Service Authorization. February 2017
|
|
- Matthew Poole
- 5 years ago
- Views:
Transcription
1 Service Authorization February 2017
2 Overview Service Authorizations Identifying Service Authorizations Requirements Requesting Service Authorizations 2
3 Service Authorizations 3
4 Service Authorization Certain services, procedures, and medications covered by Alaska Medical Assistance require service authorization (SA) An SA is an authorization to provide a service to a member Some services require an SA before those services can be rendered Refer to section II of the billing manuals Refer to fee schedule Complete request accurately and completely SA does not guarantee payment 4
5 Identifying Service Authorizations Requirements 5
6 When To Get a Service Authorization Service authorizations may be required for whole categories of service or individual services/items depending on the type of service. Examples of each include: Categories of Service Outpatient imaging Enhanced adult dental procedures Transportation Hospital stays longer than three days Hospice Home health Behavioral health Waiver and PCA Individual Service or Item Certain hospital stays three days and less Specific surgical procedures Chiropractic services for children under six years old Some services in the following service categories: Child dental services Audiology services Physician services 6
7 Billing Manual Authorization Information 7
8 Fee Schedules Fee schedules tell you: What services are covered Maximum allowed reimbursement Additional documentation requirements Other special considerations Fee schedules can be found on in the Documents & Forms section under Fee Schedules. 8
9 Dental Fee Schedule Authorization Information 9
10 Authorization Requests 10
11 Authorization Request Coding Requirements Authorization Requests ICD-9 codes must be used for dates of service on or before 9/30/2015 ICD-10 codes must be used for dates of service on or after 10/1/2015 Service Authorization requests with service dates spanning 10/1/2015 must incorporate both ICD-9 and ICD-10 codes Behavioral Health Authorization Requests Treatment plan begin dates on or before 9/30/2015 must continue to be use DSM-IV-TR codes Treatment plan begin dates on or after 10/1/2015 must use ICD-10 diagnosis codes 11
12 Service Authorization Approving Agencies Each of the following agencies review and approve SA requests for specific services; refer to the appropriate billing manual for an explanation of the SA process: Conduent Magellan Medicaid Administration (MMA) Qualis Health Division of Senior and Disabilities Services (DSDS) 12
13 Services Authorized by Conduent Conduent authorizes these select professional/outpatient services: Air Ambulance (Medevacs and Backhauls) In-Office Injections (Some J-code drugs Behavioral Health Limited Surgical Procedures Chiropractic Care (Children Under 6) Maternal/Newborn Stays (Meeting Certain Criteria) Dental Nutrition Services Durable Medical Equipment/Supplies Private Duty Nursing Hearing Prosthetics and Orthotics Home Health Respiratory Therapy Home Infusion Services exceeding the established service limits Hospice Transportation (Emergency and Non-Emergent) Incontinence Supplies Vision 13
14 Services Authorized by Conduent Service authorizations can be requested through Conduent using the following options: Submitting an authorization request form by mail to: Service Authorization PO Box Anchorage, AK Submitting an authorization request form by fax to: Behavioral health request forms Dental request forms All other request forms All services must be requested on the correct service authorization request form Conduent service authorization forms are available at Always follow the instructions for completion and submission given on the forms 14
15 Service Authorization Request 15
16 Service Authorization Request 16
17 Services Authorized by Conduent Behavioral Health Mental health physician and community behavioral health clinic providers must request service authorizations for behavioral health treatment when the amount of services indicated exceeds the annual service limitations set out by Alaska Medical Assistance The behavioral health provider is responsible for keeping track of service limits for their members and submitting SA requests when the member s behavioral health treatment plan identifies the need for frequency and duration of services in excess of the daily or annual service limits 17
18 Services Authorized by Conduent Behavioral Health Behavioral health authorization requests must: Be documented in the clinical record Include a listing of AK Medicaid reimbursable services and expected duration of services as set forth in the treatment plan Affirm that the appropriate parties have reviewed the treatment plan and agree that the requested services are medically necessary Be submitted on the correct form for the requested service Community Behavioral Health Clinic Services Mental Health Physician Clinic Services Residential Behavioral Rehabilitation Services 18
19 Community Behavioral Health Services Request Providers should continue to use this SA request form to request services under 12 hours per day 19
20 Community Behavioral Health Services Request 20
