Medical Policies and Clinical Utilization Management Guidelines



Similar documents
Medical Policies and Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines

Iowa Wellness Plan Benefits Coverage List

Preauthorization Requirements * (as of January 1, 2016)

(FIDA) FIDELIS CARE AUTHORIZATION REQUIREMENTS

Anthem Blue Cross and Blue Shield in Connecticut Precertification Guidelines

Alternative Benefit Plan (ABP) ABP Cost-Sharing & Comparison to Standard Medicaid Services

APPENDIX C Description of CHIP Benefits

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

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

Anthem Blue Cross and Blue Shield in New Hampshire Precertification Guidelines

REFERRALS CPT CODES COMMENTS

OGB MAGNOLIA LOCAL COMPREHENSIVE MEDICAL BENEFIT PLAN SCHEDULE OF BENEFITS

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

Oregon CPT Preapproval Grid

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

University of Michigan Group: , 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance

Prior Authorization Requirements for Florida Effective March 1, 2015

TENNESSEE SEPTEMBER The following entries apply to all Tennessee Amerigroup Community Care Providers. Medical Policies Update

Independence Blue Cross Plan Summary PPO Core Medical Plan

Prior Authorization List Adults, FHP, CHP

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

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

Summary of PNM Resources Health Care Benefits Active Employees 2011

PPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA

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

Commercial. Individual & Family Plan. Health Net California Farm Bureau and PPO. Insurance Plans. Outline of Coverage and Exclusions and Limitations

Coventry Health and Life Insurance Company PPO Schedule of Benefits

Hawaii Benchmarks Benefits under the Affordable Care Act (ACA)

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

Advance Notification Requirements for New York Effective June 1, 2015

Your Medical Care Services Medical Benefits with Community Health Plan of Washington

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

UnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits

Medical Management Requirements Effective January 1, 2008

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

UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage

CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) Effective Date: July 1, 2015 Benefits-at-a-Glance

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

Transmittal 55 Date: MAY 5, SUBJECT: Changes Conforming to CR3648 for Therapy Services

GIC Medicare Enrolled Retirees

Lesser of $200 or 20% (surgery) $10 per visit. $35 $100/trip $50/trip $75/trip $50/trip

Treatment Category Inpatient Treatment Categories DRG (MS DRG) ICD9 [Hip & Knee Only]

please refer to our internet site, or contact the Member Services

Greater Tompkins County Municipal Health Insurance Consortium

Greater Tompkins County Municipal Health Insurance Consortium

SCHEDULE OF BENEFITS

BlueCare Direct Gold SM HMO 101 BlueCare Direct SM HMO Network

GENERAL ADMISSION CRITERIA INPATIENT REHABILITATION PROGRAMS

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

Blue Cross Premier Bronze Extra

MedStar Family Choice Benefits Summary District of Columbia- Healthy Families WHAT YOU GET WHO CAN GET THIS BENEFIT BENEFIT

Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2015

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

CSAC/EIA Health Small Group Access+ HMO 15-0 Inpatient Benefit Summary

MyHPN Solutions HMO Silver 4

SERVICES IN-NETWORK COVERAGE OUT-OF-NETWORK COVERAGE

Objective of This Lecture

If you have a question about whether MedStar Family Choice covers certain health care, call MedStar Family Choice Member Services at

Inpatient Rehabilitation Facilities (IRFs) [Preauthorization Required]

American Maritime Officers Medical Plan Employer Identification Number: Plan Number: 501 Group Number:

Summary of Services and Cost Shares

Miscellaneous Services

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

National PPO PPO Schedule of Payments (Maryland Small Group)

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

International Student Health Insurance Program (ISHIP)

$250 copay per admit. $250 copay per admit

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

Basic Standards for Residency Training in Physical Medicine and Rehabilitation

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

Patient Guide to Lower Back Surgery

2015 Medicare Advantage Summary of Benefits

SISC Custom SaveNet Zero Admit 10 Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix)

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

FEATURES NETWORK OUT-OF-NETWORK

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

2015 Medical Plan Summary

January 1, 2015 December 31, 2015 Summary of Benefits. Altius Advantra (HMO) H UTWY A

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

Cost Sharing Definitions

Ambulatory Surgery Center Coding and Payment Guide 2015

Highlights of your Health Care Coverage

Covered Services. Health and Development History. Nutritional assessment. visit per year from 2 to 20 years of age

UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage

UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage

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

I want a health care plan with all the options.

