2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
|
|
|
- Shana Gallagher
- 7 years ago
- Views:
Transcription
1 2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services With the exception of ER, Ambulance, Urgent Care Center services, Immunizations, Family planning services, chiropractic services, podiatry, and ologists, except if service is otherwise listed on PA list. Facility to facility ambulance transport (non-emergent transport) A0426 & A0428 Air Ambulance A0430, A0431, A0435, A0436 Elective/emergent/urgent medical, surgical inpatient admissions, and skilled nursing facility services Inpatient Rehabilitation Subacute admission POS 21 POS 21, 51, 61, 31 Maternity stays are notification only and no prior authorization number is issued. POS 21 or 61 and accommodation codes 024, POS 21 or POS 61. Revenue code 024 Transplants Bariatric Surgery including the work up/ evaluation for transplant POS 21 - For outpatient need to have the following: S9975, Solid: Heart/lung: Liver: Pancreas: Bone Marrow: 38240, Heart valve tissue transplants: 33933, Stem cell: , 38221, 38230, 38231, Pancreas: Intestine: , Roux-en-Y:43644, Gastroplasty: 43842, Gastric banding sleeve: Gastrectomy: 43644, 43847, 43848, 43886, 46887, Duodenal switch: , 43775, 43844, Cochlear Implants surgery (See DME for device) General anesthesia for dental procedures D D9248
2 Type of Service Requires PA Coding Hysterectomy 51925, , , Mastectomy reconstructive surgery Same as breast reconstruction below Maxillofacial surgeries/tmj -including Arthroplasty, Arthroscopy, Reconstruction, Discectomy (with or without disc replacement), trigger point injections, Arthrocentesis, and mandibular orthopedic repositioning appliances (MORA) Non-cosmetic reconstructive surgery 21010, 21025, 21026, 21050, 21060, 21070, 21073, 21116, , , 21255, 29800, 29804, S , 11201, , , 15775, 15776, , 15847, , , 19300, , , 30520, , 37785, , , 54660, , 67730, 67974, 67975, 69300, S2066, S2067,S2068, , Breast congenital anomaly (i.e. polymastia) Included in Breast Reconstruction Breast enlargement (same as Augmentation) Same as Augmentation above Congenital craniofacial anomaly surgery Included in Maxillofacial above Tonsillectomy & Adenoidectomy Uvulopalatoplasty including laser assisted Home health services Home oxygen Hospice (inpatient and outpatient) Nutritionals and Supplements, Enteral/ Parenteral Nutrition and services, regardless of total claim cost 42820, 42821, 42825, 42826, 42830, 42831, 42835, POS 12 with the following codes: G0151, G0152, G0153, G0155, 99600, TE, TD, 99601, 99602, 92610, S9349, S9127, 97001, 97003, Initial evaluation codes for PT, OT, ST in home and all subsequent therapy visits in home requires PA. A4615, A4616, A7046, E0424, E0425, E0426-E0463, E1352-E1392, E1405, E1406, K0738 All POS 34, For POS 12, the following should pend: 651, 652, 655 and 656 with HCPCS codes Q5001-Q5010 B4034 -B9998
3 Type of Service Requires PA Coding Outpatient ST/OT/PT The initial evaluation does not require prior auth. Prior authorization is required for PT or OT exceeding the 12 hours or visits per discipline within 30 calendar days. No PA required for ST for the first 12 visits or hours within a calendar year PT - Revenue codes - 420, 421, 422, 423, 429, and 97002, 97004, , OT - Revenue codes , 439 ST - Revenue codes 440,-443, 449, 92507, 92508, 92520, 92521, 92522, 92523, 92524, 92525, Outpatient Pulmonary rehab G G HX G G HX G0237-G0239, 948, G0424 Cochlear Implants (device) L8614- L8619 Durable Medical equipment Electric breast pump Hearing Aids Orthotics Prosthetics TENS (see pain management) Bone Density study for members under 65 years of age Botox Injections all DME and supplies >$500 (total claim) including rental or purchase requires prior authorization, rental or purchase of $500 or more per claim for orthotics of $250 or more of $500 or more per claim ALL DME codes. Please also refer to the orthotics category of this document for other items that may be considered DME that require prior authorization. Left and Right ear- V5030, V5040, V5050, V5060, V5070, V5080, V5095, V5100, V5120, V5130, V5140, V5150, V5170, V5180, V5190, V5210, V5220, V5230, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5263, V5267 Bilateral- V5100, V5120, V5130, V5140, V5150, V5248, V5249, V5250, V5251, V5252, V5253, V5258, V5259, V5260, V5261 L0100-L4631 L5000 L9900 A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731, A4290 G G HX CP CP CP J0585, J0586, J0587, J0588 Please refer to worksheet titled Drugs requiring PA
