MEDICAL POLICY POLICY TITLE POLICY NUMBER ACUTE INPATIENT REHABILITATION MP-8.003

Size: px
Start display at page:

Download "MEDICAL POLICY POLICY TITLE POLICY NUMBER ACUTE INPATIENT REHABILITATION MP-8.003"

Transcription

1 Original Issue Date (Created): July 1, 2002 Most Recent Review Date (Revised): Effective Date: May 27, 2008 May 1, RETIRED I. DESCRIPTION/BACKGROUND Inpatient rehabilitation hospitals provide an intensive multidisciplinary approach to rehabilitation services for injured and disabled individuals to restore lost function following illness or accidental injury. II. DEFINITIONS ACUTE REHABILITATION HOSPITAL is a facility or distinct part of a facility that is licensed or approved under state and local law as an acute specialty hospital providing a comprehensive inpatient rehabilitation program. The facility must be approved by the Joint Commission on the Accreditation of Healthcare Organizations, or by the Commission on Accreditation of Rehabilitation Facilities, and be primarily engaged in providing skilled rehabilitation services on an inpatient basis. Skilled rehabilitation services consist of the combined use of medical, social, educational and vocational services to enable members disabled by disease or injury to achieve the highest possible level of functional ability. Skilled rehabilitation services are provided by or under the supervision of an organized staff of physicians. Continuous nursing services are provided by or under the supervision of a registered nurse. DAILY REHABILITATION SERVICES are skilled rehabilitation services that must be required and provided no less than five (5) days per week. INTENSE LEVEL OF REHABILITATION SERVICES is one in which the patient requires and receives at least three (3) hours of skilled rehabilitation services in any combination of modalities. MULTIDISCIPLINARY TEAM usually includes a physician, rehabilitation nurse, social worker and/or psychologist and therapists involved in the patient s care. At a minimum, the team must include a physician, rehabilitation nurse and a therapist. Page 1

2 SKILLED REHABILITATION SERVICES are those services which are furnished pursuant to a physician order that: Require the skills of qualified technical or professional health personnel such as physical therapists, occupational therapists and speech pathologists; Must be provided directly by or under the supervision of these skilled nursing or rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result. III. POLICY The medical necessity and appropriateness of Acute Rehabilitation Hospital inpatient admission determinations will be made following the guidelines set forth in this policy and further described in the Center for Medicare & Medicaid Services (CMS)/Medicare guidelines as documented in the Medicare Benefit Policy Manual, Chapter 1 -Inpatient Hospital Services Covered Under Part A, Section 110- Inpatient Hospital Stays for Rehabilitation Care. For inpatient care in an Acute Rehabilitation Hospital to be considered medically necessary all of the following criteria must be met: The patient s condition must require the close medical supervision and twenty-four (24) hour per day availability of a physician who specializes or is experienced in the field of rehabilitation; The patient s condition requires twenty-four (24) hours per day availability of a registered nurse that specializes or is experienced in the field of rehabilitation; The patient must require an intense level of rehabilitation services on a daily basis; The rehabilitation plan of care must utilize a multidisciplinary approach to delivery of care and services; The rehabilitation program must be a coordinated process that includes frequent periodic team conferences for assessment of progress, identification and resolution of impediments to progress and ongoing evaluation of the validity of the individualized patient goals; and Realistic, individualized patient goals must be established by the treatment team and must be attainable within a reasonable timeframe. Page 2

3 NOTE: Cognitive therapy is not addressed in this policy. Cognitive therapy is addressed in MP IV. Cross-Reference MP Cognitive Therapy MP Long Term Acute Care Hospital (LTACH) EXCLUSIONS Inpatient acute rehabilitation care and services are not considered medically necessary and an appropriate level of care when: The patient no longer demonstrates significant, consistent progress towards established goals; The care and services required to meet established goals can be provided in a less intensive setting; or Rehabilitation goals are achieved. V. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. Page 3

4 VI. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VII. REFERENCES Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Publication Chapter 1. Section 110-Inpatient Hospital Stays for Rehabilitation Care. [Website]: Accessed March 27, Hopman WM, Verner J. Quality of life during and after inpatient stroke rehabilitation. Stroke Mar;34(3): Epub 2003 Feb 13. VIII. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] CHIP POS [N] PPO [N] HMO [N] CHIP HMO [N] SeniorBlue [N] SeniorBlue PPO [N] Indemnity [N] SpecialCare [N] POS [N] FEP HMO [N] FEP PPO Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 4

5 IX. POLICY HISTORY CAC 5/25/04 CAC 6/28/05 CAC 7/26/05 CAC 6/27/06 CAC 6/26/06 CAC 6/26/07 CAC 5/27/08 Policy approved for retirement effective 5/1/2008. Page 5

All requests for admission or transfer to an LTACH facility must be reviewed by a plan medical director.

