arelink Benefit Matrix 2015 arelink Provider Hotline: 358-3719 - UniversityHealthSystem.com/areLink
Definitions: arelink - For uninsured Bexar ounty residents. Routinely, up to an 11-month membership contract. Services discounted to negotiated allowable, and then to maximum liability. Assigned a primary care physician. TAP - Temporary assistance program for Bexar ounty homeless. 90 day memberships. Guiding Principles Services are only covered if provided by the University Health System, ommunity Medicine Associates, UT Medicine, or other contracted arelink providers. Services not routinely provided by or at the University Health System are not covered services (EXEPT: radiation therapy, open sided MRIs, PET scans, bone marrow transplants, urological robotic assisted surgery). ontracts will be entered into with other facilities and providers only to address access issues. Pre-authorization is required in these cases. Other Health System emergency room services are not covered. Pre-Authorization requirements routinely apply to elective facility services, home health, durable medical equipment, and professional fees greater then $250. A complete listing of authorization requirements are outlined in the arelink Provider Manual located here. TAP members may NOT be referred to community providers for any service regardless of availability and timeliness within University Health System. = overed Benefit Benefit arelink TAP Abortions (funding only involving life endangerment, rape, and incest) Allergy Testing and Serum * Administration of Blood & Blood Plasma Amniocentesis Anesthetics, Admin. of Anesthesiology Bone Marrow Transplant* Botox (ophthalmology, urological and neurological rehab) (non-cosmetic) * Provider Hotline: 358-3719 - UniversityHealthSystem.com/areLink 1
= overed Benefit Benefit arelink TAP apsule endoscopy entral Supply items (JOBST stockings, ostomy supplies, dressing supplies). Dispensed in 30 day supply quantities. olonoscopy (once every 24 months for high risk patients, one every 10 years for all other patients age 50 and older) olonoscopy VIRTUAL for arelink A&B only Dental (Emergencies Only) Dermatology UV light * DEXA Scan Durable Medical Equipment (PAP / BPAP / O2) Education Emergency Services Endoscopic ultrasound Family Planning Genetic testing (limited to breast, ovarian and non-polyposis colon cancer) * Hospitalization Home Health IMRT Implantable automatic defibrillator * Immunization and Inoculations Immun. Suppressive Drugs Provider Hotline: 358-3719 - UniversityHealthSystem.com/areLink 2
= overed Benefit Benefit arelink TAP Insulin and Syringe IUDs * Intravascular ultrasound imaging Laboratory / Pathology Lithotripsy Low vision OT Magnetic Resonance Angiography Mammography Medical Transportation provided by UHS ambulance within UHS MOHS Surgery Mental Health Nuclear Medicine Nutritional/Dietetic ounseling Obstetrics Observations - Emergent - Non-emergent Diagnostics requiring observation (e.g. cardiac cath, angiograms) Office Visits/ onsultations Orthotics (diabetic shoes limited to one pair annually) Outpatient Surgery Outpatient Diagnostic Services Pediatric Services (newborn) Provider Hotline: 358-3719 - UniversityHealthSystem.com/areLink 3
= overed Benefit Benefit arelink TAP PET scans Pharmacy Physical Therapy Physician Services Podiatry Services Preventive are Prosthetic Devices Radiation Therapy Radiology Services Reconstructive Surgery (Medically Necessary) (Subsequent surgery and nipple tattooing following the initial reconstruction are not covered) Reduction Mammoplasty Rehabilitation (Short term) (i.e. P.T., O.T., Speech, ardiac Therapy) Sacral nerve stimulators (Interstim) * Sleep Studies Substance abuse DETOX & Residential Rehabilitation (must be referred by UHS) TMJ Diag. & Medically necessary correction Transesophageal echos Ultrasonic bone stimulator (electronic) * Urgent are Provider Hotline: 358-3719 - UniversityHealthSystem.com/areLink 4
= overed Benefit Benefit arelink TAP Urological robotic assisted surgery * Vision are - Implanted lenses (cataract and keratonius surgery) Vision are - Diabetic annual screening and eye health *Pre-authorized and meeting specific criteria **Medical and Administrative review prior to consideration THE FOLLOWING SERVIES ARE NOT OVERED FOR ANY PROGRAM. Acupuncture Anodine therapy Apnea Monitor Artificial Insemination Breast prosthesis (external) ustodial care lothing orrective appliances (hearing aids, cochlear implants) overage for surgical treatment of obesity. osmetic Surgery Dental Services - Non-emergent services and supplies for routine dental care, X-rays or exams, dental prostheses, and treatment of teeth or periodontium (no braces, implants, or dentures and alveoplasty and alveolectomy). Durable medical equipment canes, walkers, wheelchairs, feeding pumps, hospital beds. Treatment of Erectile Dysfunction (to include medications, pumps and other appliances) Experimental procedures or services Eyeglasses and eye surgery such as radial keratotomy, when the primary purpose is to correct myopia (nearsightedness), hyperopia (farsightedness or astigmatism such as blurring). Eye examinations and refractions for the sole purpose of evaluation and dispensing of a prescription for eye glasses or contact lens. Hospice Humidifiers Infertility diagnosis and treatment Marriage ounseling Multi-sleep latency test for narcolepsy Norplant Oral prosthesis for sleep apnea Solid Organ Transplants (may be provided by University Hospital if approved by Transplant team) Personal comfort and convenience items and services Sex hanges Provider Hotline: 358-3719 - UniversityHealthSystem.com/areLink 5
THE FOLLOWING SERVIES ARE NOT OVERED FOR ANY PROGRAM. Skilled Nursing Facility Weight scales Workers ompensation, Insurance, and Third Party liability recoveries, Victims of rime and other funding sources. Vocational rehabilitation Rev 3/15 Provider Hotline: 358-3719 - UniversityHealthSystem.com/areLink 6