REFERRALS CPT CODES COMMENTS

Size: px
Start display at page:

Download "REFERRALS CPT CODES COMMENTS"

Transcription

1 Gundersen Health Plan (GHP) Procedures & Services Requiring Prior Authorization Benefits and eligibility must be verified with the Health Plan Customer Service. Self-funded and Fully Insured Employer Group Plans: or Senior Preferred: or BadgerCare Plus: or GundersenOne: or This grid applies to all GHP members; it is intended to be a guide and does not guarantee coverage. Medical benefit plan language supersedes the general information provided on this grid. The presence or absence of an item on this list does not define whether or not coverage or benefits exist for the service or procedure and/or CPT code. Failure to prior authorize procedures or services on this grid may result in denial of coverage; as a result financial responsibility may be yours. Senior Preferred members may see Evidence of Coverage for complete benefit information. REFERRALS CPT CODES COMMENTS Any referral to a non-participating provider/facility for non-emergent services A signed written referral from the Health Plan is required prior to receiving services from a non participating provider/facility Initial Low Back Pain Consults with Orthopedic or Neurosurgery departments (follow up visits do not require prior authorization) For State of Wisconsin ETF members. Submit supporting medical documentation. Effective 1/01/2013 EXPERIMENTAL Experimental/Investigational Considered provider responsibility when the member would not be reasonably expected to know that the service is experimental. The Health Plan utilizes Hayes Medical Technology Directory to determine if services are experimental/ investigational. In addition to Hayes, other sources may be reviewed which include but are not limited to the evidence based medical literature, specialty Medical Advisory Panel, and other technology review resources.

2 MEDICAL SERVICES CPT CODES COMMENTS Autism Spectrum Disorders Continuous Passive Motion (CPM) E0935 (Coverage limited to knee only) Prior authorization required for CPM usage beyond 21 days post op. Submit supporting medical documentation Cranial Remolding Orthotic S1040 Durable Medical Equipment (DME) Senior Preferred All DME purchases, rentals and repairs (no dollar threshold) Senior Preferred Call Customer Service to verify eligibility of member Review Medicare criteria: - If item is statutorily excluded by Medicare, notify member item is not covered by Senior Preferred; if member wants to purchase item, obtain signature on NDMC (available on website) - If item meets Medicare criteria, dispense and bill Health Plan - If item does not meet Medicare medical necessity criteria, submit PA to Health Plan for organizational determination Commercial/BadgerCare Plus/ GundersenOne DME purchases exceeding dollar threshold (varies by group) and all rentals and repairs Commercial/BadgerCare Plus/GundersenOne Call Customer Service to verify eligibility of member and prior authorization requirements (please provide HCPCS code) Enteral Therapy B4034-B9999 Genetic Testing Home Health Member must be homebound and meet criteria for home health. Home Prothrombin Time Monitoring G0249, G0248 Home Sleep Studies (under C-PAP policy) Prior authorization required from a sleep disorder physician specialist or provider practicing under the supervision of a sleep disorder specialist. Submit supporting medical documentation Hyperbaric Oxygen Therapy (HBOT) Prior authorization is required. Submit supporting medical documentation.

3 Insulin pumps /Continuous glucose monitors/receivers and supplies IV Drugs outpatient hospital and clinic (except EPO) IV Infusions Mental Health, Alcohol and other drug addictions (M.H./A.O.D.A), Transitional Treatment (includes Partial Hospitalization services), Day Treatment BadgerCare Therapies E0784/S1030, S1031, A9276-A9278, E0607, E2100, E2101 Home IV Therapy requires prior authorization. Request to be received from supplier. Prior authorizations required after 35 visits per therapy discipline; however, some services always require prior authorization per ForwardHealth Guidelines. Please refer to the ForwardHealth portal. Providers must use the PA forms available via the portal. Senior Preferred Part B Therapies. All Part B therapies require prior authorization. Refer the Health Plan website for detailed instructions. Skilled Nursing Facility Prior authorization required from facility. Swing Bed Prior authorization required prior to admission. TheraSphere/Sir-Spheres Treatment CPT: 77790, 36245, 75726, 77778, HCPCS: C2616, Q3001, S2095 Submit supporting medical documentation and appropriate codes. PROCEDURES\SURGICAL CPT CODES COMMENTS TREATMENTS Abortions Only if medically necessary as determined by the Health Plan. Artificial Intervertebral Disc Replacement for Cervical and Lumbar Degenerative Disc Disease 0092T, 0095T, 0098T, 0163T, 0164T, 0165T, Member must be 18 or over. Medicare does not provide coverage for patients over age 60. Coverage will be limited to the cost of the procedure and the cost of one artificial intervertebral disc. Bone Anchored Hearing Aide (BAHA) Bariatric surgical treatment for Severe Obesity , , , S2083, 43886,43888 Blepharoplasty Upper and lower lid blepharoplasty will be subject to prior authorization. Photos and visual fields will be required.