4 Type of Service Requires PA Coding Clinical trials for cancer treatment Dialysis Rev codes 082x, 083x, 084x-, 085x Genetic testing Hyperbaric oxygen PET Scan- All MRA- ALL MR Spectroscopy , 81229, 88230, 88367, 88291, 80502, 88262, 88289, 88230, 72090, C1300, A4575, E , G0219,G0220, G0221, G0222, G0223, G0224, G0225, G0226, G0227, G0228, G0229, G0230, G0231, G0232, G0233, G0234, G0235, 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78813, 78814, 78815, , 73225, 71555, 70544, 70545, 70546, 73725, 70547, 70548, 70549, 72198, (billed under MRI revenue codes) MRI- Abdomen 74181, 74182, MRI - Pelvis 72195, 72196, MRI - Lower Extremity MRI- 3D MRI - Brain 73718, 73719, 73720, 73721, 73722, , 70552, 70553, 70554, 70555, 70556, 70557, 70558, MRI - chest 71550, 71551, 71552, MRI - Cervical, Thoracic, lumbar spine MRI - Breast CT scan - Cervical, Thoracic, lumbar spine CT scan -Thorax CT-Scan -Abdomen , 72142, 72143, 72144, 72145, 72146, 72147, 72148, 72149, 72150, 72151, 72152, 72153, 72154, 72155, 72156, 72157, 72158, CT scan - maxillofacial 70486, 70487, CT Scan -Pelvis 72191, 72192, 72193, D CT scans 77061, 77062, 77063, Podiatry after 6 visits Pulse generator Podiatry visits require prior authorization AFTER the 6th visit. All services rendered during the visit unless otherwise noted on this prior authorization list are included in the visit limit without authorization
5 Type of Service Requires PA Coding The following radiation therapy requires prior auth: IMRT and Vision training therapy Routine OB Ultrasounds PICC line insertion for OB services (i.e. hyperemesis gravidarum) Pain management- including trigger point injection, facet joint and/or facet joint nerve injection, Epidural steroid injection, transcutaneous electric nerve stimulator Sacral nerve, Neuro or Spinal Cord stimulator Behavioral Health, more than 2 OB ultrasounds require prior authorization the following require prior authorization (TENS) with Diagnosis codes Z34.00, Z34.80, Z34.90, Z33.1, O09.00-O09.93, Z36, O00-O99, P05.00-P with diagnosis of O21-O21.8, O20-O21.9, O44-O47, O67-O6 A4556,-A4558, A4595, A4630, E0720, E0730, E0731, A4290, , 62310, 62311, , 72275, 77003, 64550,-64581, , 64561, 64581, E0744-E0749, E0762, E0766, L8679-L , 64454, 64455, (for implant) 43647, 43881(for electrodes) PA requirements as outlined on the following pages.
6 Behavioral Health Services that Require PA MDwise BH contracted providers - outpatient prior authorization requirements for Hoosier Healthwise only. Service Type Psychiatric Diagnostic Interview CPT code or (Interactive Interview) Therapy Services CPT code: Psytx Office 30 min Psytx Office 45 min Psytx off. 60 min Family medical psychotherapy Family Psytx conjoint Group Psychotherapy Medication Management , new patient, office , existing patient, office PA is not required for CPT codes , , , (contracted providers only) Therapy visits with E/M: Interactive Psytx w/medical EM 60 min PA Requirements 1 unit per member, per billing provider, per rolling 12-months allowed with no PA. 2 units are allowed without PA when member is separately evaluated both by a physician, an advanced practice nurse or HSPP and another mid-level practitioner. No PA is required for contracted providers. Interactive Complexity (CPT code 90785) is an add-on code to this CPT group and does not require a separate authorization. PA not required Interactive Complexity (CPT code 90785) is an add-on code to this CPT group and does not require a separate authorization. For non-contracted IHCP phsychiatrists, PA required after 30 visits PA is not required. Multi-Family Group Therapy PA not required. Psychoanalysis Requires PA Office Patient Visits and Consultations: New patient visits Established patient visits Psychological Testing: Psychological Testing, per hour of the Psychologist or Physicians time, face to face time Psychological Testing administered by technician, per hour of time face to face Developmental Test, Extensive Neurobehavioral Status, Neurobehavioral Test by Psych Neuropsychological testing per hour of technician time, face to face PA is not required. Requires PA Please note: If PA is given for the PA would also apply to If PA is given for the PA would also apply to CPT Code Developmental Test, w/interpretation & Report does not require a PA.
