitedHealthcare Community Plan web site, or contact our Provider Call Center directly if you should have any questions or concerns. Again, thank you for your continued participation and cooperation with UnitedHealthcare Community Plan! The term Provider Manual appears in UnitedHealthcare Community Plan of Pennsylvania's contract with the Pennsylvania Department of Public Welfare and in Pennsylvania Department of Health regulations. For purposes of your provider contract with UnitedHealthcare Community Plan of Pennsylvania, the reference to the phrase Provider Manual is synonymous with the contract term Administrative Guide and therefore both terms should be considered to have the same meaning. 1

6 The UnitedHealthcare Community Plan Provider Manual This Provider Manual is designed to give you and your staff a comprehensive guide for your participation with UnitedHealthcare Community Plan. It is also an integral part of your contract with UnitedHealthcare Community Plan and is specifically incorporated by reference in your provider agreement. It is imperative that you keep it in an accessible place for easy day-to-day reference. The Provider Manual is available electronically at Paper copies are available on request. This Provider Manual replaces all earlier editions of Provider Manuals and Provider Alerts. The information contained in this manual reflects the policies of UnitedHealthcare Community Plan as of the current printing. It also reflects the policies, procedures and benefits of state and federal health programs communicated to UnitedHealthcare Community Plan as of current printing. If it is necessary to update any information sooner, UnitedHealthcare Community Plan will send updates via provider newsletters or Provider Alerts. The Provider Manual, Newsletters and Alerts together constitute the most current information on UnitedHealthcare Community Plan programs and, along with your provider contract, outline your legal responsibilities under these programs and your contractual relationship with UnitedHealthcare Community Plan. Participating dentists, pharmacists, and vision care providers receive separate instructions, guidelines, and alerts. If you need additional copies or have any questions about your Provider Manual, please call the Provider Services Helpline at UnitedHealthcare Community Plan Programs UnitedHealthcare Community Plan of Pennsylvania currently offers three programs: UnitedHealthcare Community Plan Medicaid is offered through the product name UnitedHealthcare Community Plan for Families under HealthChoices program of the Pennsylvania Department of Public Welfare. UnitedHealthcare Community Plan CHIP is offered through the product UnitedHealthcare Community Plan for Kids under State Children s Health Insurance Program (CHIP) administered by the Pennsylvania Insurance Department. UnitedHealthcare Community Plan Medicare Advantage is offered through the products UnitedHealthcare Community Plan Dual Complete and UnitedHealthcare Community Plan Medicare Complete. 2

7 How to Contact Us Web portal As our valued health care partner, we know your time is important. So we've designed our website to help you save time, improve efficiency and reduce errors caused by conventional claims submission practices. Member Services Helpline Member services helpline is available Monday thru Friday from 8:00 am to 5:00pm, and on Wednesdays until 8:00pm. 24 hour, seven day a week service is available to assist members with urgent or emergent issues/concerns. Interactive Voice Response Line Use our toll-free Interactive Voice Response (IVR) system 24 hours a day 7 days a week to check member eligibility Dental Services Unitedhealthcare Speciality Dental Benefits is the Dental Provider for UnitedHealthcare Community Plan, effective July 11, 2011 Provider Service Helpline Call center available to providers to answer general questions or to be able to status claims Network Management For contract, demographic and network 100 Penn Square East-Suite related issues. Philadelphia, PA Oxford Drive Monroeville, PA National Intake (Pre-Certifications) Providers contact regarding medical, (fax) surgical, maternity and/or newborn hospitalizations, DME, home health care etc. Specialty Units Healthy First Steps Healthy First Steps is designed to assist pregnant mothers with various issues. Sales and Marketing (CHIP) Department available to assist people in obtaining CHIP insurance Pharmacy Services Providers contact regarding pharmacy needs, issues or concerns Vision Services March Vision Care is the Vision Provider for UnitedHealthcare Community Plan, effective January 1, 2011 Special Needs Unit Special Needs Unit is designed to assist members and providers with various special needs issues 3