4 CardioMems C97412, C2624 Chorionic Villus Sampling (CVS) Cochlear Implants 69930, Required for members age 18 and over LINX Reflux Management System Submit supporting medical documentation PROCEDURES/SURGICAL CPT CODES TREATMENTS CONTINUED Deep Brain Stimulation , L8680-L8689 High Tech Radiology Tests CT & CTA: 70450,70460,70470, , , , 70496, 70498, 71250, 71260, 71270, 71275, , , , 73206,73700, 73702, , 74150, 74160, 74170, , , , 75635, 76380, 77078,77079,S8092 COMMENTS For State of Wisconsin ETF members. Submit supporting medical documentation. Effective 1/01/2013. MRI & MRA: 70336, 70540, , ,71555, 72141, 72142, , , , ,73225, ,73725, , 74185, 75557, 75559, 75561, 75563, 75565, 77058, 77059, 77084, S8037, PET: 78608, 78609, , G0235, 0159T, S8037, , Nuclear Stress Test: , 78481, 78483, 78499, Hyperhidrosis, Surgical Treatment Reduction Mammoplasty Refractive Surgery 65765, S0800, S0810, S0812 Rhinoplasty or Rhino portion of Septorhinoplasty Surgical Removal of Redundant Skin , Surgical Treatment of Obstructive Sleep Apnea(OSA) Pillar Implants are not covered for Commercial or GundersenOne members.

5 Surgical Treatment of Pectus Excavatum and Carinatum Syndrome Transmyocardial Revascularization (TMR) Transplants (excluding corneal A referral request is required for all members. transplants) Surgical/Laser Treatment of Scars Vagus Nerve Stimulation , Varicose Vein Treatment (excludes vein stripping) 36468, 36469, , 37766

Advance Notification Requirements for New York Effective June 1, 2015

Advance Notification Requirements for New York Effective June 1, 2015 Advance Notification Requirements for New York Effective June 1, 2015 General Information This list represents our prior authorization review requirements for UnitedHealthcare Community Plan of New York.

More information

The Deductible is applicable to all covered services except for flat dollar Copayment services.

The Deductible is applicable to all covered services except for flat dollar Copayment services. PRIORITY HEALTH www.priorityhealth.com/mpsers PRIORITYHMO SM PLUS PLAN MICHIGAN PUBLIC SCHOOL EMPLOYEES RETIREMENT SYSTEM (MPSERS) Effective January 1, 2016 through December 31, 2016 The HMO Plus plan

More information

Prior Authorization Requirements for Florida Effective March 1, 2015

Prior Authorization Requirements for Florida Effective March 1, 2015 for Florida Effective March 1, 215 General Information The following list represents our prior authorization requirements for UnitedHealthcare in Florida. All services rendered by a non-contracted physician,

More information

COMPREHENSIVE PRIOR AUTHORIZATION LISTS NJ FAMILYCARE/MEDICAID & DUAL COMPLETE HMO SNP PRODUCTS EFFECTIVE 7/1/13

COMPREHENSIVE PRIOR AUTHORIZATION LISTS NJ FAMILYCARE/MEDICAID & DUAL COMPLETE HMO SNP PRODUCTS EFFECTIVE 7/1/13 TO ALL HEALTHCARE PROFESSIONALS: COMPREHENSIVE PRIOR AUTHORIZATION LISTS NJ FAMILYCARE/MEDICAID & DUAL COMPLETE HMO SNP PRODUCTS EFFECTIVE 7/1/13 BEFORE SEEKING PRIOR AUTHORIZATION, PLEASE VERIFY MEMBER

More information

Prior Authorization List Adults, FHP, CHP

Prior Authorization List Adults, FHP, CHP Please verify the member s benefits before requesting prior authorization (PA). Services vary within plans. To check member eligibility, please call Provider Services at 888-362-3368 or visit UnitedHealthcareOnline.com.

More information

Anthem Blue Cross and Blue Shield in New Hampshire Precertification Guidelines

Anthem Blue Cross and Blue Shield in New Hampshire Precertification Guidelines Anthem Blue Cross and Blue Shield in New Hampshire Precertification Guidelines The following guidelines apply to Anthem Blue Cross and Blue Shield ( Anthem ) products issued and delivered by Anthem in

More information

PRIORITY HEALTH priorityhealth.com HealthbyChoice Incentives Summary of Benefits TRINITY HEALTH -HbCI 2 1/1/13 12/31/13

PRIORITY HEALTH priorityhealth.com HealthbyChoice Incentives Summary of Benefits TRINITY HEALTH -HbCI 2 1/1/13 12/31/13 PRIORITY HEALTH priorityhealth.com Healthby Incentives Summary of Benefits TRINITY HEALTH -HbCI 2 1/1/13 12/31/13 The Healthby Incentives HMO plan is a Consumer Engaged Health plan that offers a choice

More information

Anthem Blue Cross and Blue Shield in Connecticut Precertification Guidelines

Anthem Blue Cross and Blue Shield in Connecticut Precertification Guidelines Anthem Blue Cross and Blue Shield in Connecticut Precertification Guidelines The following guidelines apply to Anthem Blue Cross and Blue Shield ( Anthem ) products issued and delivered by Anthem in Connecticut.

