How To Get A Medical Insurance Plan
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1 MODA HEALTH PRIOR AUTHORIZATION GUIDELINES - WASHINGTON AUTHORIZATION INFORMATION Authorization requests may be phoned in toll-free to or faxed to AUTHORIZATION REQUEST REQUIREMENTS The following information should be included with a prior authorization request All pertinent patient information (subscriber, ID #, group #, relation to subscriber, and patient s birth date) The name of the facility where the procedure is to be performed The date of the procedure or date of admission Full name of surgeon s or specialist CPT & ICD (numeric only) codes Length of stay (indicate if outpatient) Chart notes and any other supporting documentation SERVICES THAT DO NOT REQUIRE AUTHORIZATION Aspiration EMG CPT: Biopsies Hydration therapy Bone mineral density studies, diagnostic Kidney dialysis Brachytherapy for breast cancer Routine lab tests Cardiovascular Stress Test Needle biopsy Colonoscopy with medical diagnosis (not virtual) Colonoscopy with routine diagnosis, including family history diagnosis (not virtual) Diabetic Shoes (unless less than $500 and/or more than 1 pair per year) ECG, EKG Echocardiography EEG Punch biopsy Trigger point injections Ultrasound X-rays
2 SERVICES THAT REQUIRE AUTHORIZATION The following is a complete list of services and supplies that require authorization to determine medical necessity or plan benefit limitations. COSMETIC PROCEDURES Potentially cosmetic procedures may be an exclusion unless medical necessity has been established. Abdominoplasty Lipectomy Blepharoplasty and/or brow lift Otoplasty Botox injections Panniculectomy Breast surgery - augmentation or reduction Port wine stain treatment Dermabrasion Rhinoplasty Hormone related conditions Scar revisions (includes Kenalog injections) Intralesional Injections (i.e., Kenalog) Silicone breast implant removal Laser treatment (except for retinopathy) Varicose vein surgery/sclerotherapy ORAL/MAXILLOFACIAL PROCEDURES TMJ surgeries TMJ surgical splints Treatment of dental accidents Orthognathic services DIAGNOSTIC PROCEDURES Genetic Testing RAST allergy testing Positron emission tomography (PET) scans Single photon emission computed tomography (SPECT) scans CT scans,(including computed tomography angiogram (CTA) MRI (including MRA, MRS, MRM) Nuclear cardiology imaging studies fmri Upper endoscopies Sleep studies Virtual colonoscopy
3 EQUIPMENT/BRACES/DEVICES/APPLIANCES/SUPPLIES Airway clearance devices (chest percussors, Low air loss products vests, etc.) Augmentative communication device and Muscle stimulator system Bone growth stimulator Nebulizer,portable over $300 Braces/Orthotics over $3,000 (except Oxygen (initial certification only) custom-made foot orthotics) Continuous glucose monitor Patient lift Custom compression stockings over $500 Phototherapy lights (for dermatologic diagnosis) Custom/special seating system Power wheelchair/scooter (also repairs over $500) Custom wheelchair (also repairs over $500) Prosthetics (except breast prosthetics) Dynasplint/JAS (or other mechanical stretching device) Sonic Accelerated Fracture Healing System Enteral feedings/nutritional formulas Spinal cord stimulator External wearable cardiac defibrillator Trapeze Gradient pressure aid Wound vac (including wound warming cover) Hospital bed Insulin pump Intrapulmonary percussive ventilation INR Monitor, for home use Light box EAR/NOSE/THROAT PROCEDURES Cochlear implantation/removal Septo-rhinoplasty Otoplasty Uvulopalatopharyngoplasty (UPPP)/Uvulectomy Rhinoplasty EXPERIMENTAL OR INVESTIGATIONAL Active Cooling Devices (i.e., Game Ready) Micronutrient Testing Anodyne Therapy System Mobile Outpatient Cardiac Telemetry (MOCT) Automated, noninvasive nerve conduction Nucleoplasty study (e.g. NC-Stat) Balloon Sinuplasty (as standalone Ossatron/Orthotripsy/ESWT