8 Behavioral Health (Mental Health and Substance Abuse Services) UnitedHealthcare Community Plan Behavioral Health can be contacted at UnitedHealthcare Community Plan -Medicaid Behavioral health services are carved out of the agreement between UnitedHealthcare Community Plan and the Department of Public Welfare (DPW). Members contact the following organizations at the numbers listed based on the counties they reside in for behavioral health services. UnitedHealthcare Community Plan -Medicare UnitedHealthcare Community Plan -Medicare contracts with United Behavioral Health to provide benefits to UnitedHealthcare Community Plan -Medicare members. Outpatient therapy with a participating provider does not require prior authorization. UnitedHealthcare Community Plan for Kids-CHIP UnitedHealthcare Community Plan -Medicare contracts with United Behavioral Health to provide benefits to UnitedHealthcare Community Plan-CHIP members. Outpatient therapy with a participating provider does not require prior authorization. Community Behavioral Health Philadelphia Community Care Behavioral Health Organization: Adams Allegheny Berks Bradford Cameron Carbon Centre Chester Clarion Clearfield Columbia Elk Erie Forest Huntington Jefferson Juniata Lackawanna Luzerne McKean Mifflin Monroe Montour Northumberland Pike Potter Schuylkill Snyder Sullivan Susquehanna Tioga Union Warren Wayne Wyoming York Value Behavioral Health: Armstrong Beaver Butler Cambria Crawford Fayette Greene Indiana Lawrence Mercer Venango Washington Westmoreland Magellan Behavioral Health of Pennsylvania: Bucks Delaware Lehigh Montgomery Northampton Community Behavioral Health Care Network of PA: Bedford Blair Clinton Cumberland Dauphin Franklin Fulton Lancaster Lebanon Lycoming Perry Somerset

9 Covered and Non-Covered Services Each UnitedHealthcare Community Plan product has a set of covered and non-covered services. In general, all products cover comprehensive primary care, specialty care, outpatient laboratory and radiology, emergency care, hospitalization, and outpatient/ambulatory surgery and procedures. From the provider s perspective, the list of covered services is important in developing treatment plans and in obtaining prior authorization when necessary. For more detail on services that must be given prior authorization, contact the National Intake Department at Covered Benefits Service Medicaid* Medicare CHIP** Abortions Covered. Must meet current federal and state guidelines and be medically necessary. Covered. Must meet current federal and state guidelines and be medically necessary. Covered. Must meet current federal and state guidelines and be medically necessary. Allergy Testing Covered. Covered. Covered. Audiology Covered. Covered. Covered. Autism Services Covered. Not Covered. Covered. Birth Control Services Covered. Covered. Covered. Blood & Blood Plasma Covered. Covered. Covered. Bone Mass Measurement (bone density) Covered. Covered. Covered. Case Management Covered. Covered. Covered. Chemotherapy Covered. Covered. Covered. Chiropractic Services (manipulation/subluxation) Covered. Covered. Not Covered. Colorectal Screening Exams Covered. Covered. Covered. Cosmetic Services Not Covered. Not Covered. Not Covered. Custodial Services Not Covered. Not Covered. Not Covered. Dental Services (preventive & routine services, dentures, surgical extractions) Covered, benefit limits may apply. Covered. Covered. Diabetic Education, Home Visits & Monitoring Covered. Covered. Covered. Diabetic Supplies & Equipment Covered. Covered. Covered. Diapers for Disabled Children (over age 3) Covered. Covered. Covered. Durable Medical Equipment Covered. Covered. Covered. EPSDT Services & Immunizations (under age 21) Covered. Covered. Covered. Emergency Transporation (ambulance) Covered. Covered. Covered. Family Planning Basic Services Covered. Not Covered. Covered. Hearing Exams Covered. Covered. Covered. Hearing Aids & Batteries Covered, under age 21 only. Covered. Covered. Hemodialysis Covered. Covered. Covered. 5