More information

UnitedHealthcare Medicare Solutions Notification/Prior Authorization Requirements Effective Jan. 1, 2016

UnitedHealthcare Medicare Solutions Notification/Prior Authorization Requirements Effective Jan. 1, 2016 This list represents our advance notification/prior authorization review requirements as referenced in the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider 2016 Administrative

More information

Provider Information Guide 2014

Provider Information Guide 2014 MDwise Eskenazi Health Hoosier Healthwise Provider Information Guide 2014 MDwise Eskenazi Health Hoosier Healthwise All members will have an ID card. The Hoosier Healthwise ID card is the standard, state

More information

(FIDA) FIDELIS CARE AUTHORIZATION REQUIREMENTS

(FIDA) FIDELIS CARE AUTHORIZATION REQUIREMENTS Fully Integrated Duals Advantage (FIDA) FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION 7/1/2016 I. Inpatient Admissions-All inpatient

More information

Medical Management Requirements Effective January 1, 2008

Medical Management Requirements Effective January 1, 2008 December 1, 2007 Dear Provider and Colleague: Please be advised that effective January 1, 2008, Health Plan will change its Medical Management Policies to include new requirements for prior authorizations

More information

I. Out of Network: There are no OON benefits. However for any medically necessary service not available in network, authorization will be provided

I. Out of Network: There are no OON benefits. However for any medically necessary service not available in network, authorization will be provided The New York State of Health Authorization Grid FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION EFFECTIVE 7/1/2016 I. Out of Network:

More information

PREVENTIVE CARE See the REHP Benefits Handbook for a list of preventive benefits* MATERNITY SERVICES Office visits Covered in full including first

PREVENTIVE CARE See the REHP Benefits Handbook for a list of preventive benefits* MATERNITY SERVICES Office visits Covered in full including first Network Providers Non Network Providers** DEDUCTIBLE (Per Calendar Year) None $250 per person $500 per family OUT-OF-POCKET MAXIMUM (When the out-of-pocket maximum is reached, benefits are paid at 100%

More information

Schedule of Benefits HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS MEMBER COST SHARING

Schedule of Benefits HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS MEMBER COST SHARING Schedule of s HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS ID: MD0000003378_ X Please Note: In this plan, Members have access to network benefits only from the providers in the Harvard Pilgrim-Lahey

More information

Preauthorization Requirements * (as of January 1, 2016)

Preauthorization Requirements * (as of January 1, 2016) OFFICE VISITS Primary Care Office Visits Primary Care Home Visits Specialist Office Visits No Specialist Home Visits PREVENTIVE CARE Well Child Visits and Immunizations Adult Annual Physical Examinations

More information

AVMED POS PLAN. Allergy Injections No charge 30% co-insurance after deductible Allergy Skin Testing $30 per visit 30% co-insurance after deductible

AVMED POS PLAN. Allergy Injections No charge 30% co-insurance after deductible Allergy Skin Testing $30 per visit 30% co-insurance after deductible AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copays for 2015. This is not a contract, it s a summary of the plan highlights and is subject to change. For specific

More information

2015 Medical Plan Summary

2015 Medical Plan Summary 2015 Medical Plan Summary AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copayments for 2015. This is not a contract, it s a summary of the plan highlights and is

More information

HUSKY Health Benefits and Prior Authorization Requirements Grid* Hospital Outpatient Effective: January 1, 2012

HUSKY Health Benefits and Prior Authorization Requirements Grid* Hospital Outpatient Effective: January 1, 2012 Cardiac Rehab 100% covered 100% covered 100% covered Dialysis 100% covered 100% covered 100% covered Emergency Care Covered no co- pays for Emergency Room visits Covered no co- pays for Emergency Room

More information

OFFICE OF GROUP BENEFITS 2014 OFFICE OF GROUP BENEFITS CDHP PLAN FOR STATE OF LOUISIANA EMPLOYEES AND RETIREES PLAN AMENDMENT

OFFICE OF GROUP BENEFITS 2014 OFFICE OF GROUP BENEFITS CDHP PLAN FOR STATE OF LOUISIANA EMPLOYEES AND RETIREES PLAN AMENDMENT OFFICE OF GROUP BENEFITS 2014 OFFICE OF GROUP BENEFITS CDHP PLAN FOR STATE OF LOUISIANA EMPLOYEES AND RETIREES PLAN AMENDMENT This Amendment is issued by the Plan Administrator for the Plan documents listed

More information

Harvard Pilgrim Health Care of New England, Inc. THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO - LP NEW HAMPSHIRE

Harvard Pilgrim Health Care of New England, Inc. THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO - LP NEW HAMPSHIRE ID: MD0000003228_B3 X Schedule of s Harvard Pilgrim Health Care of New England, Inc. THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO - LP NEW HAMPSHIRE Coverage under this Plan is under the jurisdiction

More information

Blue Cross Premier Bronze Extra

Blue Cross Premier Bronze Extra An individual PPO health plan from Blue Cross Blue Shield of Michigan. You will have a broad choice of doctors and hospitals within Blue Cross Blue Shield of Michigan s unsurpassed statewide PPO network

More information

Benefit Summary - A, G, C, E, Y, J and M

Benefit Summary - A, G, C, E, Y, J and M Benefit Summary - A, G, C, E, Y, J and M Benefit Year: Calendar Year Payment for Services Deductible Individual $600 $1,200 Family (Embedded*) $1,200 $2,400 Coinsurance (the percentage amount the Covered

More information

Chapter 2. Medical Management and Quality Improvement

Chapter 2. Medical Management and Quality Improvement Medical Management Overview...3 Introduction...3 Objectives...3 Important Program Points...3 Prior Authorization...4 Overview...4 MedicareBlue PPO Covered Items and Services...4 Medical Policy...5 Prior

More information

What is the overall deductible? Are there other deductibles for specific services?