All requests for admission or transfer to an LTACH facility must be reviewed by a plan medical director. Original Issue Date (Created): September 20, 2005 Most Recent Review Date (Revised): May 24, 2011 Effective Date: I. POLICY July 1, 2012- RETIRED All requests for admission or transfer to an LTACH facility

More information

MEDICAL POLICY POLICY TITLE DENTAL AND ORAL SURGERY SERVICES AFTER AN ACCIDENT POLICY NUMBER MP- 1.108

MEDICAL POLICY POLICY TITLE DENTAL AND ORAL SURGERY SERVICES AFTER AN ACCIDENT POLICY NUMBER MP- 1.108 Original Issue Date (Created): July 1, 2005 Most Recent Review Date (Revised): Effective Date: June 29, 2010 May 25, 2011- RETIRED I. POLICY II. Dental and/or oral surgery services (on a limited basis)

More information

MEDICAL POLICY POLICY TITLE DIABETIC SELF-MANAGEMENT TRAINING PROGRAM POLICY NUMBER MP- 2.076

MEDICAL POLICY POLICY TITLE DIABETIC SELF-MANAGEMENT TRAINING PROGRAM POLICY NUMBER MP- 2.076 Original Issue Date (Created): July 1, 2005 Most Recent Review Date (Revised): Effective Date: May 24, 2011 August 31, 2011- RETIRED I. POLICY Initial diabetic self-management training (DSMT) may be considered

More information

MEDICAL POLICY I. POLICY POLICY TITLE HOME HEALTH POLICY NUMBER MP-3.002

MEDICAL POLICY I. POLICY POLICY TITLE HOME HEALTH POLICY NUMBER MP-3.002 Original Issue Date (Created): 7/1/2002 Most Recent Review Date (Revised): 1/27/2015 Effective Date: 6/1/2015 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER

More information

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY Original Issue Date (Created): October 25, 2011 Most Recent Review Date (Revised): January 27, 2015 Effective Date: April 1, 2015 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS

More information

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY Original Issue Date (Created): 7/1/2002 Most Recent Review Date (Revised): 1/27/2015 Effective Date: 6/1/2015 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER

More information

MEDICAL POLICY I. POLICY OCCUPATIONAL THERAPY (OUTPATIENT) MP-8.004 POLICY TITLE POLICY NUMBER

MEDICAL POLICY I. POLICY OCCUPATIONAL THERAPY (OUTPATIENT) MP-8.004 POLICY TITLE POLICY NUMBER Original Issue Date (Created): 7/1/2002 Most Recent Review Date (Revised): 3/24/2015 Effective Date: 11/2/2015 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS

More information

Practice Guidelines. Professional Practice Medical Record Documentation Guidelines

Practice Guidelines. Professional Practice Medical Record Documentation Guidelines Practice Guidelines 2010 Professional Practice Medical Record Documentation Guidelines Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage

More information

Inpatient Rehabilitation Facilities (IRFs) [Preauthorization Required]

Inpatient Rehabilitation Facilities (IRFs) [Preauthorization Required] Inpatient Rehabilitation Facilities (IRFs) [Preauthorization Required] Medical Policy: MP-ME-05-09 Original Effective Date: February 18, 2009 Reviewed: April 22, 2011 Revised: This policy applies to products

More information

MEDICAL POLICY POLICY TITLE

MEDICAL POLICY POLICY TITLE Original Issue Date (Created): July 1, 2002 Most Recent Review Date (Revised): Effective Date: April 15, 2008 July 1, 2009- RETIRED I. DESCRIPTION/BACKGROUND High dose chemotherapy (HDC) involves the administration

More information

MEDICAL POLICY HIGH-DOSE CHEMOTHERAPY WITH OR WITHOUT AUTOLOGOUS STEM CELL RESCUE FOR AUTOIMMUNE DISEASES, INCLUDING MULTIPLE SCLEROSIS MP-9.

MEDICAL POLICY HIGH-DOSE CHEMOTHERAPY WITH OR WITHOUT AUTOLOGOUS STEM CELL RESCUE FOR AUTOIMMUNE DISEASES, INCLUDING MULTIPLE SCLEROSIS MP-9. Original Issue Date (Created): August 23, 2002 Most Recent Review Date (Revised): Effective Date: June 17, 2008 July 1, 2009- RETIRED I. DESCRIPTION/BACKGROUND High dose chemotherapy (HDC) involves the

More information

Credentialing and Provider Maintenance

Credentialing and Provider Maintenance Anthem Blue Cross and Blue Shield Credentialing and Provider Maintenance Stacy Smith stacy.smith@bcbswi.com May 25, 2011 Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of

More information

BCBSKS Billing Guidelines. For. Home Health Agencies

BCBSKS Billing Guidelines. For. Home Health Agencies BCBSKS Billing Guidelines For Home Health Agencies BCBSKS IPM BCBSKS Home Health Agency Manual -1 TABLE OF CONTENTS I. Overview II. General Guidelines III. Case Management IV. Home Care Benefits V. Covered

More information

Extended Care Facility

Extended Care Facility Definitions... 2 Custodial Care Services... 3 Patient Eligibility... 4 Precertification Requirements... 4 Billing Example 1: Blue Cross Primary... 6 Billing Example 2: Medicare Primary, Blue Cross Supplemental...