10 Service Medicaid* Medicare CHIP** HIV/AIDS Testing Covered. Covered. Covered. Home Assessment Covered. Covered. Covered. Home Adaptation Not Covered. Not Covered. Not Covered. Home Delivered Meals Not Covered. Not Covered. Not Covered. Home Health Care & Infusion Therapy Covered. Covered. Covered. Hospice Care Covered. Not Covered. Covered. Immunizations (pneumococcal, flu, hepatitis A & B) Covered. Covered. Covered. Infertility Not Covered. Not Covered. Not Covered. Inpatient Hospitalization (semi-private, unless medically necessary) Covered. Covered. Covered. Lab Tests & X-rays Covered. Covered. Covered. Mental Health/Substance Abuse Provided by BH MCOs Covered. Covered Mammograms Covered. Covered. Covered. Nutrition Covered. Covered. Covered. Obstetrical (Maternity) Care Covered. Covered. Covered. Occupational Therapy Covered. Covered. Covered. Organ Transplant Evaluation Covered. Covered. Covered. Orthodontia Covered under 21 years old. Not Covered. Covered. Orhtopedic Shoes Covered. Covered. Covered. Outpatient Surgery, Same-Day Surgery, Ambulatory Surgical Center Covered. Covered. Covered. Pain Clinic Services Covered. Covered. Covered. Pap Smears & Pelvic Exams Covered. Covered. Covered. Parenting & Child Birth Education Covered. Not Covered. Not Covered. Personal Emergency Response System Not Covered. Not Covered. Not Covered. Physical Therapy Covered. Covered. Covered. Podiatry Care: Medically Necessary, Routine, Preventive (office-based, non-surgical) Covered. Covered. Covered. Prescription Drugs Covered, under age 21 only. Covered. Covered. Preventive Services Covered. Covered. Covered. PCP Visits Covered. Covered. Covered. Private Duty or Skilled Nursing Care Covered. Covered. Covered. Prostate Cancer Screening Exams Covered. Covered. Covered. Prosthetics & Orthotics (less than $500) Covered. Covered. Covered. Prosthetics & Orthotics (more than $500) Covered. Covered. Covered. Radiation Therapy Covered. Covered. Covered. Radiology Scans, MRI, MRA, PET Covered. Covered. Covered. 6

11 Service Medicaid* Medicare CHIP** Rehabilitation (occupational, physical & speech therapy; inhouse therapy) Covered. Covered. Covered. Reproductive Health (procedures & devices) Covered. Covered. Covered. Second Opinions (Medical & Surgical) Covered. Covered. Covered. Skilled Nursing Facility Covered. Covered. Covered. Sleep Apnea Studies Covered. Covered. Covered. Smoking Cessation Products & Classes Covered. Covered. Covered. Specialty Physician Services (except OB/GYN) Covered. Covered. Covered. Speech Therapy Covered. Covered. Covered. Transportation: Non-Emergency Ambulance Covered. Covered. Covered. Transplants Covered. Covered. Covered. Urgent Care Covered. Covered. Covered. Vision Care Covered. Covered. Covered. *Adult Medicaid benefit limits: Outpatient office visits are limited to 18 per year for adults over 21. Dental benefit limits are limited for adults over 21. Prescription drugs are limited to 6 prescriptions per month for adults over 21. For more detail and a list of drugs for which an automatic exception can be processed at the point of sale, please refer to pharmacy program information at: Benefit limits do not apply to pregnant women or residents of a nursing home or Intermediate Care facility. An exception to the benefit limits can be approved if the following criteria are met: The member has a serious chronic illness or health condition and without the additional service, their life would be in danger; or The member has a serious chronic illness or health condition and without the additional service, their health would get much worse; or The member would need more expensive services if the exception was not granted; or, It would be against federal law for UnitedHealthcare to deny the service. **CHIP members are limited to 50 outpatient physical health visits per year. This limit does not apply to any well baby, well child, adolescent, or prenatal visits. The 50 visit limit applies to such services as sick visits, outpatient ambulatory surgery visits, and visits to specialists. NOTE: Co-payments for Medicaid recipients: co-payments do not apply to members under 18, pregnant or in a nursing home. Also, most Medicaid limits do not apply to pregnant women, residents of nursing homes or intermediate care facilities. Substance Abuse and Mental Health inpatient services are subject to limits. Per PA Act 62, Autism Services are covered for CHIP members Limitations and most exclusions do not apply to children under age 21, but some services do require a referral or prior authorization. If you have any questions about the benefit chart, call Provider Services at Note: The list above is not an all-inclusive list, but represents a sample of some of the covered services of the plan. For additional information please contact Provider Services at