What is the overall deductible? Are there other deductibles for specific services? : MyPriority POS RxPlus Silver 1800 Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Subscriber/Dependent Plan Type:

More information

BENEFIT PLAN. What Your Plan Covers and How Benefits are Paid. Appendix A. Prepared Exclusively for The Dow Chemical Company

BENEFIT PLAN. What Your Plan Covers and How Benefits are Paid. Appendix A. Prepared Exclusively for The Dow Chemical Company Appendix A BENEFIT PLAN Prepared Exclusively for The Dow Chemical Company What Your Plan Covers and How Benefits are Paid Choice POS II (MAP Plus Option 2 - High Deductible Health Plan (HDHP) with Prescription

More information

Oregon CPT Preapproval Grid

Oregon CPT Preapproval Grid * The following grid only identifies items that require preapproval from. Breast Pumps Notes: No preapproval required for 1st month rental; beyond one month rental requires preapproval Genetic Testing

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.pplusic.com or by calling 608-282-8900 (1-800-545-5015).

More information

Physicians Plus Insurance Corporation Coverage Period: 01/01/2016 12/31/2016

Physicians Plus Insurance Corporation Coverage Period: 01/01/2016 12/31/2016 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.pplusic.com or by calling 1-800-545-5015. Important Questions

More information

NJ FamilyCare D. Medicaid, NJ FamilyCare A and Alternative Benefit Plan (ABP) NJ FamilyCare B NJ FamilyCare C

NJ FamilyCare D. Medicaid, NJ FamilyCare A and Alternative Benefit Plan (ABP) NJ FamilyCare B NJ FamilyCare C Service Medicaid, NJ FamilyCare A and Alternative Benefit Plan (ABP) NJ Division of Developmental Disabilities (DDD) NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D Abortions and related services (covered

More information

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Laramie County School District 2 Open Access Plus Base - Effective 7/1/2015

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Laramie County School District 2 Open Access Plus Base - Effective 7/1/2015 SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. Laramie County School District 2 Open Access Plus Base - Effective General Services In-Network Out-of-Network Physician office visit Urgent care

More information

BadgerCare Plus and Wisconsin Medicaid Covered Services Comparison Chart

BadgerCare Plus and Wisconsin Medicaid Covered Services Comparison Chart and Wisconsin Covered Services Comparison Chart The covered services information in the following chart is provided as general information. Providers should refer to their service-specific publications

More information

Plans. Who is eligible to enroll in the Plan? Blue Care Network (BCN) Health Alliance Plan (HAP) Health Plus. McLaren Health Plan

Plans. Who is eligible to enroll in the Plan? Blue Care Network (BCN) Health Alliance Plan (HAP) Health Plus. McLaren Health Plan Who is eligible to enroll in the Plan? All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined

More information

Benefit Handbook THE HARVARD PILGRIM PPO PLAN MASSACHUSETTS EFFECTIVE DATE: 05/2012 FORM #1133_01

Benefit Handbook THE HARVARD PILGRIM PPO PLAN MASSACHUSETTS EFFECTIVE DATE: 05/2012 FORM #1133_01 Benefit Handbook THE HARVARD PILGRIM PPO PLAN MASSACHUSETTS EFFECTIVE DATE: 05/2012 FORM #1133_01 INTRODUCTION Welcome to The Harvard Pilgrim PPO Plan (the Plan) offered by Harvard Pilgrim Health Care,

More information

Covered Benefits. Covered. Must meet current federal and state guidelines. Abortions. Covered. Allergy Testing. Covered. Audiology. Covered.

Covered Benefits. Covered. Must meet current federal and state guidelines. Abortions. Covered. Allergy Testing. Covered. Audiology. Covered. Covered Benefits Services Abortions Allergy Testing Audiology Birth Control Services Blood & Blood Plasma Bone Mass Measurement (bone density) Case Management Chemotherapy Chiropractor Services (manipulation/subluxation)

More information

Medical Benefits. The Regional Health Plan is a self insured plan. The claims administrator is NGS CoreSource.