More information

Recovery After Stroke: Health Insurance

Recovery After Stroke: Health Insurance Recovery After Stroke: Health Insurance Stroke recovery can require lots of time and medical attention. Ideally, some of that medical care is covered by health insurance. Dealing with health insurance

More information

MEDICAL POLICY POLICY TITLE POLICY NUMBER SURGICAL TREATMENT OF ACNE AND DERMABRASION MP-1.102

MEDICAL POLICY POLICY TITLE POLICY NUMBER SURGICAL TREATMENT OF ACNE AND DERMABRASION MP-1.102 Original Issue Date (Created): July 26, 2004 Most Recent Review Date (Revised): Effective Date: December 21, 2010 August 31, 2011- RETIRED I. POLICY Surgical Treatment of Acne The surgical excision or

More information

OVERVIEW This policy is to document the criteria for coverage of services at the acute inpatient rehabilitation level of care.

OVERVIEW This policy is to document the criteria for coverage of services at the acute inpatient rehabilitation level of care. Medical Coverage Policy Acute Inpatient Rehabilitation Level of Care EFFECTIVE DATE: 07 06 2010 POLICY LAST UPDATED: 06 04 2013 sad OVERVIEW This policy is to document the criteria for coverage of services

More information

PROTOCOLS FOR OCCUPATIONAL THERAPY PROVIDERS

PROTOCOLS FOR OCCUPATIONAL THERAPY PROVIDERS PROTOCOLS FOR OCCUPATIONAL THERAPY PROVIDERS Type of Services Provided Services provided by Occupational Therapy providers are covered for Santa Barbara Health Initiative (SBHI), San Luis Obispo Health

More information

MEDICAL POLICY No. 91332-R3 NON-ACUTE INPATIENT SERVICES

MEDICAL POLICY No. 91332-R3 NON-ACUTE INPATIENT SERVICES NON-ACUTE INPATIENT SERVICES Effective Date: November 16, 2007 Review Dates: 1/93, 12/99, 12/01, 12/02, 11/03, 11/04, 10/05, 10/06, 10/07, 10/08, 10/09, 10/10, 10/11, 10/12, 10/13, 11/14 Date of Origin:

More information

Solutions. Quality Service Plan Choice Value-Added Programs. for small business.

Solutions. Quality Service Plan Choice Value-Added Programs. for small business. Solutions Quality Service Plan Choice Value-Added Programs for small business. How does a small business attract and keep talented workers? One of the most important and attractive employee benefits an

More information

School Based Medicaid Claiming Program Snapshot

School Based Medicaid Claiming Program Snapshot Occupational Therapy IEP; prescribed by a physician Registered by the American Occupational Therapy Association (now the NBCOT for certification purposes); or a graduate of a program in occupational therapy

More information

PROVIDER BULLETIN No. 05-05

PROVIDER BULLETIN No. 05-05 PROVIDER BULLETIN No. 05-05 February 15, 2005 TO: FROM: BY: RE: Speech Therapy Providers Mary Steiner, Interim Administrator, Medicaid Division Marsha Rekart, Program Specialist Medicaid coverage of speech

More information

Brain Injury Alliance of New Jersey

Brain Injury Alliance of New Jersey Understanding the Rehabilitation Process after No one can prepare a family for the trauma of experiencing brain injury. Following the injury the subsequent move from the hospital to various rehabilitation

More information

Chapter 17. Medicaid Provider Manual

Chapter 17. Medicaid Provider Manual Chapter 17 Medicaid Provider Manual February 2011 TABLE OF CONTENTS 17.1 Occupational Therapy... 1 17.1.1 Description... 1 17.1.2 Amount, Duration and Scope... 1 17.1.3 Exclusions... 1 17.1.4 Limitations...

More information

REV. JULY 1, 2008 NEBRASKA DEPARTMENT OF NMAP SERVICES MANUAL LETTER # 51-2008 HEALTH AND HUMAN SERVICES 471 NAC 17-000

REV. JULY 1, 2008 NEBRASKA DEPARTMENT OF NMAP SERVICES MANUAL LETTER # 51-2008 HEALTH AND HUMAN SERVICES 471 NAC 17-000 MANUAL LETTER # 51-2008 HEALTH AND HUMAN SERVICES 471 NAC 17-000 CHAPTER 17-000 PHYSICAL THERAPY SERVICES 17-001 Standards for Participation: To participate in the Nebraska Medical Assistance Program (NMAP),

More information

Regulatory Compliance Policy No. COMP-RCC 4.20 Title:

Regulatory Compliance Policy No. COMP-RCC 4.20 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.20 Page: 1 of 11 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2)

More information

1. Clarification regarding whether an admission order must be completed before any therapy evaluations are initiated.

1. Clarification regarding whether an admission order must be completed before any therapy evaluations are initiated. Follow-up information from the November 12 provider training call I. Admission Orders 1. Clarification regarding whether an admission order must be completed before any therapy evaluations are initiated.