12 BEHAVIORAL HEALTH All Medicaid members receive their mental health and substance abuse services through the contracted behavioral health managed care organization or the county. CHIP and Medicare Advantage members receive mental health and substance abuse services through United Behavioral Health (UBH). Members and/or providers may call UBH Care Management at

13 Prior Authorizations Primary Care Physician Responsibility for Prior Authorization and Notification The Primary Care Physician or Specialist referring a patient for an elective admission or same day surgery is responsible for contacting UnitedHealthcare Community Plan for prior authorization. UnitedHealthcare Community Plan recommends calling at least 5 days in advance of the admission or surgery. Requests for prior authorization are prioritized according to level of medical necessity. Certain cases are reviewed under emergency guidelines. Requests for program exceptions and exceptions to benefit limits should follow the same process. For prior authorizations, Monday Friday, 8:00 A.M. 5:00 P.M., providers should call , fax , or enter request into I-Exchange, a web-based authorization system. Any discharge or urgent needs, providers need to call Prior Authorization Grid see Covered and Non-Covered Grid (above) PRIOR AUTHORIZATION REQUIREMENTS Inpatient Acute, Sub-Acute, Rehab and SNF admissions require prior notification. All non-par service require prior authorization. Prior notification not required for emergency services but hospitals must provide notification within 2 business days of inpatient admission. Service PA Medicaid PA CHIP PA Medicare COMMENTS Abortions Auth Required Auth Required Auth Required Medicaid- Proper completion of consent and MA forms required (MA-3, MA-368) Acupuncture NCB NCB NCB Allergy Services Not Required Not Required Not Required Ambulance Services - Emergency (Par and Nonpar) Not Required Not Required Not Required Ambulance Services - Non emergency, Facility to Facility transports (Par) Ambulance Services - Non emergency, Facility to Facility transports (Nonpar) Ambulance Services - Non emergency, other than Facility to Facility (Par and Non par) Not Required Not Required Not Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Amniocentesis Not Required Not Required Not Required Barium swallow (upper GI) Not Required Not Required Not Required Biopsies Not Required Not Required Not Required NCB = Not a Covered Benefit Not Required = No Authorization is required for the service Auth Required = The provider must obtain a prior authorization before rendering the service. 9