Medical Benefits. The Regional Health Plan is a self insured plan. The claims administrator is NGS CoreSource. The Regional Health Plan is a self insured plan. The claims administrator is NGS CoreSource. For a complete outline of your benefits, please refer to the Regional Health INTRANET site Employee Hub/Summary

More information

National PPO 1000. PPO Schedule of Payments (Maryland Small Group)

National PPO 1000. PPO Schedule of Payments (Maryland Small Group) PPO Schedule of Payments (Maryland Small Group) National PPO 1000 The benefits outlined in this Schedule are in addition to the benefits offered under Coventry Health & Life Insurance Company Small Employer

More information

New York. UnitedHealthcare Community Plan Claims System Migration Provider Quick Reference Guide. Complete Claims. Our Claims Process

New York. UnitedHealthcare Community Plan Claims System Migration Provider Quick Reference Guide. Complete Claims. Our Claims Process Our Claims Process Here are a few steps to ensure you receive prompt payment: 1 Review and copy both sides of the member s ID card. members receive an ID card containing information that helps you process

More information

UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage

UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage UnitedHealthcare Choice Plus UnitedHealthcare Insurance Company Certificate of Coverage For the Health Savings Account (HSA) Plan 4X8 of Southern State Community College Enrolling Group Number: 755032

More information

HUSKY Health Benefits and Prior Authorization Requirements Grid* Hospital Outpatient Effective: January 1, 2012

HUSKY Health Benefits and Prior Authorization Requirements Grid* Hospital Outpatient Effective: January 1, 2012 Cardiac Rehab 100% covered 100% covered 100% covered Dialysis 100% covered 100% covered 100% covered Emergency Care Covered no co-pays for Emergency Room visits Covered no co-pays for Emergency Room visits.

More information

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective 1/1/2015

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective 1/1/2015 SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective General Services In-Network Out-of-Network Primary care physician You pay $25 copay per visit Physician office

More information

California Small Group MC Aetna Life Insurance Company

California Small Group MC Aetna Life Insurance Company PLAN FEATURES Deductible (per calendar year) $1,000 per member $1,000 per member Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate

More information

American Maritime Officers Medical Plan Employer Identification Number: 13-5600786 Plan Number: 501 Group Number: 0081717

American Maritime Officers Medical Plan Employer Identification Number: 13-5600786 Plan Number: 501 Group Number: 0081717 AMENDMENT #4 American Maritime Officers Medical Plan Employer Identification Number: 13-5600786 Plan Number: 501 Group Number: 0081717 This Amendment is duly adopted and effective as of October 1, 2014.

More information

CHAPTER 7: UTILIZATION MANAGEMENT

CHAPTER 7: UTILIZATION MANAGEMENT OVERVIEW The Plan s Utilization Management (UM) program is collaboration with providers to promote and document the appropriate use of health care resources. The program reflects the most current utilization

More information

PPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA2000-20

PPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA2000-20 PPO Schedule of Payments (Maryland Large Group) Qualified High Health Plan National QA2000-20 Benefit Year Individual Family (Amounts for Participating and s services are separated in calculating when

More information

California Small Group MC Aetna Life Insurance Company

California Small Group MC Aetna Life Insurance Company PLAN FEATURES Deductible (per calendar year) $3,000 Individual $6,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate separately

More information

GLANCE GATEWAY. Providers AT A. for Medicare Assured SM. Gateway Health Medicare Assured SM 444 Liberty Avenue, Suite 2100 Pittsburgh, PA 15222-1222

GLANCE GATEWAY. Providers AT A. for Medicare Assured SM. Gateway Health Medicare Assured SM 444 Liberty Avenue, Suite 2100 Pittsburgh, PA 15222-1222 GATEWAY AT A GLANCE for Medicare Assured SM Providers Gateway Health Medicare Assured SM 444 Liberty Avenue, Suite 2100 Pittsburgh, PA 15222-1222 YOUR PROVIDER NUMBERS: Group Provider Number : Individual

More information

I. Out of Network: Any Medicaid, CHP and HealthierLife service provided by a nonparticipating provider/facility/physician requires authorization.

I. Out of Network: Any Medicaid, CHP and HealthierLife service provided by a nonparticipating provider/facility/physician requires authorization. Medicaid, Child Health and HealthierLife (HARP) Plus Authorization Grid FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION REVISED 1/1/2016

More information

Iowa Wellness Plan Benefits Coverage List

Iowa Wellness Plan Benefits Coverage List Iowa Wellness Plan Benefits Coverage List Service Category Covered Duration, Scope, exclusions, and Limitations Excluded Coding 1. Ambulatory Services Primary Care Illness/injury Physician Services Should

More information

Blue Choice Silver PPO 004 Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Blue Choice Silver PPO 004 Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsil.com/member/policy-forms/ or by calling 1-800-538-8833.

More information

Miscellaneous Services

Miscellaneous Services Miscellaneous Services Acute Physical Medicine and Rehabilitation (Acute PM&R) Inpatient PM&R is limited to Department-contracted facilities. Please see the Department s Acute PM&R Billing Instructions

More information

Summary of Services and Cost Shares

Summary of Services and Cost Shares Summary of Services and Cost Shares This summary does not describe benefits. For the description of a benefit, including any limitations or exclusions, please refer to the identical heading in the Benefits

More information

Service Name Prior Auth Reqd? PA Form Notification Reqd? Notify. Form Threshold Product List. Yes, notification within 24 hours.