Western Health Advantage: City of Sacramento HSA ABHP Coverage Period: 1/1/ /31/2016

The State Health Benefits Program Plan

SUMMARY OF BADGERCARE PLUS BENEFITS

Physician Coding and Payment Guide 2015

BERMUDA GOVERNMENT EMPLOYEES (HEALTH INSURANCE) (BENEFITS) ORDER 1997 BR 32 / 1997

Transcription:

providers.amerigroup.com Medical Policies and Clinical Utilization Management Guidelines Amerigroup Iowa, Inc. uses nationally recognized, evidence-based Medical Policies and Clinical Utilization Management (UM) Guidelines. The full list of Medical Policies and Clinical Utilization Management Guidelines are publicly available on the Amerigroup website, under Medical Policy and Clinical UM Guidelines their purpose is to help you provide quality care by reducing inappropriate use of medical resources. Effective March 1, 2014, McKesson InterQual Level of Care criteria will be used for medical necessity review for medical inpatient concurrent review, inpatient site of service appropriateness, home health and outpatient rehabilitation. Anthem Behavioral Health Medical Policies, Clinical Utilization Management Guidelines and American Society of Addiction Medicine Guidelines will be used for all behavioral health reviews. In all cases, Medicaid contracts, regulatory guidance and Centers for Medicare & Medicaid Services requirements supersede both McKesson InterQual Level of Care and Amerigroup medical policy criteria. Determinations of medical necessity are made on a case-by-case basis in accordance with the definition of medical necessity. If the request does not meet established criteria guidelines, it will then be referred to the licensed physician with the appropriate clinical expertise for review. This change applies only to states, covered populations and services for which Amerigroup provides behavioral health utilization management services and where the use of Anthem Behavioral Health UM Guidelines is not superseded by regulatory or contractual requirements. WEBPIA-0028-15 December 2015

Clinical Utilization Management Guidelines Guideline number CG-ANC-04 CG-ANC-05 CG-ANC-06 CG-BEH-01 CG-BEH-02 CG-BEH-03 CG-BEH-04 CG-BEH-05 CG-BEH-07 CG-BEH-09 CG_BEH-10 CG-BEH-11 CG-BEH-12 CG-BEH-13 CG-DME-01 CG-DME-03 CG-DME-05 CG-DME-07 CG-DME-08 CG-DME-09 CG-DME-10 CG-DME-12 CG-DME-13 CG-DME-15 Effective August 18, 2015, the Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division. To see the full list of UM Guidelines on the Amerigroup website, select the link above. Clinical UM Guidelines name/title Ambulance Services: Air and Water Ambulance Services: Ground; Emergent Ambulance Services: Ground; Non-Emergent Assessment for Autism Spectrum Disorders and Rett Syndrome Adaptive Behavioral Treatment for Autism Spectrum Disorder Psychiatric Disorder Treatment Substance-Related and Addictive Disorder Treatment Eating and Feeding Disorder Treatment Psychological Testing Assertive Community Treatment (ACT) Basic Skills Training/Social Skills Training Mental Health Support Services Psychosocial Rehabilitation Services Targeted Case Management (TCM) External (Portable) Continuous Insulin Infusion Pump Neuromuscular Stimulation in the Treatment of Muscle Atrophy Cervical Traction Devices for Home Use Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) Infant Home Apnea Monitors Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump During the Post-Operative Period Durable Medical Equipment Home Phototherapy Devices for Neonatal Hyperbilirubinemia Lower Limb Prosthesis Hospital Beds and Accessories CG-DME-16 Pressure Reducing Support Systems Groups 1,2 & 3 CG-DME-18 Home Oxygen Therapy CG-DME-19 Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes CG-DME-20 Orthopedic Footwear CG-DME-21 External Infusion Pumps for the Administration of Drugs in the Home or Residential Care

CG-DME-22 CG-DME-23 CG-DME-24 CG-DME-25 CG-DME-31 CG-DME-33 CG-DME-34 CG-DME-35 CG DME-36 CG-DRUG-01 CG-DRUG-03 CG-DRUG-04 CG-DRUG-05 CG-DRUG-07 CG-DRUG-08 CG-DRUG-09 CG-DRUG-11 CG-DRUG-13 CG-DRUG-15 CG-DRUG-16 CG-DRUG-19 CG-DRUG-20 CG-DRUG-21 CG-DRUG-24 CG-DRUG-27 CG-DRUG-28 CG-DRUG-29 CG-DRUG-30 CG-DRUG-33 CG-DRUG-34 CG-DRUG-38 CG-DRUG-40 CG-DRUG-41 CG-DRUG-42 CG-DRUG-43 CG-DRUG-44 CG-DRUG-45 CG-DRUG-46 CG-DRUG-47 Settings Ankle-Foot & Knee-Ankle-Foot-Orthotics (Braces) Lifting Devices for Use in the Home Wheeled Mobility Devices: Manual Wheelchairs Standard, Heavy Duty, Lightweight Seat Lift Mechanisms Wheeled Mobility Devices: Wheelchairs Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) Wheeled Mobility Devices:Manual Wheelchairs-Ultra Lightweight Wheeled Mobility Devices: Wheelchair Accessories Breastfeeding Pumps Pediatric Gait Trainers Off-Label Drug and Approved Orphan Drug Use Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra ), and Direct Thrombin Inhibitors in the Outpatient Setting Recombinant Erythropoietin Products Hepatitis C Pegylated Interferon Antiviral Therapy Enzyme Replacement Therapy for Gaucher Disease Immune Globulin (Ig) Therapy Infertility Drugs Hepatitis B Interferon Antiviral Therapy Gonadotropin Releasing Hormone (GnRH) Analogs White Blood Cell Growth Factors Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk Women Enfuviritide (Fuzeon) Naltrexone (Vivitrol ) Injections for the Treatment of Alcohol and Opioid Dependence Repository Corticotropin Injection (H.P. Acthar Gel) Clostridial Collagenase Histolyticum Injection Alglucosidase alfa (Lumizyme, Myozyme ) Hyaluronan Injections in the Knee Oprelvekin (Neumega) Palonosetron (Aloxi ) Docetaxel (Taxotere ) Pemetrexed Disodium (Alimta ) Bortezomib (Velcade ) Zoledronic acid Asparagine Specific Enzymes (Asparaginase) Natalizumab (Tysabri ) Pegloticase (Krystexxa ) Octreotide acetate (Sandostatin ; Sandostatin LAR Depot) Fosaprepitant (Emend ) Level of Care: Specialty Pharmaceuticals