14 Service PA Medicaid PA CHIP PA Medicare COMMENTS Blood transfusion admin & Not Required Not Required Not Required supplies Cardiac event monitor (Holter) Not Required Not Required Not Required Cardioversion Not Required Not Required Not Required Carotid duplex Not Required Not Required Not Required Chemotherapy Not Required Not Required **Auth Required **Medicare Only: Chemotherapy generally requires prior authorization with the exception of the following chemotherapy agents: Amifostine, Asparaginase, BCG, Bleomycin, Cisplatin, Cyclophosphamide,Cytarabine, Dacarbazine, Dactinomycin, Daunorubicin, Dlxorubicin, Etoposide,Fluorouracil, Idarubicin, Leucovorin, Mechlorethamine HCL, Melphalan, Mesna,Methotrexate, Mitomycin, Vinblastine, Vincristine Chiropractic services Auth Required NCB Auth Required Cosmetic Surgery Auth Required Auth Required Auth Required All Products: Cosmetic surgery is not covered. Reconstructive surgery is covered with a prior authorization - All cases will be referred to the Medical Director for review. D & C w/hysteroscopy Not Required Not Required Not Required Dental - Preventive/Routine Services Not Required Not Required Not Required Dental Services are managed by UHC Specialty Dental Benefits- All of PA Effective 7/11/11. Dental - Comprehensive Services Auth Required Auth Required Auth Required Dental Services are managed by UHC Specialty Dental Benefits- All of PA Effective 7/11/11. Diabetic teaching Not Required Not Required Not Required ADA approved facility (*10 sessions annually (par) - Additional visits require prior authorization. If diabetes education is provided in the member's home, prior authorization is required Diagnostic Procedures Angiogram, coronary (Cardiac Not Required Not Required Auth Required Cath) - Outpt Angiogram, non coronary Not Required Not Required Not Required Arthrogram Not Required Not Required Not Required Arthroscopy Not Required Not Required Auth Required Audiogram Not Required Not Required Not Required Bone Marrow Aspiration Not Required Not Required Not Required Bronchoscopy Not Required Not Required Not Required NCB = Not a Covered Benefit Not Required = No Authorization is required for the service Auth Required = The provider must obtain a prior authorization before rendering the service. 10

15 Service PA Medicaid PA CHIP PA Medicare COMMENTS Colonoscopy Not Required Not Required Not Required Colposcopy Not Required Not Required Not Required Cystoscopy Not Required Not Required Not Required Cystometrogram Not Required Not Required Not Required Cystourethrogram (VCUG) Not Required Not Required Not Required Cystourethroscopy Not Required Not Required Not Required Discogram Not Required Not Required Not Required Echocardiogram (ECG/EKG) Not Required Not Required Not Required Electroencephalogram (EEG) Not Required Not Required Not Required Electromyelogram(graphy) (EMG) Not Required Not Required Not Required Endoscopy Not Required Not Required Not Required Gastroscopy Not Required Not Required Not Required Hysteroscopy Not Required Not Required Not Required IVP (intravenous pyelogram) Not Required Not Required Not Required Laparoscopy Not Required Not Required Auth Required Laryngoscopy Not Required Not Required Not Required Mammogram Not Required Not Required Not Required Myelogram Not Required Not Required Not Required Nerve Conduction Study Not Required Not Required Not Required Pneumogram Not Required Not Required Not Required Sigmoidoscopy Not Required Not Required Not Required Transesophageal echocardiogram (TEE) Not Required Not Required Not Required Ureteroscopy Not Required Not Required Not Required Urogram Not Required Not Required Not Required Venogram Not Required Not Required Not Required Dialysis Not Required Not Required Not Required DME- Billed amount >$500 Auth Required Auth Required Auth Required Drugs (except cancer agents) administered in the provider's office. Billed charges of $ and less. Drugs (except cancer agents) administered in the outpatient hospital setting. Billed charges of $ or less. Not Required Not Required Not Required Not Required Not Required Not Required NCB = Not a Covered Benefit Not Required = No Authorization is required for the service Auth Required = The provider must obtain a prior authorization before rendering the service. 11

