MS CAN - Mississippi Coordinated Access Network Benefit Summary Prior Auth is necessary for all NON-Par Providers MS - Houston

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1 MS CAN - Mississippi Coordinated Access Network Benefit Summary Prior Auth is necessary for all NON-Par Providers (Revised 3/08/ FINAL) Benefit Limitation Prior Authorization Contact for Prior Authorization tes Ambulatory Surgical Center Services Ambulance services Prior authorization required for Urgent Air Ambulance (Fixed Wing) only. *Emergency services no PA required *n-emergent transport either fixed wing or otherwise PA required. Limited to covered services n-emergency transportation services only. Excluded if service limits have - Logisticare (Mon - Fri 7:00AM - 6:00PM CST) been exceeded. Excluded if beneficiary has transportation resources. Logisticare NOTE: DOM determines the limitation. Chiropractic services DOM has a $700 maximum per calendar year Christian Science Sanatoria services Community Mental Health Center (CMHC) services See policy section Cosmetic and Reconstructive Surgery - Outpatient Dental services Children Preventive Diagnostic Restorative Orthodontia Adults Emergency pain relief Palliative care Dialysis Outpatient Center services Durable Medical Equipment Medical Supplies EPSDT Dental $2500 maximum per calendar yearadults and children; additional benefits if prior authorized. Orthodontia $4200 maximum per lifetime per child. All policy restrictions apply. Diapers and underpads age 3-20 with medical condition causing incontinence with bowel and bladder. Max of 6 per day. If greater than 6 it will require prior auth, Certain dental procedures such as crowns, root canals, dentures and orthodontics require prior authorization. For more specific and detailed information please warm transfer member to: INTERNAL USE ONLY DOM DBP Prior auth needed for items over $500., if greater than 6 per day for the diapers/underpads entitled to every benefit offers even Specific listing of DME items provided at the following web address - tion.aspx?section%2010%20-%20dme NOTE: supplies one month supply at a time. Limited to those that are State approved EPSDT providers

2 Expanded EPSDT services Eye care (Eye exams and glasses) Family Planning services Federally Qualified Health Center services Genetic Testing Health Department services Hearing services Prior authorization required for services not covered, or any service that exceeds service limits. Limited to beneficiaries under 21 years of 2 pair per calendar year for children (PA is required after the first pair) 1 pair every 3 years for adults (EPSDT), for children after 2nd pair per calendar year - DME over $500 - for testing VSP Limited to those that are State approved EPSDT providers Health Department services includes: Pharmacy services through (MSDH) - Mississippi State Department of Health and MSDH EIP - early intervention program. Hearing aid provided by Epic Home Health services Home Infusion Hospice Inpatient Outpatient Adults 25 visits per calendar year Children no limitation Adults - no prior auth required Children - prior auth required after 25 visits Injectables may require a PA depending on the PDL. _mcan.pdf UHC will provide benefits for Hospice Services unless it is concurrent of an inpatient stay. Limited to a diagnosis of 6 months or less life expectancy as certified by physician. Hospital services - UHC does not cover Inpatient days Swing Bed Services Outpatient Mental Health Services 30 days per fiscal year *Adults only Hospital services Outpatient ER visits 6 visits per calendar year ICF/MR (Intermediate Care Facilities for the Mentally Retarded) Inpatient services Inpatient psychiatric services Therapeutic leave days limited to 90 days per calendar year. entitled to every benefit offers even. gets even though we don't entitled to every benefit offers even Imaging: nuclear studies, computed tomography (CT and SPECT scans), magnetic resonance studies (MRI, MRA), and PET Scans

3 Laboratory and X-Ray services NOTE: PA is required for: Imaging: nuclear studies, computed tomography (CT and SPECT scans), magnetic resonance studies (MRI, MRA),and PET Scans n-contracted Provider Services (outpatient facility and professional) Nurse Practitioner services Applies to physician office visit limit Nursing facility services Orthotics & Prosthetics Outpatient PT/OT/ ST >$500 Pediatric skilled nursing (Private Duty Nursing) services Perinatal High Risk Management Services Physician Assistant services Applies to physician office visit limit Physician Services Long-term care visits Physician Services Office (PCP and Specialists) 36 per calendar year, Prior Authorization is required after the 12th visit. does not cover treatment for flat feet and arch supports, this is not a covered benefit under our MS CAN plan. Maintenance therapy is not a covered service. Services including, but not limited to Home uterine monitoring. gets even though we don't entitled to every benefit offers even Office Unlimited Office and ER covered under MS CAN. Physician Services ER ER visits 6 per calendar year Office and ER covered under MS CAN. Physician Services Psychiatry 12 per fiscal year gets even though we don't entitled to every benefit offers even Podiatrist services Private Duty Nursing (PDN) Prescription drugs 5 per month with no more than 2 of the 5 being brand name drugs; beneficiaries under 21 can receive more than the monthly limits with a medical necessity PA - for beneficiaries under 21 that require more than 5 prescriptions per month Pharmacy Prior Authorization forms can be faxed to: If you have questions you can call:

