Last updated December 2015
|
|
|
- Annabel Green
- 7 years ago
- Views:
Transcription
1 Last updated December 2015 All inpatient stays require authorization All provided by non-contracted providers require pre-authorization SoCO/NoCO (POS 11) - For contracted providers in office specialty do not require an authorization regardless of who the referred by provider is. Grid Legend: "Yes" or "Yes" with additional text, indicates service requires pre-authorization. "No" indicates no pre-authorization is necessary. Services Denver/Boulder Southern Colorado Northern Colorado Mountain Colorado Comments Acute Rehab (inpatient) Yes Allergy Serum No No Yes, for non-kp Allergy Treatment & Injections and Doctor No No Yes, for non-kp Services Ambulance Services Anesthesia (Non-Pain management) No No Yes, for non-network Autism (Behavioral Health) Autism Treatment Yes Bariatric Surgery Biofeedback Yes Blood Services locations No No Yes Breast Biopsies No No No No, for contracted Cardiac Rehab No No No No, for contracted Cardio - Coronary Cath No No No No, for contracted Cardio - ECG No No No No, for contracted Cardio - Echo No No No No, for contracted KPCO authorization guide Page 1 of 7
2 Cardio - Function No No No No, for contracted Cardio - ICD device No No No No, for contracted Cardio - ICM device No No No No, for contracted Cardio - Stress Test No No No No, for contracted Cardiology - Programming Device No No No No, for contracted Cardiology - Stress Test No No No No, for contracted Cardiology Consultation No No or non Cardiology EP No No or non Cardiovascular Surgery - Peds Yes CHCO/RMHC only providers Chemical Dependency Yes Child Advocacy Team at CHCO Yes Child Development Unit at CHCO Yes NoCO auths obtained through KP "BHAC" (Behaviroal Health Access Center) Chiropractic Services Yes, for Medicare Members Yes, for Medicare Members Yes, for Medicare Members Yes, for Medicare Members Complementary Medicine Services N/A N/A N/A N/A All covered benefits can be accessed by self referral except medicare chiropractic Concussion Clinic at CHCO Yes Continuous Glucose Monitoring System Yes Dental - Cleft Palate Yes No No Yes Dental Services -Oral and TMJ No No Yes Dermatology Dermatology Light Therapy No No or non No No or non This does not apply as a DME item KPCO authorization guide Page 2 of 7
3 Diabetes for Children Yes No No Yes Home Health would require an authorization Dialysis Yes, unless perfomed at St. Joseph, Good or Davita No No Yes, for non-contracted. DME and Orthotics Yes EMG Services No No No No, for contracted Endocrinology Yes No No or non ENG/EEG Services Enteral / Parenteral Therapy Yes Enuresis Encopresis Clinic Yes Extracorporeal Shock Wave Yes Gait Clinic - Peds Yes Gamma and Cyber Knife Yes Yes or non Gastroenterology Eosinophilic Esophagitis Clinic EEC Genetics counseling or testing Yes GI Scopes at St. Joseph, Good or Skyridge No No or non Gynecological Services Health Education Services Hearing Aid Exams and Equipment No No or non No No N/A No No or non KPCO authorization guide Page 3 of 7
4 Hemophilia Center Yes Holter & Event Monitors No No No No, for contracted Home Health Services at at at at Complete Home Complete Home Health Banner Home Care, Banner Home Care & Hospice of Health Care, Denver Care, Interim, VNA Home MedSolutions, the Valley Hospice, Interim, Tru Interim Community Care, VNA Hormonal Treatment of prostate cancer No No No Hospice No No No at Home Care & Hospice of the Valley Hyperbaric Oxygen Therapy Yes Implantable devices Excludes Ambulatory BP Monitoring In Office Medication and Injectables: Growth Hormone, Asthma Management, e.g. Xolair, CHF Management, e.g. Flolan, Tracleer, Immunization for RSV, e.g. Synagis, Immunosuppressive Management e.g. Humira, Remicade, Enbrel, Tysabri, Orencia, Actemra, Osteoporosis Treatment, e.g. Reclast, Prolia, Boniva, Xgeva, Zometa, Immune Globulin In Office Procedures: ENT, Plastic Surgery, Vascular In Office Procedures: Any other specialty (For example: MOHs, Opthalmology, OB/GYN, Oral Surgery, Podiatry) Yes No No No No Infertility Services KPCO authorization guide Page 4 of 7