More information

Stakeholder s Report. 2525 SW 75 th Ave Miami, Florida 33155 305.262.6800 www.westgablesrehabhospital.com

Stakeholder s Report. 2525 SW 75 th Ave Miami, Florida 33155 305.262.6800 www.westgablesrehabhospital.com 212 Stakeholder s Report 2525 SW 75 th Ave Miami, Florida 33155 35.262.68 www.westgablesrehabhospital.com PROFILE REPORT For more than 25 years, West Gables Rehabilitation Hospital has made a mission of

More information

Provider Additions and Maintenance

Provider Additions and Maintenance Working with Anthem Subject Specific Webinar Series Provider Additions and Maintenance Access to Audio Portion of Conference: Dial-In Number: 877-497-8913 Conference Code: 1322819809# Please Mute Your

More information

Subpart B--Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities

Subpart B--Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities (Revised as of January 1, 2003) Subpart B--Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities 485.50 Basis and scope. This subpart sets forth the conditions that facilities

More information

Benefit Chart of Medicare Supplement Plans Sold on or After January 1, 2014

Benefit Chart of Medicare Supplement Plans Sold on or After January 1, 2014 Benefit Chart of Medicare Supplement Plans Sold on or After January 1, 2014 This chart shows the benefits included in each of the standard Medicare Supplement plans. Every company must make available Plans

More information

Observation Care Evaluation and Management Codes Policy

Observation Care Evaluation and Management Codes Policy Policy Number REIMBURSEMENT POLICY Observation Care Evaluation and Management Codes Policy 2016R0115A Annual Approval Date 3/11/2015 Approved By Payment Policy Oversight Committee IMPORTANT NOTE ABOUT

More information

Subacute Inpatient MH - Adult

Subacute Inpatient MH - Adult Subacute Inpatient MH - Adult Definition Subacute Inpatient hospital psychiatric services are medically necessary short-term psychiatric services provided to a client with a primary psychiatric diagnosis

More information

Center for Medicare and Medicaid Innovation

Center for Medicare and Medicaid Innovation Center for Medicare and Medicaid Innovation Summary: Establishes within the Centers for Medicare and Medicaid Services (CMS) a Center for Medicare & Medicaid Innovation (CMI). The purpose of the Center

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: skilled_nursing_facility_care 02/2008 2/2015 2/2016 2/2015 Description of Procedure or Service A skilled

More information

PROVIDER POLICIES & PROCEDURES

PROVIDER POLICIES & PROCEDURES PROVIDER POLICIES & PROCEDURES HOMEMAKER-HOME HEALTH AIDE MEDICATION ADMINISTRATION SERVICES The purpose of this policy is to provide guidance to providers enrolled in the Connecticut Medical Assistance

More information

Professional Practice Medical Record Documentation Guidelines

Professional Practice Medical Record Documentation Guidelines Professional Practice Medical Record Documentation Guidelines INTRODUCTION Consistent and complete documentation in the medical record is an essential component of quality patient care. All Participating

More information

Understanding Health Insurance

Understanding Health Insurance Understanding Health Insurance Health insurance can play an important role when it comes to medical bills and prescription medications it can help protect you from high expenses. There are many types of

More information

ICD-10 Updates. Working with Anthem Subject Specific Webinar Series. Special Session

ICD-10 Updates. Working with Anthem Subject Specific Webinar Series. Special Session Working with Anthem Subject Specific Webinar Series Special Session ICD-10 Updates Access to Audio Portion of Conference: Dial-In Number: 877-497-8913 Conference Code: 1322819809# Please Mute Your Phone

More information

Solutions for Today Flexibility for Tomorrow.

Solutions for Today Flexibility for Tomorrow. Solutions for Today Flexibility for Tomorrow. Medicare Products and Services For More Information call our Senior Care Specialist, Raun Lynch at 856.380.5079 Or visit us on the web at www.cbdi-inc.com

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Keystone 65 Select Medical-Only (HMO) offered by Independence Blue Cross Annual Notice of Changes for 2015 You are currently enrolled as a member of Keystone 65 Select Medical-Only. Next year, there will

More information

MEDICAL POLICY No. 91608-R1 MENTAL HEALTH RESIDENTIAL TREATMENT: ADULT

MEDICAL POLICY No. 91608-R1 MENTAL HEALTH RESIDENTIAL TREATMENT: ADULT MENTAL HEALTH RESIDENTIAL TREATMENT: ADULT Effective Date: June 4, 2015 Review Dates: 5/14, 5/15 Date Of Origin: May 12, 2014 Status: Current Summary of Changes Clarifications: Pg 4, Description, updated

More information

NEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES POLICY GUIDELINES

NEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES POLICY GUIDELINES NEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES POLICY GUIDELINES Version 2015-1 Page 1 of 11 Table of Contents SECTION I REQUIREMENTS FOR PARTICIPATION IN MEDICAID 3 QUALIFIED PRACTITIONERS. 3

More information

National Stroke Association s Guide to Choosing Stroke Rehabilitation Services

National Stroke Association s Guide to Choosing Stroke Rehabilitation Services National Stroke Association s Guide to Choosing Stroke Rehabilitation Services Rehabilitation, often referred to as rehab, is an important part of stroke recovery. Through rehab, you: Re-learn basic skills

More information

Rehabilitation Where You Recover. Inpatient Rehabilitation Services at Albany Medical Center

Rehabilitation Where You Recover. Inpatient Rehabilitation Services at Albany Medical Center Rehabilitation Where You Recover Inpatient Rehabilitation Services at Albany Medical Center You're Here and So Are We As the region s only academic medical center, Albany Medical Center offers a number

More information

Capital BlueCross offers a variety of health care choices. Pick the one that s right for you!