7 Service Type PA Requirements Electroconvulsive Therapy ECT Health and Behavior Assessment: PA is required for persons with Autism Spectrum Disorder Diagnosis. Authorizations are to be given in accordance with treatment plan which can only be required every 6 months Assess health/behavior, subsequent Intervene health/behavior, initial Intervene health/behavior, group Intervene health/behavior, family W/E&M Health/behavior family, no intervention Requires PA. Anesthesia (CPT code 00104) and outpatient facility (i.e., observation room) may also be provided. If ECT authorized, anesthesia/ anesthesia provider and facility service to be authorized. Does not require PA except when used with ASD diagnosis for ABA services. PA is required for persons with Autism Spectrum Disorder Diagnosis (ICD-9 codes 299.0, 299.8, ICD-10 codes F84.0 or F84.9). Authorizations are to be given in accordance with treatment plan which can only be required every 6 months. Cognitive Skills Development Requires PA. Screening & Brief Intervention Services (SBI) - Drug/Alcohol Abuse: Alcohol &/or SA structured SBI min Alcohol &/or SA SBI greater than 30 min PA not required for one or per member, per contracted billing provider. PA is required for non-contracted providers, except if provided as emergency service. SBI services are not typically billed by behavioral health clinics as screening and interventions are already include in behavioral health assessment/treatment CPT codes. Partial Hospitalization Services H0035 Partial Hospitalization Services Smoking Cessation Treatment Services S9075 Smoking Cessation Treatment Services Requires PA PA is not required. Benefit maximum - one 12-week course of treatment per member per calendar year. Non-contracted BH providers - outpatient prior authorization requirements. *Except for the following self-referral services for any non-contracted IHCP enrolled Psychiatrist, all outpatient BH services provided by non-contracted behavioral health providers require PA. This includes observation stays. Service Type Self-Referral Services for non-contracted IHCP Psychiatrist: Psychiatric Diagnostic Interview Interactive Psychiatric Diagnostic Interview Individual Psychotherapy Psychoanalysis Family/Group Psychotherapy Health/Behavior Assessment Codes PA Requirements Members may see any non-contracted IHCP enrolled psychiatrist for 20 visits, per rolling 12 months without PA. Per billing provider, this includes (in combination): 90791, 90792, , , & PA is required for additional visits. See NOTE below for authorization application guideline.
8 Behavioral Health Professional Services During Medical/Surgical Stay Service Type Diagnostic Interview CPT codes or PA Requirements PA is not required per inpatient episode of care. Inpatient Services: With the exception of emergency admissions, prior authorization is required for any psychiatric admission stay, including admissions for substance abuse and nursing facility stays. Please note: For services requiring authorization, authorizations provided for a higher level code may be applied to the claim submitted by that provider with a lower level code, rather than denying the lower level code for no authorization. For example, in the event an authorization is given for a more involved visit, i.e., 90837, but in turn, a claim is submitted with CPT code or 90834, the claim would be paid on the authorization rather than denied for no authorization. P0827 (12/15) Rev. 7/6/16
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
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
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
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
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,
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:
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,
2016 MDwise HIP Medical Services that Require Prior Authorization
2016 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Coding All Out of Network services Facility to facility ambulance transport
(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
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.
2016 MDwise HIP Medical Services that Require Prior Authorization
2016 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Coding All Out of Network services Facility to facility ambulance transport
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 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
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
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.
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
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
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
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
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
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%
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
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
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
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
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)
Covered Services. Health and Development History. Nutritional assessment. visit per year from 2 to 20 years of age
You may receive covered services that are performed, prescribed or directed by a participating provider. As an Enrollee, you must receive your healthcare services from a participating PCP or medical provider.
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
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
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)
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
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
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
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
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
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
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
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
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)
Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016
Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016 This Schedule of Benefits summarizes your obligation towards the cost of certain covered services. Refer to
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
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.
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
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.
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
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
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
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
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
Explanation and Limitations for Plan A. Annual Maximum UNLIMITED UNLIMITED. See page 4 for services that require Carewise Health preauthorization
Page 1 of 6 Benefit Description Individual Deductible Family Deductible Individual OOP Family OOP UFCW LOCAL 711 AND RETAIL STORES GROUP # s S1644 / S1645 SCHEDULE OF MEDICAL BENEFITS FOR PLAN A All benefits
$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
MEDICAL CERTAINTY WITHIN YOUR REACH PLANS COMPARATIVES EFECTIVE MARCH 1, 2015
MEDICAL CERTAINTY WITHIN YOUR REACH PLANS COMPARATIVES EFECTIVE MARCH 1, 2015 BENEFITS Maximum Annual Benefit USD$10 million USD$5 million USD$2 million USD$1 million USD$1.5 million (benefit available
REFERRALS CPT CODES COMMENTS
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
CDHP (Consumer Driven Health Plan)
CDHP (Consumer Driven Health Plan) Benefit Booklet Group Number: 976208 & 976209 Effective Date: January 1, 2013 An Independent Member of the Blue Shield Association Claims Administered by Blue Shield
Coventry Health & Life Insurance Company Small Group PPO Schedule of Benefits:
Coventry Health & Life Insurance Company Small Group PPO Schedule of Benefits: Plan ID#: Silver Traditional 3000 90-14 (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain
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
Cigna Supported Service Types for Eligibility and Benefit Inquiries
This document lists the service type codes that can be submitted to Cigna on an eligibility and benefit inquiry transaction. If a service type code not included on this list is submitted, Cigna's general
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
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
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
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
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
Covered Service Description
Advanced registered nurse practitioner (ARNP) Ambulatory surgical center (ASC) These are given by an ARNP who s licensed to practice in the State of Florida The ARNP and a doctor must make decisions about
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.