5 Influenza Vaccine No No No No Infusion Services Inpatient Hospital Services and Inpatient Rehabilitation Hospital Services at St. Joseph, Good, Complete Home Health Care, Denver Hospice, Interim, Tru Community Care, VNA at Complete Home Health Care, Interim, VNA at Banner Home Care, Banner Home MedSolutions, Interim Yes, except for Chemotherapy Yes This does not apply to chemotherapy J Codes Yes, See J Code Tab Yes, See J Code Tab Yes, See J Code Tab Yes, See J Code Tab Laboratory Services No No No, for contracted /providers Lap Band Adjustments No No or non LTAC (Long Term Acute Care) Yes Medicare Annual Wellness visit Mental Health Treatment No No No Yes Metabolic Clinic Yes Nephrology No No or non Neurology No No or non Neurosurgery No No or non Neuropsychological evaluation and testing Yes See Genetics Testing NoCO auths obtained through KP "BHAC" (Behaviroal Health Access Center) Observation Bed Yes Office Circumcision Procedure Yes Office Vasectomy Ophthalmology No No or non No No or non KPCO authorization guide Page 5 of 7
6 Optical Services for Lenses, Frames, and No No No No Contacts Oral Maxillofacial Yes No No Yes Orthopedics Office Visits Otolaryngology Outpatient /Ambulatory Surgery Services Outpatient Rehabilitation Hospital Services Outpatient physical, occupational, speech therapy No No or non No No or non Pacemaker Checks No No No or non Pain Management including epidural steroid injections Yes Yes or non Photopheresis Yes Podiatry No No or non Procedures performed outside of office setting require authorization Prenatal Maternity Service by an OB/GYN specialty including ultrasound No No or non Preventive Services - Adult No No or non Prostate/ Colorectal cancer screening 18+ No No or non Prosthetics Yes Pulmonary Function Test No No No No, for contracted Pulmonary Rehabilitation No No No No, for contracted KPCO authorization guide Page 6 of 7
7 Radiation/Oncology Therapy at St. Joseph, Good or Skyridge No No or non Radiology Services not including MRI, CT, PET, and Nuclear Medicine Radiology: MRI (including open and standing), MRA, CT, PET and Nuclear Med Studies No No No No Plain Films, Ultrasound, Bone Density, Fluoroscopy, Mammograms at St. Joseph or Good, or by Radiology Imaging Associates or Diversified Radiology Yes, through CareCore Yes, through CareCore No, for MtCO Facilities Sleep Study Yes Yes or non SNF (Skilled Nursing Facility) Yes Surgical Sterilizations Yes Therapeutic Abortions Yes Transgender Service (Surgical) Yes Transplants (organ and tissue) Yes Travel Immunizations No No or non Treadmill Testing No No No No, for contracted Urology No No or non Well Child Routine Services No No or non KPCO authorization guide Page 7 of 7
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
Hawaii Benchmarks Benefits under the Affordable Care Act (ACA)
Hawaii Benchmarks Benefits under the Affordable Care Act (ACA) 10/2012 Coverage for Newborn and Foster Children Coverage Outside the Provider Network Adult Routine Physical Exams Well-Baby and Well-Child
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,
SERVICES IN-NETWORK COVERAGE OUT-OF-NETWORK COVERAGE
COVENTRY HEALTH AND LIFE INSURANCE COMPANY 3838 N. Causeway Blvd. Suite 3350 Metairie, LA 70002 1-800-341-6613 SCHEDULE OF BENEFITS BENEFITS AND PRIOR AUTHORIZATION REQUIREMENTS ARE SET FORTH IN ARTICLES
WVP Health Authority - MPCHP Referral/Preauthorization Grid
Referral Preauthorization Contacts Members A thru Em: 503-581-7010 Option 2 Option 1 Members En thru Led 503-581-7010 Option 2 Option 2 Members Lee thru Roa: 503-581-7010 Option 2 Option 3 Members Rob
SCHEDULING GUIDE. April 15, 2016. FOR CHANGES TO THE SCHEDULING DIRECTORY, PLEASE EMAIL gainer@musc.edu.