Capital BlueCross offers a variety of health care choices. Pick the one that s right for you! Traditional Our traditional product features comprehensive benefits and complete freedom to choose your physician, specialist or hospital. You minimize your out-of-pocket costs by receiving covered services

More information

Your Anthem Blue Cross HMO Plan Amendment

Your Anthem Blue Cross HMO Plan Amendment Your Anthem Blue Cross HMO Plan Amendment Anthem Blue Cross ( Anthem ) agrees to modify your Combined Evidence of Coverage and Disclosure (Evidence of Coverage) Form by this amendment. All other provisions

More information

OBSERVATION CARE EVALUATION AND MANAGEMENT CODES

OBSERVATION CARE EVALUATION AND MANAGEMENT CODES REIMBURSEMENT POLICY OBSERVATION CARE EVALUATION AND MANAGEMENT CODES Policy Number: ADMINISTRATIVE 232.8 T0 Effective Date: April, 205 Table of Contents APPLICABLE LINES OF BUSINESS/PRODUCTS... APPLICATION...

More information

Update: Medical Necessity Documentation. Kerry Dunning, MHA, MSH, CPAR, RAC-CT GPS HEALTHCARE CONSULTANTS November 2013

Update: Medical Necessity Documentation. Kerry Dunning, MHA, MSH, CPAR, RAC-CT GPS HEALTHCARE CONSULTANTS November 2013 Update: Medical Necessity Documentation Kerry Dunning, MHA, MSH, CPAR, RAC-CT GPS HEALTHCARE CONSULTANTS November 2013 REMINDER Many claim denials occur because the providers or suppliers do not submit

More information

MEDICAL POLICY No. 91607-R1 MENTAL HEALTH RESIDENTIAL TREATMENT: CHILD AND ADOLESCENT

MEDICAL POLICY No. 91607-R1 MENTAL HEALTH RESIDENTIAL TREATMENT: CHILD AND ADOLESCENT Summary of Changes MEDICAL POLICY MENTAL HEALTH RESIDENTIAL TREATMENT: CHILD ADOLESCENT Effective Date: June 4, 2015 Review Dates: 5/14, 5/15 Date Of Origin: May 14, 2014 Status: Current Clarifications:

More information

Check List. Telehealth Credentialing and Privileging Sec. 482.12. Conditions of Participation Governing Body

Check List. Telehealth Credentialing and Privileging Sec. 482.12. Conditions of Participation Governing Body Check List Telehealth Credentialing and Privileging Sec. 482.12. Conditions of Participation Governing Body The Centers for Medicare and Medicaid Services (CMS) final rule on credentialing and privileging

More information

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY ALPHA-FEROTEIN-L3 FOR DETECTION OF HEPATOCELLULAR (LIVER) Original Issue Date (Created): October 1, 2014 Most Recent Review Date (Revised): September 30, 2014 Effective Date: February 1, 2015- RETIRED

More information

10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER II SECTION 68 OCCUPATIONAL THERAPY SERVICES ESTABLISHED 9/1/87 LAST UPDATED 1/1/14

10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER II SECTION 68 OCCUPATIONAL THERAPY SERVICES ESTABLISHED 9/1/87 LAST UPDATED 1/1/14 MAINECARE BENEFITS MANUAL TABLE OF CONTENTS 68.01 PURPOSE... 1 PAGE 68.02 DEFINITIONS... 1 68.02-1 Functionally Significant Improvement... 1 68.02-2 Long-Term Chronic Pain... 1 68.02-3 Maintenance Care...

More information

Acute Inpatient Rehabilitation Level of Care

Acute Inpatient Rehabilitation Level of Care Printer-Friendly Page Acute Inpatient Rehabilitation Level of Care EFFECTIVE DATE 07/06/2010 LAST UPDATED 07/06/2010 Prospective review is recommended/required. Please check the member agreement for preauthorization

More information

PROTOCOLS FOR PHYSICAL THERAPY PROVIDERS

PROTOCOLS FOR PHYSICAL THERAPY PROVIDERS PROTOCOLS FOR PHYSICAL THERAPY PROVIDERS A Member may access Physical Therapy services (PT) when treatment is prescribed by a physician to restore or improve a person s ability to undertake activities

More information

ATAM Brief: Highlights and Text of the New Minnesota Autism Laws Passed by the Legislature in 2013