4 procedure) (extracorporeal shock wave therapy) Bronchial Thermoplasty (Alair) Platelet Rich Plasma Injections Carotid Sinus Baroreflex Stimulation System Prolotherapy (Rheos) Computer Assisted Navigation for musculoskeletal procedures Percutaneous Lumbar Discectomy and Laser- assisted Disc Decompression Cryoablation of Breast Fibroadenomas Quantitative Sensory Testing Dynamic spine stabilization (Dynesys) Saliva Hormone Testing ExMI (Extracorporeal Magnetic Innervation) Sublingual Immunotherapy (SLIT) Intradiscal Electrothermal Therapy (IDET) Somnoplasty /Coblation High Density Lipid Profile Tissue Grafts/Mesh (Biologic engineered from human or xenograft source) Home Interferential Muscle Stimulator Thermal Imaging/Thermography Microcurrent Stimulators (MENS) (e.g. Transcranial Magnetic Stimulation Alpha Stim unit) Vertebral Axial Decompression HOME SERVICES Home health services Long-term facility care Home infusion services Palliative care Hospice care IMMUNOTHERAPY/ALLERGY AND INJECTIONS Prior authorization is required for more than 56 units of CPT (56 units = 2 treatment sets at 28 doses per treatment set) IMMUNIZATIONS Zostavax for under age 60 Rabies Vaccine INFUSION SERVICES (OUTPATIENT) New FDA approved drugs are subject to review and may be subject to additional coverage requirements or limits established by the Plan. Ado-trastuzumab (Kadcyla) Agalsidase Beta (Fabrazyme) Alglucosidase Alfa (Lumizyme)
5 Alpha 1 Proteinase Inhibitor (GLASSIA) Amevive Infusion Belimumab (Benlysta) Bendamustine (Treanda) Bevacizumab (Avastin) Brentuximab (Adcetris) Bortezomib (Velcade) Cabazitaxel (Jevtana) Carfilzomib (Kyprolis) Cetuximab (Erbitux) Eribulin Mesylate (Halaven) Denosumab (Xgeva and Prolia) Golimumab (Simponi Aria) Ipilimumab (Yervoy) Iron Intravenous Immune Globulin (IVIG) Octreotide (Sandostatin) Omacetine Mepesuccinate (Synribo) Orencia Paclitaxel Protein Bound (Abraxane) Palonosetron (Aloxi) Pamidronate (Aredia) Panitumumab (Vectibix) Pegloticase (Krystexxa) Pemetrexed (Alimta) Pertuzumab (Perjeta Provenge (Sipuleucel-T) Reclast and Zometa (Zoledronic acid) Remicade Infusion Rituximab (for rheumatoid arthritis) Soliris Stelara (Ustekinumab) Tocilizumab (Actemra) Trastuzumab (Herceptin) Tysabri ( Natalizumab) Ziv-Aflibercept (Zaltrap)
6 INJECTABLES New FDA approved drugs are subject to review and may be subject to additional coverage requirements or limits established by the Plan. Aflibercept (Eylea) Infergen Aranesp Intron A Arixtra Kineret Avonex Pegasys Betaseron Peg-Intron Botox Rebetron Cimzia Rebig Copaxone Remodulin Enbrel Somavert Forteo Synagis Growth Hormone Xolair Hepsara Neupogen Hydroxyprogesterone Caproate (Makena) Leukine Humira Neulasta Epogen Pegaptanib Sodium (Macugen) Ranibizumab (Lucentis) INPATIENT STAY - ALL ADMISSION Including substitution of care for hospitalization or other institutional expenses INPATIENT REHABILITATION LONG TERM CARE FACILITY AFTER HOSPITALIZATION PAIN MANAGEMENT Epidural pain pump insertion Spinal Cord Stimulator (trial and permanent placement Multidisciplinary pain team evaluation at Progressive Rehab Spine injections for chronic back pain Synvisc, Supartz, Hyalgan, Orthovisc, Euflexxa Injections (all viscosupplementation) PEDIATRIC DENTAL CARE Periodontal scaling and root planing for ages 13 and older Periodontal maintenance for ages 13 and older
7 Stainless steel crowns for primary anterior teeth for ages 13 and older Metal/ porcelain crowns and porcelain crowns on anterior teeth PHARMACETICAL Self-administered anti-cancer medications. Certain prescription drugs and/or quantities of prescription drugs may require prior authorization. A complete list of drugs that require prior authorization is available on mymoda or by contacting Customer Service. In addition to those drugs included in the current prior authorization list on mymoda, prior authorization is required for: Retail prescriptions with a net cost over $1,000 for a 30-day supply Mail-order and specialty prescriptions with a net cost over $3,000 Compounded medications with a net cost over $150 for a 30-day supply Claims for drugs purchased outside of the United States and its territories other than for emergency or urgent care situations Early refill of drugs for travel outside of the United States more than once every 6 months REHABILITATIVE AND RECUPERATIVE SERVICES Outpatient visits for physical therapy, occupational therapy, and speech therapy require authorization prior to the 26 th visit. Chronic illness programs, including but not limited to programs listed below, require prior authorization: Cardiac rehabilitation Multidisciplinary pain team evaluation Pulmonary rehabilitation at progressive Rehab REPRODUCTIVE SERVICES DNA testing Genetic testing RESIDENTIAL PROGRAMS FOR CHEMICAL DEPENDENCY AND MENTAL HEALTH SKILLED NURSING FACILITY