SCHEDULING GUIDE April 15, 2016 FOR CHANGES TO THE SCHEDULING DIRECTORY, PLEASE EMAIL gainer@musc.edu. Service Telephone Fax Adolescent Medicine 876-0444 876-1493 Allergy & Immunology 876-8282 876-8181
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
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
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)
Compare your plan options
SMALL BUSINESS GROUP Compare your plan options 2014 plans for businesses with 1 50 employees I SMALL BUSINESS GROUP Group Health plans offer value, choice, and more A well-run business takes a lot of time,
Summary of PNM Resources Health Care Benefits Active Employees 2011
of PNM Resources Health Care Benefits Active Employees 2011 The following charts show deductibles, limits, benefit levels and amounts for the PNM Resources medical, dental and vision programs. For more
LOCKHEED MARTIN AERONAUTICS COMPANY PALMDALE 2011 IAM NEGOTIATIONS UNDER AGE 65 LM HEALTHWORKS SUMMARY
Annual Deductibles, Out-of-Pocket Maximums, Lifetime Maximum Benefits Calendar Year Deductible Calendar Year Out-of- Pocket Maximum Lifetime Maximum Per Individual Physician Office Visits Primary Care
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
Alternative Benefit Plan (ABP) ABP Cost-Sharing & Comparison to Standard Medicaid Services
Alternative Benefit Plan (ABP) ABP Cost-Sharing & Comparison to Standard Medicaid Services Most adults who qualify for the Medicaid category known as the Other Adult Group receive services under the New
S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/14-6/30/15
S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/14-6/30/15 This information sheet is for reference only. Please refer to Evidence of Coverage requirements, limitations
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
VACAVILLE MEDICAL CENTER. Staff Navigator
VACAVILLE MEDICAL CENTER Staff Navigator VACAVILLE MEDICAL CENTER Hospital VACAVILLE MEDICAL CENTER - Hospital Department Floor Bldg Pg Administration - HIMS 4 H 9 Admitting 1 H 6 Bed Repair B H 5 Cafeteria
MGMA PROVIDER COMPENSATION 2015
Physicians Allergy/Immunology 203 86 Anesthesiology 2,146 120 Anesthesiology: Pain Management 127 59 Cardiology: Electrophysiology 327 126 Cardiology: Invasive 424 148 Cardiology: Invasive-Interventional
2015 Medicare Advantage Summary of Benefits
2015 Medicare Advantage Summary of Benefits HNE Medicare Premium No Rx and HNE Medicare Basic No Rx January 1, 2015 - December 31, 2015 H8578_2015_034 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2015
S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16
S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16 This information sheet is for reference only. Please refer to Evidence of Coverage requirements, limitations
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
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
Senate Bill 91 (2011) Standard Plan - EHB and Cost Share Matrix - Updated for 2016 ***NOT INTENDED AS A STATEMENT OF COVERAGE***
Deductible Medical: $1,250; Medical: $2,500; Integrated Medical/Rx: Rx: $0 Rx: $0 $5,000 Maximum OOP Combined Medical Combined Medical Combined Medical and and Drug: $6,350 and Drug: $6,350 Drug: $6,350
Greater Tompkins County Municipal Health Insurance Consortium
WHO IS COVERED Requires both Medicare A & B enrollment. Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement None None Medical Benefit Management Program Not
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%
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,
International Student Health Insurance Program (ISHIP) 2014-2015
2014 2015 Medical Plan Summary for International Students Translation Services If you need an interpreter to help with oral translation services, you may contact the LifeWise Customer Service team at 1-800-971-1491
UnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits
UnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits Please refer to your Provider Directory for listings of Participating Physicians, Hospitals, and other Providers.
Greater Tompkins County Municipal Health Insurance Consortium
WHO IS COVERED Requires Covered Member to be Enrolled in Both Medicare Parts A & B Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement Not Applicable Not Applicable
Compare your plan options
SMALL BUSINESS GROUP 2015 Compare your plan options Plans for businesses with 1 50 employees 1 SMALL BUSINESS GROUP Value, choice, and quality the Group Health difference Your job is running a business.