ATAM Brief: Highlights and Text of the New Minnesota Autism Laws Passed by the Legislature in 2013 ATAM Brief: Highlights and Text of the New Minnesota Autism Laws Passed by the Legislature in 2013 Reference: HF 1233 Health and Human Services Omnibus Bill Article 7, Sec. 14. [256B.0949] AUTISM EARLY

More information

PSYCHIATRIC UNIT CRITERIA WORK SHEET

PSYCHIATRIC UNIT CRITERIA WORK SHEET DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PSYCHIATRIC UNIT CRITERIA WORK SHEET RELATED MEDICARE PROVIDER NUMBER ROOM NUMBERS IN THE UNIT FACILITY NAME AND ADDRESS

More information

INTRODUCTION. The Workers Compensation Act provides in part as follows:

INTRODUCTION. The Workers Compensation Act provides in part as follows: INTRODUCTION The Maryland Workers Compensation Commission (Commission) amended COMAR 14.09.03.01 (Guide of Medical and Surgical Fees) on February 12, 2004. AUTHORITY The Workers Compensation Act provides

More information

Facility Enrollment Required Document Checklist

Facility Enrollment Required Document Checklist Facility Enrollment Required Document Checklist Facility Classification Ambulatory Infusion Center (AIC) Ambulatory Surgical Facility (ASF) End Stage Renal Disease Facility (ESRD) - Accreditation Commission

More information

Risk Adjustment ABC s

Risk Adjustment ABC s Medicare Advantage Risk Adjustment and Coding Academy Coding Risk Adjustment Documentation Training Risk Adjustment ABC s What is Risk Adjustment? Risk adjustment is the process by which the Medicare &

More information

WellPoint Cancer Care Quality Program Provider FAQs

WellPoint Cancer Care Quality Program Provider FAQs WellPoint Cancer Care Quality Program Provider FAQs WellPoint Cancer Care Quality Program What is the WellPoint Cancer Care Quality Program? Anthem Blue Cross and Blue Shield (Anthem) is pleased to bring

More information

2014 Provider Expo. Karen Geiger Associate General Counsel, Anthem Blue Cross and Blue Shield of Wisconsin

2014 Provider Expo. Karen Geiger Associate General Counsel, Anthem Blue Cross and Blue Shield of Wisconsin Change 2014 Provider Expo Karen Geiger Associate General Counsel, Anthem Blue Cross and Blue Shield of Wisconsin This presentation contains proprietary information of Anthem Blue Cross and Blue Shield.

More information

Chapter 4 Health Care Management Unit 1: Care Management

Chapter 4 Health Care Management Unit 1: Care Management Chapter 4 Health Care Unit 1: Care In This Unit Topic See Page Unit 1: Care Care 2 6 Emergency 7 4.1 Care Healthcare Healthcare (HMS), Highmark Blue Shield s medical management division, is responsible

More information

Independence Blue Cross Plan Summary MLH Select Medical Plan

Independence Blue Cross Plan Summary MLH Select Medical Plan TO: FROM: SUBJECT: MLH Medical Plan Participants MLH Human Resources Benefits Team Independence Blue Cross Plan Summary MLH Select Medical Plan Attached you will find the Independence Blue Cross (IBC)

More information

Rehabilitation Reimbursement Update By: Cherilyn G. Murer, JD, CRA

Rehabilitation Reimbursement Update By: Cherilyn G. Murer, JD, CRA Rehabilitation Reimbursement Update By: Cherilyn G. Murer, JD, CRA Introduction The Centers for Medicare & Medicaid Services (CMS) and legislators in this country remain dedicated to ensuring that beneficiaries

More information

Physical Therapy/Occupational Therapy Utilization Management Program FAQs November 2015

Physical Therapy/Occupational Therapy Utilization Management Program FAQs November 2015 Physical Therapy/Occupational Therapy Utilization Management Program FAQs November 2015 Background: Effective November 1, 2015, Anthem Blue Cross and Blue Shield (Anthem) implemented a physical therapy

More information

IOWA. State/Territory:

IOWA. State/Territory: Attachment 3.1-A PAGE - 10- State/Territory: 9. Clinic services as defined in 42 CFR 440.90 and as further described in Section 4320 (Clinic Services) of the State Medicaid Manual are provided with additional/imitations

More information

PPO Choice. It s Your Choice!

PPO Choice. It s Your Choice! Offered by Capital Advantage Insurance Company A Capital BlueCross Company PPO Choice It s Your Choice! Issued by Capital Advantage Insurance Company, a Capital BlueCross subsidiary. Independent licensees

More information

Application Instructions for BlueCross BlueShield of Illinois Medicare Supplement Plan

Application Instructions for BlueCross BlueShield of Illinois Medicare Supplement Plan Application Instructions for BlueCross BlueShield of Illinois Medicare Supplement Plan 1. Have your Medicare card and Social Security card available to fill in the required information below. 2. Print

More information

Clinical Medical Policy Cognitive Rehabilitation

Clinical Medical Policy Cognitive Rehabilitation Benefit Coverage Outpatient cognitive rehabilitation is considered to be the most appropriate setting for members who have sustained a traumatic brain injury or an acute brain insult. Covered Benefit for

More information

I want a health care plan with all the options.