8 SURGERY ALL INPATIENT ELECTIVE SURGERIES AND PROCEDURES SURGERY/TREATMENT OUTPATIENT All outpatient surgeries on this prior Prophylactic surgery (e.g. mastectomy) authorization list Cartilage Transplants of the knee Thoracic Sympathectomy (for hyperhidrosis) Capsule Endoscopy Kyphoplasty/Vertebroplasty Circumcision after 3 months of age Stereotactic Radiosurgery (ie Gamma Knife Eye surgery for cataracts with implant of Outpatient Arthroscopies intraocular telescopic lens Hyperbaric Oxygen Therapy Hip, knee, shoulder surgeries Neck/back/spine surgeries TRANSPLANTS All transplants except cornea Donor services
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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
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
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
New York Small Group Indemnity Aetna Life Insurance Company Plan Effective Date: 10/01/2010. PLAN DESIGN AND BENEFITS - NY Indemnity 1-10/10*
PLAN FEATURES Deductible (per calendar year) $2,500 Individual $7,500 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services,
What are Supplemental Instructions Article (SIA) and Medical Policy Articles?
Local Coverage Determinations (LCDS) and Medical Policy Articles for Jurisdiction 6 National Government Services Will Become Effective With Implementation The Centers for Medicare & Medicaid Services (CMS)
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
OPIP HEALTH & HEALTH PLUS Plan Details and Cost Comparisons
& HEALTH PLUS Plan Details and Cost Comparisons With the OMA Priority Insurance Program (OPIP), you have the opportunity to enhance your existing government subsidized OPIP Health Plan with optional self-funded
2Page 2 of 11. Baker Hughes Incorporated. Benefits At A Glance International Plan Policy#: 05679B
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Schedule of Benefits. Plan Information Participating Provider Non-Participating Provider
Schedule of Benefits UPMC Consumer Advantage HSA PPO - Premium Network Primary Care Provider: 10% after Deductible Specialist: 10% after Deductible Deductible: $1,950 / $3,900 Rx: 10% after Deductible
National Government Services Local Coverage Determinations and Medical Policy Articles for Jurisdiction 6
Local Coverage Determinations and Medical Policy Articles for Jurisdiction 6 Have Been Posted Courtesy of J6 Medicare News National Government Services Local Coverage Determinations and Medical Policy
PLAN DESIGN AND BENEFITS - New York Open Access EPO 1-10/10
PLAN FEATURES Deductible (per calendar year) $1,000 Individual $3,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services,
PLAN CODE: A-10 MERCY HEALTH PLANS SCHEDULE OF COVERAGE AND BENEFITS
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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
2016 Summary of Benefits
2016 Summary of Benefits Health Net Violet Option 3 (PPO) Douglas and Josephine counties, OR Benefits effective January 1, 2016 H5520 Health Net Life Insurance Company H5520_2016_0202 CMS Accepted 09162015
Coventry Health & Life Insurance Company
Coventry Health & Life Insurance Company (Benefits underwritten by Coventry Health & Life Insurance Company and Administered by Coventry Health Care of Missouri, Inc.) Small Group PPO Schedule of Benefits:
PLAN DESIGN AND BENEFITS POS Open Access Plan 1944
PLAN FEATURES PARTICIPATING Deductible (per calendar year) $3,000 Individual $9,000 Family $4,000 Individual $12,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being