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
Primary and Acute Medical Services
Primary and Acute Medical Ambulance Medically necessary emergent ground and air ambulance transport. Air (fixed wing and air) ambulance Ground ambulance Chemotherapy Outpatient hospital for radiation therapy
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
Moses Telephone Directory
MONTEFIORE MEDICAL CENTER THE HENRY AND LUCY MOSES DIVISION 111 EAST 210TH STREET BRONX, NEW YORK 10467 Moses Telephone Directory (When calling from the outside use 920 before extension) NUMBER TIE-LINE
ROCHESTER INSTITUTE OF TECHNOLOGY 2014 Medical Benefits Comparison Chart Medicare-Eligible Retirees in the Rochester Area
Contacting the Carrier Voice: (877) 883-9577 TTY: (585) 454-2845 Website: Voice: (800) 665-7924 TTY: (800) 252-2452 Website: www.excellusbcbs.com www.mvphealthcare.com Deductible Carry Over None None Deductible,
HNE Premier 1 (HMO) and HNE Premier 2 (HMO)
2016 Medicare Advantage Summary of Benefits HNE Premier 1 (HMO) and HNE Premier 2 (HMO) January 1, 2016 - December 31, 2016 H8578_2016_429 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2016 SECTION I
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
GIC Medicare Enrolled Retirees
GIC Medicare Enrolled Retirees HMO Summary of Benefits Chart This chart provides a summary of key services offered by your HNE plan. Consult your Member Handbook for a full description of your plan s benefits
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
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
METROWEST MEDICAL CENTER
(508) 650-7000 Framingham Union METROWEST MEDICAL CENTER 115 Lincoln Street (508) 383-1000 24-hour Emergency Department Care Community Healthcare Provider This healthcare network encompasses the entirety
University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance
University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview of your benefits.
League of Women Voters. November 20, 2012
League of Women Voters November 20, 2012 Palo Alto Medical Foundation Multi-Specialty Medical Group for past 82 years. Outpatient Medical Centers not a hospital Community based, not-for-profit Physician-led
$250 copay per admit. $250 copay per admit
BENEFIT IN- NETWORK OUT- OF- NETWORK Deductible NONE NONE Out- of- Pocket Maximum $6,350 Single/ $12,700 Family NONE HOSPITAL INPATIENT FACILITY - NON MATERNITY Medical/Surgical Skilled Nursing Facility
Your Medical Care Services Medical Benefits with Community Health Plan of Washington
Your Medical Care Services Medical Benefits with Community Health Plan of Washington Including: Your Benefits: Services covered by Community Health Plan Services covered by Health Care Authority or other
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
Your Out-of-Pocket Type of Service
Calendar Year Deductible (CYD) 1 $5,000 single/ 2x family Out-of-Pocket Maximum - Deductibles and copays all accrue towards the out-of-pocket $6,000 single/ 2x family maximum. With respect to family plans,
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.
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
January 1, 2015 December 31, 2015 Summary of Benefits. Altius Advantra (HMO) H8649-003 80.06.361.1-UTWY A
January, 205 December 3, 205 Summary of Benefits H8649-003 80.06.36.-UTWY A Y0022_205_H8649_003_UT_WYa Accepted /204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of
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
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
California Ironworkers Field Welfare Plan 1/1/2014 Open Enrollment Benefit Plan Comparison Non-Medicare Retired Participants Residing in Nevada
Non- Choice of Providers Calendar Year Deductible *The Fund s Calendar Year Deductible is never waived. However, some services are not subject to the Deductible. If you live in Nevada, your network of
2014 Summary of benefits plan comparison
2014 Summary of benefits plan comparison The tables below summarize the 2014 Benefits for the Samaritan Choice Medical Plan options (Basic, Wellness and High-Deductible Plans). Pease refer to your plan
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
[2015] SUMMARY OF BENEFITS H1189_2015SB
![[2015] SUMMARY OF BENEFITS H1189_2015SB](/thumbs/32/15705129.jpg "[2015] SUMMARY OF BENEFITS H1189_2015SB")
[2015] SUMMARY OF BENEFITS H1189_2015SB Section I You have choices in your health care One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare
Summary of Benefits Community Advantage (HMO)
Summary of Benefits Community Advantage (HMO) January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list
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
January 1, 2015 December 31, 2015
BLUESHIELD FOREVER BLUE MEDICARE PPO VALUE AND BLUESHIELD MEDICARE PPO 750 (PPO) (a Medicare Advantage Preferred Provider Organization (PPO) offered by HEALTHNOW NEW YORK INC. with a Medicare contract)
CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance
CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview
Services and supplies required by Health Care Reform Age and frequency guidelines apply to covered preventive care Not subject to deductible if PPO
Page 1 of 5 Individual Deductible Calendar year $400 COMBINED Individual / Family OOP Calendar year $4,800 Individual $12,700 per family UNLIMITED Annual Maximum July 1 st to June 30 th UNLIMITED UNLIMITED
2009 Cost Center Setup Cross Reference Exhibit 3, 4, 11, 19, 20, 30, 31A, and 46. Exh 4, S-3. 30 & 31A Line
Setup Cross Reference General Service Assignments (95) (38) Standard 001-026, 029-030, 033, 040-047, 095 (57)Variable 027-028, 031-032, 034-039, 048-094 (Program Capabilities 200) 1 0100 Old Capital Related
Independent Health s Medicare Passport Advantage (PPO)
Independent Health s Medicare Passport Advantage (PPO) (a Medicare Advantage Preferred Provider Organization Option (PPO) offered by INDEPENDENT HEALTH BENEFITS CORPORATION with a Medicare contract) Summary
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
Carelink CaroMont Provider Directory
Carelink CaroMont Product Service Area: Cleveland, Lincoln, and Gaston Counties November 2013 Carelink from Coventry benefit plans are underwritten and administered by Coventry Health Care of the Carolinas,
Every New Hampshire Resident Qualifies For Health Insurance. About NHHP. Eligibility
About NHHP New Hampshire Health Plan (NHHP) is a non-profit organization formed by the New Hampshire legislature. NHHP provides health coverage to New Hampshire residents who otherwise may have trouble
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
Coventry Health Care of Missouri
Small Group PPO Schedule of Benefits: Coventry Health Care of Missouri Plan ID#: Platinum Carelink from Coventry A000-14 (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain
APPENDIX C Description of CHIP Benefits
Inpatient General Acute and Inpatient Rehabilitation Hospital Unlimited. Includes: Hospital-provided physician services Semi-private room and board (or private if medically necessary as certified by attending)
Physician Practice Acquisitions
Trend Watch: Physician Practice Acquisitions Tracking Which Physician Practices Hospitals are Acquiring Introduction Are hospitals actively acquiring physician practices? If so, which specialties? In this
Schedule of Benefits. Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM INDEPENDENCE PLAN POS MASSACHUSETTS
Schedule of s Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM INDEPENDENCE PLAN POS MASSACHUSETTS ID: MD0000004281_ X Please Note: This Plan includes a tiered provider network which rewards members
January 1, 2015 December 31, 2015 Summary of Benefits. Advantra (HMO) H3928-001 80.06.360.1-LA1
January, 205 December 3, 205 Summary of Benefits H3928-00 80.06.360.-LA Y0022_205_H3928_00_LA Accepted 9/204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of what we
CSAC/EIA Health Small Group Access+ HMO 15-0 Inpatient Benefit Summary
CSAC/EIA Health Small Group Access+ HMO 15-0 Inpatient Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE
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:
Fee-For-Service Fee-For-Service Fee-For-Service Fee-For-Service Fee-For-Service
bortion and related BP cupuncture llergy testing Except when performed as anesthesia for an approved surgery. with udiology Limited children under the age of 16 years. Limited $1,000 per ear every 24 months.
Commercial. Individual & Family Plan. Health Net California Farm Bureau and PPO. Insurance Plans. Outline of Coverage and Exclusions and Limitations
Commercial Individual & Family Plan Health Net California Farm Bureau and PPO Insurance Plans Outline of Coverage and Exclusions and Limitations Table of Contents Health Plans Outline of coverage 1 Read
2015 Summary of Benefits
2015 Summary of Benefits Plans 003 and 004 H6298_14_027 accepted Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list
IN-NETWORK MEMBER PAYS. Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services)
HMO-OA-CNT-30-45-500-500D-13 HMO Open Access Contract Year Plan Benefit Summary This is a brief summary of benefits. Refer to your Membership Agreement for complete details on benefits, conditions, limitations
DRAFT. Select VHA ENTERPRISE STANDARD TITLE:??
Select VHA ENTERPRISE STANDARD TITLE:?? Choose from: ACUPUNCTURE CONSULT ACUPUNCTURE NOTE ADDENDUM ADDICTION PSYCHIATRY ADDICTION SEVERITY INDEX NOTE ADDICTION PSYCHIATRY ADMINISTRATIVE NOTE ADDICTION
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 https://eoc.anthem.com/eocdps/aso or by calling 1-888-650-4047.
Effective: July 28, 2015. Arizona Prior Authorization Requirements Health Net Access, Inc.