4 Psychiatric Residential Treatment Facility (PRTF) services Psychiatry services Rural Health Clinic services Sleep Studies Surgery *Inpatient surgery Therapeutic and Evaluative Mental Health Services for Children Transplant Services Benefit Exclusions Items or services which are furnished gratuitously without regard to the individual's ability to pay and without expectation of payment from any source, such as free x-rays provided by a health department. Any operative procedure, or any portion of a procedure, performed primarily to improve physical appearance and/or treat a mental condition through change in bodily form. Routine physical examinations, such as school, sports, or employment physicals that are not part of the well child screening program for beneficiaries under 21 years of age or are not covered through provisions set forth in Section 53.18, or are not covered through the Wellness Program in Section of the Provider Policy Manual. Services of a physical therapist or speech therapist are not covered for beneficiaries 21 years of age or older, except when provided as an inpatient or outpatient hospital service, or as a nursing facility service. Therapy services are not covered in a nursing facility when performed by a home health agency. gets even though we don't entitled to every benefit offers even gets even though we don't entitled to every benefit offers even gets even though we don't entitled to every benefit offers even gets even though we don't entitled to every benefit offers even The health plan does not cover inpatient services. The health plan does cover outpatient services and professional fees prior to transplant procedure. Prior Authorization is required - Refer to Policy this describes the transplants that would require a prior auth.

5 Prosthetic and orthotic devices, and orthopedic shoes for beneficiaries 21 years of age or older, except for crossover claims allowed by Medicare. Hospital inpatient items not directly related to the treatment of an illness or injury (such as TV, massage, haircuts, etc.). Psychological evaluations and testing by a psychologist except when performed as an inpatient hospital service and billed on a hospital claim form, or as a part of the EPSDT program for children under 21 years of Vitamin injections, except for B-12 as specific therapy for certain anemias such as fish tapeworm anemia, other B-12 complex deficiencies, pernicious anemia, vitamin B-12 deficiency anemia, atrophic gastritis, idiopathic steatorrhea, sprue, blind loop syndrome, partial or total gastrectomy, pancreatic steatorrhea, and other specified intestinal malabsorption. Prescription vitamins and mineral products are excluded except for prenatal vitamins for obstetrical patients, fluoride vitamins for children, and B complex with C vitamins for dialysis patients. Services denied by Health Systems of MS. Routine circumcisions for newborn infants. Interest on late pay claims. Physician assistants prior to July 1, Freestanding substance abuse rehabilitation centers and psychiatric facilities for beneficiaries 21 years of age or older. Reimbursement for services provided to only Qualified Medicare Beneficiaries (QMB) except for Medicare/ crossover payments of Medicare deductibles and coinsurance. Medicare deductibles and co-insurance will not be paid for QMBs in non- eligible facilities. Reimbursement for any service for Specified Low-income Medicare Beneficiaries (SLMB) and Qualified Individuals (QI). These individuals are entitled only to payment or partial payment of their Medicare Part B premium. Ambulance transport to and from dialysis treatment unless prior approved by. Reversal of sterilization, artificial or intrauterine insemination and in vitro fertilization. Services, procedures, supplies or drugs which are still in clinical trials and/or investigative or Routine foot care in the absence of systemic conditions. Gastric surgery (any technique or procedure) for the treatment of obesity or weight control, regardless of medical necessity. Telephone contacts/consultations and missed or cancelled appointments. Wigs Services ordered, prescribed, administered, supplied or provided by an individual or entity that has been excluded by DHHS. Services ordered, prescribed, administered, supplied or provided by an individual or entity that is no longer licensed by their governing board. Services outside the scope and/or authority of a practitioner s specialty and/or area of practice. Services not specifically listed or defined by are not covered. Any exclusion listed elsewhere in the Mississippi Provider Policy Manual, bulletins, or other Mississippi publications. Acronyms Health Systems of MS - Health Service Management MCH - Maternal & Child MH - Mental Health MS - Medical Services NET - n-emergency Transportation UHC1068c_