I want a health care plan with all the options. I want a health care plan with all the options. PERSONAL BLUEPLANS SE These are my plans. Personal BluePlans SM SE PLAN FEATURES Personal Blue BluePlans SE let you build the plan that works for you. The

More information

SUBSTANCE ABUSE FACILITY GENERAL INFORMATION

SUBSTANCE ABUSE FACILITY GENERAL INFORMATION SUBSTANCE ABUSE FACILITY GENERAL INFORMATION I. BCBSM s Substance Abuse Facility Programs Traditional The Traditional BCBSM Substance Abuse Program provides benefits for the treatment of substancerelated

More information

Coding and Billing Guidelines *Psychiatry and Psychology Services PSYCH-014 - L30489. Contractor Name Wisconsin Physicians Service (WPS)

Coding and Billing Guidelines *Psychiatry and Psychology Services PSYCH-014 - L30489. Contractor Name Wisconsin Physicians Service (WPS) Coding and Billing Guidelines *Psychiatry and Psychology Services PSYCH-014 - L30489 Contractor Name Wisconsin Physicians Service (WPS) Contractor Number 00951, 00952, 00953, 00954 05101, 05201, 05301,

More information

!"#$%$&!"'()*+,-".-,/ &01*+("12"31+4156"$,+0"!*7("819".5(<(/4*<("&,5( :(()";(,-40"&,5( !"#$%$&!",/)"'()*+,5(

!#$%$&!'()*+,-.-,/ &01*+(1231+4156$,+0!*7(819.5(<(/4*<(&,5( :(();(,-40&,5( !#$%$&!,/)'()*+,5( submitted anytime during the year to your institution HR/Benefits Office, and the tobacco premium will be waived beginning the first of the month following submission of the form. Important: A member is

More information

Application for Medicare Supplement Plan

Application for Medicare Supplement Plan P.O. Box 806162, Chicago, IL 60680-4123 Application for Medicare Supplement Plan You may apply for coverage if: You have Medicare Parts A and B; AND, You are an Illinois resident. Plan Selection (Select

More information

Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy

Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy Policy Number 2015R0121C Physical Medicine & Rehabilitation: Procedure Reduction Policy Annual Approval Date 3/11/2015 Approved By Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT

More information

Follow-up information from the November 12 provider training call

Follow-up information from the November 12 provider training call Follow-up information from the November 12 provider training call Criteria I. Multiple Therapy Disciplines 1. Clarification regarding the use of group therapies in IRFs. Answer: CMS has not yet established

More information

Medicare Outpatient Therapy Billing

Medicare Outpatient Therapy Billing DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services R Medicare Outpatient Therapy Billing August 2010 / ICN: 903663 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare

More information

Be it enacted by the People of the State of Illinois,

Be it enacted by the People of the State of Illinois, AN ACT regarding disabled persons. Be it enacted by the People of the State of Illinois, represented in the General Assembly: Section 5. The State Employees Group Insurance Act of 1971 is amended by changing

More information

Shepherd Center is a world-renowned provider of comprehensive, specialized rehabilitation for people with spinal cord injury, brain injury or stroke.

Shepherd Center is a world-renowned provider of comprehensive, specialized rehabilitation for people with spinal cord injury, brain injury or stroke. Shepherd Center is a world-renowned provider of comprehensive, specialized rehabilitation for people with spinal cord injury, brain injury or stroke. Table of Contents 1 HOPE is HERE 2 Why choose Shepherd

More information

Regulatory Compliance Policy No. COMP-RCC 4.52 Title:

Regulatory Compliance Policy No. COMP-RCC 4.52 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.52 Page: 1 of 19 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2)

More information

Therapy Services INDIANA HEALTH COVERAGE PROGRAMS. Copyright 2016 Hewlett Packard Enterprise Development LP

Therapy Services INDIANA HEALTH COVERAGE PROGRAMS. Copyright 2016 Hewlett Packard Enterprise Development LP INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Therapy Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 4 9 P U B L I S H E D : F E B R U A R Y 2 5, 2 0 1 6 P O L I

More information

Physical Medicine & Rehabilitation: Maximum Combined Frequency per Day Policy

Physical Medicine & Rehabilitation: Maximum Combined Frequency per Day Policy REIMBURSEMENT POLICY Policy Number Physical Medicine & Rehabilitation: Maximum Combined Frequency per Day Policy 2015R0101B Annual Approval Date 7/8/2015 Approved By Payment Policy Oversight Committee

More information

Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE

Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 61 Medical Day Care Services Waiver Authority: Health-General Article, 2-104(b), 15-103, and 15-111, Annotated

More information

LEIDOS. January 1, 2016. BC PPO Plan (non-california resident) Lumenos HSA Benefit Booklet SPD170105-1 116 BC PPO HEALTHY FOCUS ADVANTAGE HSA PLAN