Service Name Prior Auth Reqd? PA Form Notification Reqd? Notify. Form Threshold Product List. Yes, notification within 24 hours. *Prior authorization confirms medical necessity only and does not guarantee payment. *Payment is determined at the time the claim is received and is subject to health plan exclusions and out-of-network

More information

Health Plan of Nevada, Inc. ( HPN ) Small Business Point-Of-Service ( POS ) Rider to the Small Business Evidence of Coverage ( EOC )

Health Plan of Nevada, Inc. ( HPN ) Small Business Point-Of-Service ( POS ) Rider to the Small Business Evidence of Coverage ( EOC ) Health Plan of Nevada, Inc. ( HPN ) Small Business Point-Of-Service ( POS ) Rider to the Small Business Evidence of Coverage ( EOC ) This Rider is a supplement to your EOC issued by HPN. Subject to the

More information

MyHPN Solutions HMO Silver 4

MyHPN Solutions HMO Silver 4 MyHPN Solutions HMO Silver 4 Attachment A Schedule Calendar Year Deductible (CYD): $2,250 of EME per Member and $4,500 of EME per family. The Calendar Year Out of Pocket Maximum includes the CYD and is

More information

UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage

UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage UnitedHealthcare Choice Plus UnitedHealthcare Insurance Company Certificate of Coverage For the Plan 7EG of Educators Benefit Services, Inc. Enrolling Group Number: 717578 Effective Date: January 1, 2012

More information

UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage

UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage UnitedHealthcare Choice Plus UnitedHealthcare Insurance Company Certificate of Coverage For the Health Savings Account (HSA) Plan 7PD of Educators Benefit Services, Inc. Enrolling Group Number: 717578

More information

Corporate Medical Policy Durable Medical Equipment (DME)

Corporate Medical Policy Durable Medical Equipment (DME) Corporate Medical Policy Durable Medical Equipment (DME) File Name: Origination: Last CAP Review: Next CAP Review: Last Review: durable_medical_equipment_(dme) 1/2000 9/2015 9/2016 9/2015 Description of

More information

Section IV - Information for People with Medicare and Medicaid

Section IV - Information for People with Medicare and Medicaid TM Section IV - Information for People with Medicare and People who qualify for Medicare and are known as dual eligibles. As a dual eligible, you are eligible for benefits under both the federal Medicare

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Bronze 60 EPO - Network Name: EPO Coverage Period: Beginning on or after 1/1/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: EPO

More information

COVERAGE SCHEDULE. The following symbols are used to identify Maximum Benefit Levels, Limitations, and Exclusions:

COVERAGE SCHEDULE. The following symbols are used to identify Maximum Benefit Levels, Limitations, and Exclusions: Exhibit D-3 HMO 1000 Coverage Schedule ROCKY MOUNTAIN HEALTH PLANS GOOD HEALTH HMO $1000 DEDUCTIBLE / 75 PLAN EVIDENCE OF COVERAGE LARGE GROUP Underwritten by Rocky Mountain Health Maintenance Organization,

More information

NATIONWIDE INSURANCE $20-40 / 250A NATIONAL MANAGED CARE SCHEDULE OF BENEFITS

NATIONWIDE INSURANCE $20-40 / 250A NATIONAL MANAGED CARE SCHEDULE OF BENEFITS WASHINGTON NATIONWIDE INSURANCE $20-40 / 250A NATIONAL MANAGED CARE SCHEDULE OF BENEFITS General Features Calendar Year Deductible Lifetime Benefit Maximum (Does not apply to Chemical Dependency) ($5,000.00

More information

27. Will the plan pay for radiology done in the provider s office?... 10 28. How do providers request assistance with care management issues?...

27. Will the plan pay for radiology done in the provider s office?... 10 28. How do providers request assistance with care management issues?... Provider Q&A Contents 1. Who is Florida True Health?... 3 2. What is the new product name?... 3 3. Does the plan have a website?... 3 4. How will physicians be paid? (FFS or capitation)... 3 5. What clearing

More information

CU Care Management Matrix

CU Care Management Matrix CU Care Matrix Group Name(s) Exclusive Exclusive Exclusive High Deductible HSA Compatible and Extended Capitated/FFS Facilities Capitated for physician only UCH Childrens FFS FFS FFS Poudre Valley Center

More information

Member s responsibility (deductibles, copays, coinsurance and dollar maximums)

Member s responsibility (deductibles, copays, coinsurance and dollar maximums) MICHIGAN CATHOLIC CONFERENCE January 2015 Benefit Summary This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Gold 80 PPO Network Name: Exclusive Coverage Period: Beginning on or after 1/1/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type:

More information

SUMMARY OF BADGERCARE PLUS BENEFITS

SUMMARY OF BADGERCARE PLUS BENEFITS SUMMARY OF BADGERCARE PLUS BENEFITS Medical, mental health and substance abuse services Dental emergency NOT Pharmacy, chiropractic and dental services NOT 13 Ambulatory surgery centers Coverage of certain

More information

KAISER PERMANENTE PLAN (Non-Medicare Eligible)

KAISER PERMANENTE PLAN (Non-Medicare Eligible) CEMENT MASONS HEALTH AND WELFARE TRUST FUND FOR NORTHERN CALIFORNIA RETIRED CEMENT MASONS AND THEIR ELIGIBLE DEPENDENTS EFFECTIVE JANUARY 1, 2015 GENERAL When You Can Change Plans Type of Plan, Service

More information

OGB MAGNOLIA LOCAL COMPREHENSIVE MEDICAL BENEFIT PLAN SCHEDULE OF BENEFITS

OGB MAGNOLIA LOCAL COMPREHENSIVE MEDICAL BENEFIT PLAN SCHEDULE OF BENEFITS OGB MAGNOLIA LOCAL COMPREHENSIVE MEDICAL BENEFIT PLAN SCHEDULE OF BENEFITS Network coverage available only in Baton Rouge, New Orleans, Shreveport and St. Tammany Blue Connect and Community Blue BENEFIT

More information

Gundersen Health Plan: MN NJ Silver $2000-0% Coverage Period: 01/01/2015-12/31/2015

Gundersen Health Plan: MN NJ Silver $2000-0% Coverage Period: 01/01/2015-12/31/2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.gundersenhealthplan.org or by calling 1-800-897-1923.