CG-LAB-09 CG-MED-08 CG-MED-21 CG-MED-22 CG-MED-23 CG-MED-24 CG-MED-28 CG-MED-32 CG-MED-38 CG-MED-42 CG-MED-44 CG-MED-45 CG-MED-46 CG-MED-47 CG-MED-48 CG-MED-49 CG-MED-50 CG-MED-51 CG-MED-52 CG-OR-PR-04 CG-OR-PR-05 CG-REHAB-03 CG-REHAB-04 CG-REHAB-05 CG-REHAB-06 CG-REHAB-08 CG-SURG-03 CG-SURG-05 CG-SURG-08 CG-SURG-09 CG-SURG-12 CG-SURG-18 CG-SURG-24 CG-SURG-25 CG-SURG-27 CG-SURG-30 CG-SURG-31 CG-SURG-32 CG-SURG-33 CG-SURG-36 Drug Testing or Screening in the Context of Substance Abuse and Chronic Pain Home Enteral Nutrition Anesthesia Services and Moderate ("Conscious") Sedation Neuropsychological Testing Home Health Electromyography and Nerve Conduction Studies Iontophoresis for Medical Indications Ancillary Services for Pregnancy Complications Inpatient admission for Radiation Therapy for Cervical or Thyroid Cancer Maternity Ultrasound in the Outpatient Setting Holter Monitors Transrectal Ultrasonography Ambulatory and Inpatient Video Electroencephalography Fundus Photography Scrotal Ultrasound Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders Visual, Somatosensory and Motor Evoked Potentials Three-Dimensional (3-D) Rendering of Imaging Studies Allergy Immunotherapy (Subcutaneous) Cranial Remodeling Bands and Helmets (Cranial Orthotics) Myoelectric Upper Extremity Prosthesis Devices Pulmonary Rehabilitation Physical Therapy Occupational Therapy Speech-Language Pathology Services Private Duty Nursing in the Home Setting Blepharoplasty, Blepharoptosis Repair and Brow Lift Maze Procedure Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury Temporomandibular Disorders Penile Prosthesis Implantation Septoplasty Functional Endoscopic Sinus Surgery (FESS) Injection Treatment for Morton's Neuroma Gender Reassignment Surgery Tonsillectomy with or without Adenoidectomy for Children Treatment of Keloids and Scar Revision Pain Management: Cervical, Thoracic & Lumbar Facet Injections Lumbar Fusion and Lumbar Total Disc Arthroplasty (TDA) Adenoidectomy

CG-SURG-38 CG-SURG-39 CG-SURG-40 CG-SURG-41 CG-SURG-42 CG-SURG-43 CG-SURG-44 CG-SURG-45 CG-SURG-46 CG-SURG-47 CG-SURG-48 CG-SURG-49 CG-SURG-50 CG-SURG-51 CG-TRANS-02 Lumbar Laminectomy, Hemi-laminectomy, Laminectomy and/or Discectomy Pain Management: Epidural Steroid Injections Cataract Removal Surgery for Adults Surgical Strabismus Correction Cervical Fusion Knee Arthroscopy Coronary Angiography and Cardiac Catheterization in the Outpatient Setting Bone Graft Substitutes Myringotomy and Tympanostomy Tube Insertion Surgical Interventions for Scoliosis and Spinal Deformity Elective Percutaneous Coronary Interventions (PCI) Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities Assistant Surgeons Outpatient Cystourethroscopy Kidney Transplantation

2026 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information