Effective: July 28, 2015 Arizona Prior Authorization Requirements Health Net Access, Inc. The following services, procedures and equipment are subject to prior authorization requirements (unless noted
Elenco dei periodici elettronici in Ovid Full text
Academic Medicine Addictive Disorders & Their Treatment Advances in Anatomic Pathology Age & Ageing AIDS AIDS Patient Care & Stds AJN, American Journal of Nursing Alzheimer Disease & Associated Disorders
2015 Summary of Benefits
2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3952 Y0041_H3952_KS_15_18734 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how
North Division Telephone Directory
MONTEFIORE MEDICAL CENTER NORTH DIVISION 600 E. 233 RD STREET BRONX, NEW YORK 10466 North Division Telephone Directory (When calling internally, use all five digits of the extension. When calling from
(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
Lesser of $200 or 20% (surgery) $10 per visit. $35 $100/trip $50/trip $75/trip $50/trip
HOSPITAL SERVICES Hospital Inpatient : Paid in full, Non-network: Hospital charges subject to 10% of billed charges up to coinsurance maximum. Non-participating provider charges subject to Basic Medical
California PCP Selected* Not Applicable
PLAN FEATURES Deductible (per calendar ) Member Coinsurance * Not Applicable ** Not Applicable Copay Maximum (per calendar ) $3,000 per Individual $6,000 per Family All member copays accumulate toward
SCAN Health Plan. 2015 Summary of Benefits
SCAN Health Plan 2015 Summary of Benefits Y0057_SCAN_8713_2014F File & Use Accepted 09032014 SCAN Classic (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health Plan with
An ANALYSIS of Medicare Benefits per the 2016 Medicare and You Handbook & The State of Delaware's Special Medicfill Plan Benefits
An ANALYSIS of Medicare Benefits per the 2016 Medicare and You Handbook & The State of Delaware's Special Medicfill Plan Benefits The chart below presents the list of benefits covered by Medicare, and
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.
Summary of Benefits. Offered by. H5826_MA_194_2012_v_01_SB006 CMS Approved 08.24.2011
2012 Summary of Benefits Offered by H5826_MA_194_2012_v_01_SB006 CMS Approved 08.24.2011 Section I Introduction to the Summary of Benefits for Community HealthFirst MA Plan (HMO) January 1, 2012 - December
Cost Sharing Definitions
SU Pro ( and ) Annual Deductible 1 Coinsurance Cost Sharing Definitions $200 per individual with a maximum of $400 for a family 5% of allowable amount for inpatient hospitalization - or - 50% of allowable
STATE STANDARD 20-40/400D HMO SCHEDULE OF BENEFITS
CALIFORNIA STATE STANDARD 20-40/400D HMO SCHEDULE OF BENEFITS These services are covered as indicated when authorized through your Primary Care Physician in your Participating Medical Group. General Features
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
2015 Summary of Benefits
2015 Summary of Benefits Value (HMO-POS) Essentials Rx (HMO-POS) (H4270) January 1, 2015 - December 31, 2015 Western Wisconsin (26 Counties) H4270_082914_1 CMS Accepted (09032014) SECTION I INTRODUCTION
Coventry Health and Life Insurance Company PPO Schedule of Benefits
State(s) of Issue: Oklahoma PPO Plan: OI08C30050 30 Coventry Health and Life Insurance Company PPO Schedule of Benefits Covered Services Contract Year Deductible For All Eligible Expenses (unless otherwise
2014 Medicare Advantage Summary of Benefits HNE MEDICARE PREMIUM NO RX (HMO) HNE MEDICARE BASIC NO RX (HMO)
2014 Medicare Advantage Summary of Benefits HNE MEDICARE PREMIUM NO RX (HMO) HNE MEDICARE BASIC NO RX (HMO) HNE MEDIC ARE ADV ANTAGE ENROLLMENT KIT 2014 H8578_2014_034 Accepted SECTION I - INTRODUCTION
Benefits At A Glance Plan C
Benefits At A Glance Plan C HIGHLIGHTS OF WELFARE FUND BENEFITS WELFARE FUND BENEFITS IN BRIEF Medical and Hospital Benefits Empire BlueCross BlueShield Plan C-1 Empire BlueCross BlueShield Plan C-2 All
2016 Summary of Benefits
2016 Summary of Benefits Health Net Healthy Heart (HMO) Alameda and Stanislaus counties, CA Benefits effective January 1, 2016 H0562 Health Net of California, Inc. H0562_2016_0171 CMS Accepted 09172015
Health Choice Essential Gold Standard Gold Off Exchange Plan Network: Health Choice Essential Type of Coverage: HMO
Subscriber ID: [XXXXXXX] Health Choice Essential Gold Standard Gold Off Exchange Plan Network: Health Choice Essential Type of Coverage: HMO EOC Effective Date: [XX/XX/XXXX] Subscriber: [Subscriber Name]