More information

General Cost Sharing Features In-Network Out-of-Network

General Cost Sharing Features In-Network Out-of-Network SECTION A. Summary of Benefits 9-RCF, 10/09 This Summary is part of your Benefit Handbook. It states the Cost Sharing amounts that you must pay for Covered Benefits and some important limitations on your

More information

UnitedHealthcare Choice. UnitedHealthcare Insurance Company. Certificate of Coverage

UnitedHealthcare Choice. UnitedHealthcare Insurance Company. Certificate of Coverage UnitedHealthcare Choice UnitedHealthcare Insurance Company Certificate of Coverage For the Plan 9DF of District of Columbia Government Enrolling Group Number: 712971 Effective Date: January 1, 2013 Offered

More information

UnitedHealthcare Choice Plus. United HealthCare Insurance Company. Certificate of Coverage

UnitedHealthcare Choice Plus. United HealthCare Insurance Company. Certificate of Coverage UnitedHealthcare Choice Plus United HealthCare Insurance Company Certificate of Coverage For Westminster College Enrolling Group Number: 715916 Effective Date: January 1, 2009 Offered and Underwritten

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Minimum Coverage PPO Network Name: Exclusive Coverage Period: Beginning on or after 1/1/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? : VIVA HEALTH Access Plan Coverage Period: 01/01/2015 12/31/2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document

More information

You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Blue Cross Blue Shield Solution 102, a Multi-State Plan SM Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family

More information

Active and Retiree Health Benefit Summary Plan Description And Plan Document 7670-00-411309/7670-03-411309

Active and Retiree Health Benefit Summary Plan Description And Plan Document 7670-00-411309/7670-03-411309 Active and Retiree Health Benefit Summary Plan Description And Plan Document 7670-00-411309/7670-03-411309 BENEFITS ADMINISTERED BY Table of Contents INTRODUCTION... 1 PLAN INFORMATION... 2 BENEFIT CLASS

More information

United HealthCare Choice Plus. Plan 7EH. United HealthCare Insurance Company. Certificate of Coverage

United HealthCare Choice Plus. Plan 7EH. United HealthCare Insurance Company. Certificate of Coverage United HealthCare Choice Plus Plan 7EH United HealthCare Insurance Company Certificate of Coverage For SCSVEBA (Southern California Schools VEBA) Enrolling Group Number: 714846 Effective Date: January

More information

BlueCare Direct Gold SM HMO 101 BlueCare Direct SM HMO Network

BlueCare Direct Gold SM HMO 101 BlueCare Direct SM HMO Network BlueCare Direct Gold SM HMO 101 BlueCare Direct SM HMO Network OUTLINE OF COVERAGE 1. READ YOUR POLICY CAREFULLY. This outline of coverage provides a brief description of the important features of your

More information

SECTION 5 1 REFERRAL AND AUTHORIZATION PROCESS

SECTION 5 1 REFERRAL AND AUTHORIZATION PROCESS SECTION 5 1 REFERRAL AND AUTHORIZATION PROCESS Primary Care Physician Referral Process 1 Referral from PCP to Participating Specialists 1 Referral from Participating Specialist to Participating Specialists

More information

American Commerce Insurance Company

American Commerce Insurance Company American Commerce Insurance Company INITIAL INFORMATION LETTER TO INSURED/CLAIMANT/PROVIDERS Dear Insured and/or /Eligible Injured Person/Medical Provider: Please read this letter carefully because it

More information

You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Blue Cross Blue Shield Basic 103, a Multi-State Plan SM Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan

More information

PLAN DESIGN AND BENEFITS - Tx OAMC 1500-10 PREFERRED CARE

PLAN DESIGN AND BENEFITS - Tx OAMC 1500-10 PREFERRED CARE PLAN FEATURES Deductible (per calendar year) $1,500 Individual $3,000 Individual $4,500 Family $9,000 Family 3 Individuals per Family 3 Individuals per Family Unless otherwise indicated, the Deductible

More information

HPN Solutions HMO 15 V2 $7/35/55

HPN Solutions HMO 15 V2 $7/35/55 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.myhpnonline.com or by calling (702) 242-7300 or 1-800-777-1840.