DRAKE UNIVERSITY HEALTH PLAN
DRAKE UNIVERSITY HEALTH PLAN Effective Date: 1/1/2015 This is a general description of coverage. It is not a statement of contract. Actual coverage is subject to terms and the conditions specified in the
Medical Benefits. An Overview of Your Medical Benefits. What s Covered? Coverage Out-of-Network
Medical s An Overview of Your Medical s The Painters & Allied Trades District Council No. 35 Health Plan covers most medically necessary expenses. For provider discounts, we contract with CareLink, a Preferred
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
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
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
MS CAN - Mississippi Coordinated Access Network Benefit Summary Prior Auth is necessary for all NON-Par Providers MS - Houston
MS CAN - Mississippi Coordinated Access Network Benefit Summary Prior Auth is necessary for all NON-Par Providers (Revised 3/08/2011 - FINAL) Benefit Limitation Prior Authorization Contact for Prior Authorization
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
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
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
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
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
Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company
Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company Insureds 2009 Contents How to contact us... 2 Our claims process...
Aetna Required Data Elements, Clean Claim Elements, and Attachments
Texas Physicians, Practitioners and Other Professional Providers Claims Submitted Using HCFA 1500 Forms DISCLOSURE OF CLEAN CLAIM ELEMENTS; DISCLOSURE OF NECESSARY ATTACHMENTS; DISCLOSURE OF ADDITIONAL
INDIVIDUAL PLANS SOUTH CAROLINA OPEN ACCESS 1000
BENEFIT IN NETWORK OUT OF NETWORK This plan is intended to comply with the federal Patient Protection and Affordable Care Act. Provisions are subject to change as additional regulatory guidance becomes
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
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.
PPO Option January 1, 2015 December 31, 2015
COST SHARING LIFETIME LIMITS Calendar Year Deductible Individual Family Calendar Year Out-of-Pocket Maximum Individual Family None None $500 includes copays $1500 includes copays $100 $300 $1,000 includes
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
[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
CA Group Business 2-50 Employees
PLAN FEATURES Network Primary Care Physician Selection Deductible (per calendar year) Member Coinsurance Copay Maximum (per calendar year) Lifetime Maximum Referral Requirement PHYSICIAN SERVICES Primary
PLAN CODE: A-10 MERCY HEALTH PLANS SCHEDULE OF COVERAGE AND BENEFITS
PPO INDIVIDUAL PLAN PLAN CODE: A-10 MERCY HEALTH PLANS SCHEDULE OF COVERAGE AND BENEFITS With Mercy Health Plans PPO, You can choose to receive either Network Benefits or Non-Network Benefits. To obtain
Independence Blue Cross Plan Summary PPO Core Medical Plan
TO: FROM: SUBJECT: MLH Medical Plan Participants MLH Human Resources Benefits Team Independence Blue Cross Plan Summary PPO Core Medical Plan Attached you will find the Independence Blue Cross (IBC) Plan
Precertification Requirement Grids
Precertification Requirement Grids BCBSAZ Precertification Requirements * Page 1 Banner Health HSA Page 2 City of Mesa Out of State Page 3 City of Phoenix Page 4 FEP Page 5 Fort Mojave Indian Tribe Page
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
Highest level of coverage with free-choice of hospitals and physicians worldwide, including the richest maternity and organ transplant benefits.
Highest level of coverage with free-choice of hospitals and physicians worldwide, including the richest maternity and organ transplant benefits. Global Superior is tailored exclusively for individuals
Zurich Services Corporation Health Care Network (HCN)/Firsthealth Information, Instructions and your Rights and Obligations
Dear Employee: Zurich Services Corporation Health Care Network (HCN)/Firsthealth Information, Instructions and your Rights and Obligations Your employer has chosen Zurich Services Corporation Health Care
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
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
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
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
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
BlueSecure HMO Plan Benefit Summary
BlueSecure HMO Plan Benefit Summary NETWORK LIMITATIONS NETWORK PROVIDERS ALLOWED AMOUNT Except for emergencies, all covered services must be rendered by a network provider. Outside Arizona, this plan
Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2015
Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2015 About this chart: This chart is to be used as a guide only and does not contain all details or exclusions.
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,
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
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