LEIDOS. January 1, 2016. BC PPO Plan (non-california resident) Lumenos HSA Benefit Booklet SPD170105-1 116 BC PPO HEALTHY FOCUS ADVANTAGE HSA PLAN LEIDOS January 1, 2016 BC PPO Plan (non-california resident) Lumenos HSA Benefit Booklet SPD170105-1 116 BC PPO HEALTHY FOCUS ADVANTAGE HSA PLAN Dear Plan Member: This Benefit Booklet provides a complete

More information

SAM KARAS ACUTE REHABILITATION CENTER

SAM KARAS ACUTE REHABILITATION CENTER SAM KARAS ACUTE REHABILITATION CENTER 1 MEDICAL CARE Sam Karas Acute Rehabilitation The Sam Karas Acute Rehabilitation Center is a comprehensive and interdisciplinary inpatient unit. Medical care is directed

More information

Blue Cross and Blue Shield of New Mexico and Lovelace Health Plan Transactions Frequently Asked Questions

Blue Cross and Blue Shield of New Mexico and Lovelace Health Plan Transactions Frequently Asked Questions Blue Cross and Blue Shield of New Mexico and Lovelace Health Plan Transactions Frequently Asked Questions Please note: Do not use the Lovelace provider portal the information on that site is now invalid.

More information

RULES AND REGULATIONS FOR LICENSURE OF REHABILITATION FACILITIES CHAPTER 16

RULES AND REGULATIONS FOR LICENSURE OF REHABILITATION FACILITIES CHAPTER 16 RULES AND REGULATIONS FOR LICENSURE OF REHABILITATION FACILITIES CHAPTER 16 Section 1. Authority. These rules are promulgated by the Department of Health pursuant to the Health Facilities Licensure Act

More information

Complex Outpatient. Injury. Rehab. Integrated, evidence-based rehab that supports a timely return to home, life, work or school

Complex Outpatient. Injury. Rehab. Integrated, evidence-based rehab that supports a timely return to home, life, work or school Complex Outpatient Injury Rehab Integrated, evidence-based rehab that supports a timely return to home, life, work or school Toronto Rehabilitation Institute At Toronto Rehab, our goal is to advance rehabilitation

More information

TABLE OF CONTENTS. Medical Management. BCBSIL Provider Manual Rev 10/13 1

TABLE OF CONTENTS. Medical Management. BCBSIL Provider Manual Rev 10/13 1 TABLE OF CONTENTS Medical Management... 2 Benefit Pre-certification... 2 Benefit Pre-certification for Inpatient and Ancillary Medical Services... 2 Benefit Pre-certification for Outpatient Medical/Surgical

More information

Preface. Summary of Changes. Table of Contents. Service Contacts. October 2014 Replaces: May 2014 S-5781 10/14

Preface. Summary of Changes. Table of Contents. Service Contacts. October 2014 Replaces: May 2014 S-5781 10/14 Preface Summary of Changes Table of Contents Service Contacts October 2014 Replaces: May 2014 S-5781 10/14 Preface The Wellmark Provider Guide and specialty guides are billing resources for providers doing

More information

Occupational Therapy

Occupational Therapy Occupational Therapy Policy Number: Original Effective Date: MM.09.003 07/15/2003 Line(s) of Business: Current Effective Date: HMO; PPO; EUTF; HSTA; QUEST; Federal Plan 87 02/01/2012 Line(s) of Business

More information

CARE PLAN OVERSIGHT POLICY

CARE PLAN OVERSIGHT POLICY REIMBURSEMENT POLICY CARE PLAN OVERSIGHT POLICY Policy Number: ADMINISTRATIVE 7.0 T0 Effective Date: July, 20 Table of Contents APPLICABLE LINES OF BUSINESS/PRODUCTS... APPLICATION... OVERVIEW... REIMBURSEMENT

More information

Physical Therapy MM.09.005 07/15/2003

Physical Therapy MM.09.005 07/15/2003 Physical Therapy Policy Number: Original Effective Date: MM.09.005 07/15/2003 Line(s) of Business: Current Effective Date: HMO; PPO; EUTF; HSTA; QUEST; Federal Plan 87 09/28/2012 Line(s) of Business Excluded:

More information

Clarification of Medicaid Coverage of Services to Children with Autism

Clarification of Medicaid Coverage of Services to Children with Autism DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 CMCS Informational Bulletin DATE: July 7, 2014

More information

Basic, including 100% Part B coinsurance. Foreign Travel Emergency

Basic, including 100% Part B coinsurance. Foreign Travel Emergency BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA An Independent Licensee of the Blue Cross and Blue Shield Association OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE 1 of 2: BENEFIT PLANS A, B, D and F

More information

Basic, including 100% Part B coinsurance. Foreign Travel Emergency

Basic, including 100% Part B coinsurance. Foreign Travel Emergency BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA An Independent Licensee of the Blue Cross and Blue Shield Association OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE 1 of 2: BENEFIT PLANS A, B, D and F

More information

PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE:

PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE: PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/PROCEDURE Policy Number: MCUP3003 (previously UP100303) Reviewing Entities: Credentialing IQI P & T QUAC Approving Entities: BOARD CEO COMPLIANCE FINANCE PAC

More information