More information

SECTION A. Summary of Benefits LW-V, 10/09

SECTION A. Summary of Benefits LW-V, 10/09 SECTION A. Summary of Benefits LW-V, 10/09 This Summary is part of your Benefit Handbook. It states the Cost Sharing amounts that you must pay for Covered Benefits and some important limitations on your

More information

How To Get Health Net From Health Net

How To Get Health Net From Health Net INDIVIDUAL & FAMILY PLANS QUICK NET SHORT-TERM COVERAGE BY THE DAY OR MONTH Health coverage made easy. Effective April 15, 2007 IT S A FAST-MOVING WORLD. Keep up with Quick Net from Health Net. TWO KINDS

More information

Perioperative Charge Process

Perioperative Charge Process There are eight components to the charge process for surgical services: 1. Pre op prep and care 2. Anesthesia 3. Operating room time charges 4. Equipment charges 5. Recovery / Post Anesthesia Care Unit

More information

PLAN DESIGN AND BENEFITS - Tx OAMC 2500 08 PREFERRED CARE

PLAN DESIGN AND BENEFITS - Tx OAMC 2500 08 PREFERRED CARE PLAN FEATURES Deductible (per calendar year) $2,500 Individual $5,000 Individual $7,500 3 Individuals per $15,000 3 Individuals per Unless otherwise indicated, the Deductible must be met prior to benefits

More information

Quick Guide 2016. Peoples Health Choices 65 #14 (HMO) Jefferson, Orleans and Plaquemines parishes

Quick Guide 2016. Peoples Health Choices 65 #14 (HMO) Jefferson, Orleans and Plaquemines parishes Quick Guide 2016 $0 mium* Plan Pre Peoples Health Choices 65 #14 (HMO) Jefferson, Orleans and Plaquemines parishes *You must continue to pay your Medicare Part B premium. H1961_PH16C65S1QG Accepted Thank

More information

PPO product with drug plan being offered for January 1, 2013

PPO product with drug plan being offered for January 1, 2013 PPO product with drug plan being offered for January 1, 2013 Austin area: 8 counties Dallas/Fort Worth area: 4 counties Houston area: 3 counties Austin Area Counties (8) Bastrop Burnet Caldwell Fayette

More information

FEATURES NETWORK OUT-OF-NETWORK

FEATURES NETWORK OUT-OF-NETWORK Schedule of Benefits Employer: The Vanguard Group, Inc. ASA: 697478-A Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 3B Booklet Base: 3 For: Choice POS II - 950 Option - Retirees

More information

GATEWAY AT A GLANCE for Medicare Assured SM Providers

GATEWAY AT A GLANCE for Medicare Assured SM Providers GATEWAY AT A GLANCE for Medicare Assured SM Providers Gateway Health Medicare Assured SM offers options designed to provide more than healthcare for those who qualify. Medicare Assured SM offers medical

More information

Covered 100% No deductible Not Applicable (exam, related tests and x-rays, immunizations, pap smears, mammography and screening tests)

Covered 100% No deductible Not Applicable (exam, related tests and x-rays, immunizations, pap smears, mammography and screening tests) A AmeriHealth EPO Individual Summary of Benefits Value Network IHC EPO $30/50% Benefit Network Non network Benefit Period+ Calendar year Individual deductible $2,500 Family deductible $5,000 50% Individual

More information

STATE OF NEVADA DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS WORKERS COMPENSATION SECTION

STATE OF NEVADA DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS WORKERS COMPENSATION SECTION STATE OF NEVADA DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS WORKERS COMPENSATION SECTION NEVADA MEDICAL FEE SCHEDULE MAXIMUM ALLOWABLE PROVIDER PAYMENT February 1, 2012 through January

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://www.whyviva.com/memberaccess.aspx or by calling 1-800-294-7780.

More information

2015 EMPIRE PLAN BENEFIT SUMMARY For Active Employees and Retirees

2015 EMPIRE PLAN BENEFIT SUMMARY For Active Employees and Retirees PRE-ADMISSION CERTIFICATION 2015 EMPIRE PLAN BENEFIT SUMMARY For Active Employees and Retirees Prior authorization of inpatient hospitalization charges required. $200 penalty for failure to precertify.

More information

We know that you value your employees. Thank you for considering Optima Health to meet your employees healthcare needs.

We know that you value your employees. Thank you for considering Optima Health to meet your employees healthcare needs. We know that you value your employees. Thank you for considering Optima Health to meet your employees healthcare needs. Optima Health Products and Services Our Value Statement 1 TABLE OF CONTENTS 2 CONSUMER-DIRECTED

More information

(HSA) 1500/3000 10/30 (LHSA497)

(HSA) 1500/3000 10/30 (LHSA497) Lumenos Health Savings Account (HSA) 1500/3000 10/30 (LHSA497) 1/1/2016 This Summary of Benefits is a brief overview of your plan's benefits only. The benefits listed are for both in state and out of state

More information

Medicare Drug Coverage Under Part A, Part B, and Part D

Medicare Drug Coverage Under Part A, Part B, and Part D Medicare Drug Coverage Under Part A, Part B, and Part D Medicare Part A and Part B generally do not cover outpatient prescription drugs, most of which are now covered under Part D. This document and the

More information

please refer to our internet site, www.harvardpilgrim.org, or contact the Member Services

please refer to our internet site, www.harvardpilgrim.org, or contact the Member Services Schedule of s HPHC Insurance Company, Inc. THE HPHC INSURANCE COMPANY PPO PLAN MAINE ID: MD0000000750_F2 X This Schedule of s summarizes your benefits under The HPHC Insurance Company PPO Plan (the Plan)

More information