16 Service PA Medicaid PA CHIP PA Medicare COMMENTS Drugs (except cancer agents) Auth Required Auth Required Auth Required administered in the provider's office or outpatient hospital setting- Billed charges over $ Electroconvulsive therapy (ECT) Provider should contact BH MCO. BH **Auth Required **Auth Required MCO varies by county. Endocervical curettage Not Required Not Required Not Required EP (electrophysiology studies) Not Required Not Required Auth Required ERCP (endoscopic retrograde Not Required Not Required Not Required cholangiopancreatography) Family Planning Services Not Required Not Required NCB Fracture care - Non Surgical Not Required Not Required Not Required Fracture care - Surgical Not Required Not Required Auth Required Gastric Bypass Surgery Auth Required Auth Required Auth Required Genetic counseling Auth Required Auth Required NCB Genetic testing Auth Required Auth Required Auth Required Gynecological Services (routine) Not Required Not Required Not Required Hardware removal Not Required Not Required Not Required Home Health Care Aide Auth Required Auth Required Auth Required Coverage only for members under 21 years of age Private duty nursing Auth Required Auth Required Auth Required Shift Care **For Pediatrics ONLY** Auth Required Coverage only for members under 21 years of age Auth Required Auth Required NCB = Not a Covered Benefit Not Required = No Authorization is required for the service Auth Required = The provider must obtain a prior authorization before rendering the service. 12

17 Service PA Medicaid PA CHIP PA Medicare COMMENTS Skilled nursing Auth Required Auth Required Auth Required Visits less than 2 hours per day is a Routine Home Care Request (episode) for adults or pediatrics and is not considered Private Duty Nursing or Shift Care. Social worker Auth Required Auth Required Auth Required Hospice services Auth Required Auth Required **Auth Required Hyperbaric Oxygen Treatments Not Required Not Required Auth Required **Medicare- Hospice services are covered by the Medicare contractor and not the responsibility of the Medicare Managed Care Plan. Services unrelated to the terminal dx are the responsibility of the Health Plan. Hysterectomy Auth Required Auth Required Auth Required Infertility Services: Testing and Treatment NCB NCB NCB Medicaid- Proper completion of consent and MA forms required (MA-30). Inpatient Detoxification in a Hospital Level IV Detox - Auth Required Auth Required Auth Required Insertion/removals/ replacements Foley catheter Not Required Not Required Not Required G-tube Not Required Not Required Not Required J-tube Not Required Not Required Not Required NG-tube Not Required Not Required Not Required Suprapubic catheter Not Required Not Required Not Required Intensive Outpatient (IOP) for MH/D&A Provider should contact BH MCO. BH MCO varies by county. Auth Required NCB IV - insertions and removals AV fistula, graft, ligation, thrombectomy Not Required Not Required Not Required Central catheter Not Required Not Required Not Required Grashong Not Required Not Required Not Required Hickman Not Required Not Required Not Required Peripheral line Not Required Not Required Not Required PICC (peripherally inserted central cath) Not Required Not Required Not Required Port-a-cath Not Required Not Required Not Required Mid line Not Required Not Required Not Required NCB = Not a Covered Benefit Not Required = No Authorization is required for the service Auth Required = The provider must obtain a prior authorization before rendering the service. 13

18 Service PA Medicaid PA CHIP PA Medicare COMMENTS Labs Not Required Not Required Not Required LEEP (loop electrosurgical excision procedure) Not Required Not Required Not Required LTACs NCB NCB Auth Required Non-hospital drug & alcohol services Nuclear Cardiac Studies- Performed in the OP hospital Provider should contact BH MCO. BH MCO varies by county. Not Required **NCB Not Required Not Required Not Required **Medicare: Medicare will only reimburse hospital based programs. Nuclear Cardiac Studies- Performed in POS 11 (office) Not Required Not Required **Auth Required **Medicare: The following codes are considered Cardiac Nuclear Studies and require prior authorization in the office setting: 78414,78428,78459,78460,78461,78464,78465, 78466,78468,78469,78472,78473,78478,78480, 78481,78483,78491,78492,78494,78496,78499 Nursing facilities Auth Required Auth Required Auth Required Nutrition Services Child (under 21)- Nutritional Supplements Auth Required Auth Required N/A Nutritional and Weight Management Not Required Not Required N/A Adult Medical Nutritional Therapy Auth Required Auth Required **Auth Required **Medicare: The following codes are covered with the diagnosis of Diabetes and/or Renal Disease. Cases are entered under the MNT UM Service Group Medical nutrition, indiv, in Med nutrition, indiv, subseq Medical nutrition, group G MNT Subs tx for Change dx G Group MNT 2 or More 30 mins Nutritional and Weight Management Not Required Not Required Not Required Observation Not Required Not Required Not Required Obstetrical Services- Prenatal and Postnatal Care Not Required Not Required Not Required Outpatient Drug and Alcohol Provider should contact BH MCO. BH MCO varies by county. Not required Not required NCB = Not a Covered Benefit Not Required = No Authorization is required for the service Auth Required = The provider must obtain a prior authorization before rendering the service. 14

19 Service PA Medicaid PA CHIP PA Medicare COMMENTS Outpatient Mental Health Outpatient surgeries performed in the ASC or SPU** Provider should contact BH MCO. BH MCO varies by county. Not Required Not Required Not Required Not Required Auth Required Pain Management Specialist Services Auth Required Auth Required Auth Required Facet injections Auth Required Auth Required Auth Required Office visits for medication check Not Required Not Required Auth Required Epidural injections Auth Required Auth Required Auth Required Other services performed in the pain management setting Not Required Not Required Auth Required Paracentesis Not Required Not Required Not Required Partial/Day Hospitals for MH or Drug/Alcohol Provider should contact BH MCO. BH MCO varies by county. Auth Required Auth Required **Medicaid and CHIP- Exception abortion, hysterectomy, cosmetic procedures, and bariatric surgery require prior authorization regardless of place of service** Plastic Surgery Auth Required Auth Required Auth Required **Cosmetic procedures that are not medically necessary are not a covered benefit for Medicaid, CHIP, or Medicare. Pulmonary function test (PFTs) Not Required Not Required Not Required Radiation Therapy Not Required Not Required Not Required Radiology (Imaging studies) Bone Mass Measurements CT Scan-Bone Density Study Not Required Not Required Auth Required DEXA (dual energy xray absorptiometry) RA (radiographic absorptiometry) SEXA (single energy xray absorptiometry) Ultrasound Bone Density Study Not Required Not Required Not Required Not Required Not Required Not Required Not Required Not Required Not Required Not Required Not Required Not Required NCB = Not a Covered Benefit Not Required = No Authorization is required for the service Auth Required = The provider must obtain a prior authorization before rendering the service. 15

20 Service PA Medicaid PA CHIP PA Medicare COMMENTS CT myelogram Not Required Not Required Auth Required CT over 21 (computed tomography) Not Required N/A Auth Required CT under 21 Not Required Not Required N/A DEXA (dual energy xray absortiometry) Not Required Not Required Not Required GES (gastric emptying scan) Not Required Not Required Not Required Hida scan (hepatobiliary scan) Not Required Not Required Not Required KUB (kidney-ureter-bladder scan) MRI (magnetic resonance imaging) MRA (magnetic resonance angiogram) MUGA scan (multiple gated acquisition) PET (positron emission tomography) Not Required Not Required Not Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Not Required Not Required **Not Required Auth Required Auth Required Auth Required Renal scan Not Required Not Required Not Required SPECT Not Required Not Required Auth Required Thallium scan Not Required Not Required Not Required Thyroid scan Not Required Not Required Not Required Ultrasounds (including dopplers) Not Required Not Required Not Required VQ scan (perfusion ventilation Not Required Not Required Not Required scan) X-rays Not Required Not Required Not Required Sex Change surgery and related NCB NCB NCB services Sleep study Auth Required Auth Required Auth Required Spinal tap (lumbar puncture) Not Required Not Required Not Required Sterilization Tubal ligation Authorization entered by Intake- No medical necessity review required. NCB = Not a Covered Benefit Not Required = No Authorization is required for the service Auth Required = The provider must obtain a prior authorization before rendering the service. **Medicare- Auth required if performed in the office setting (POS 11). NCB NCB Medicaid- Proper completion of consent and MA forms required (MA-31) 16

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