21 Community Behavioral Health Services Request 21
22 Community Behavioral Health Services Request Providers should use this new form to request services that go beyond the allowed limits of 12 hours per day. Refer to the accompanying guidance document for more details. 22
23 Community Behavioral Health Services Request 23
24 Community Behavioral Health Services Request 24
25 Community Behavioral Health Services Request 25
26 Mental Health Physician Clinic Request 26
27 Mental Health Physician Clinic Request 27
28 Residential Behavioral Rehabilitation Services Request 28
29 Residential Behavioral Rehabilitation Services Request 29
30 Residential Behavioral Rehabilitation Services Request 30
31 Services Authorized by Conduent Conduent and Qualis share responsibility for authorizing certain maternal and newborn admissions. 31
32 Services Authorized by Conduent CMN Use a Certificate of Medical Necessity (CMN) or CMN for Incontinence Supplies to request an authorization for the following services or items: Durable Medical Equipment / Supplies Hearing Aids / Accessories Home Infusion Incontinence Supplies Nutrition Services Prosthetics and Orthotics Respiratory Therapy (Oxygen Equipment, etc.) Any services exceeding the established or approved service limits if the initial authorization required a CMN 32
33 Services Authorized by Conduent CMN 33
34 Services Authorized by Conduent CMN 34
35 Services Authorized by Conduent CMN 35
36 Services Authorized by Conduent CMN 36
37 Services Authorized by Conduent Incontinence 37
38 Services Authorized by Conduent Incontinence 38
39 Services Authorized by Conduent Incontinence 39
40 Services Authorized by Conduent - Transportation Emergency Transportation Alaska Medical Assistance covers emergency medical transportation to the nearest medical facility capable of handling that medical emergency IHS beneficiaries may choose to travel to the nearest IHS or Tribal facility Authorization for emergent services are made retroactively Medevac Reimbursements Submit medical justification and all required flight documentation within two business days of the member s transport date Complete Air Ambulance Flight Summary and attach to claim form Available at 40
41 Services Authorized by Conduent - Transportation Non-emergent transportation and accommodation can be submitted by: Alaska Medicaid Health Enterprise Website or Calling , option 5 or , option 1, 2 Have member s information available for request: Alaska Medical Assistance ID number First name Last name Date of birth Address, including city, state and zip code Referring and receiving providers Reason for travel Diagnosis Origin and destination Escort information - first and last name, date of birth, reason escort is needed 41
42 Transportation Request 42
43 Transportation Request 43
44 Transportation Request 44
45 Services Authorized by Conduent Surgeries Most surgical procedures are authorized by Qualis Health Any surgical procedure requiring a service authorization that is not on the Qualis Health Pre-Certification list, such as rhinoplasty and blepharoplasty, is authorized by Conduent The surgeon and the facility must be enrolled with Alaska Medical Assistance 45
46 Services Authorized by Conduent Dental The following services require authorization requests for dental: All enhanced adult dental services Prosthodontics Orthodontia Certain children s and adult emergent dental services These are identified in the Dental Fee Schedule 46
47 Dental Service Authorization Request 47
48 Vision Service Authorization Request 48
49 Attachment Requirements Many authorization requests require additional supporting documentation before they can be approved. Examples of supporting documentation could be: Prescription Therapist assessment and/or plan of care Clinical notes or letter of medical need Pricing information Documentation requirements may be found in associated billing manuals and fee schedules Attach all relevant documentation to the initial request to expedite the authorization process 49
50 Updating Conduent Service Authorizations When the information on the SA does not match the services provided, you will need to update the SA before submitting your claim. Authorization Type Transportation Behavioral Health Dental All Others Actions Needed Fax Transportation Authorization Update Form or contact Travel SA Dept. Submit a new form with total needed units, check the Update to Existing SA block and include the SA number. Fax requested changes to Dental SA Dept. Submit original approved authorization form with needed changes and required justification. Dental authorization changes must include: Additional or adjusted services needed with supporting documentation Reason(s) treatment could not be completed within the original dates, if extending a longterm treatment plan (such as orthodontic services) New estimated date for completion and any documentation to support extending the length of treatment 50
51 Updating Conduent Service Authorizations 51
52 Dental SA Update Request 52
53 Service Authorization Request Processing When authorization requests are received, Conduent reviews: Member eligibility and provider enrollment Requested services and units Any medical justification and supporting documentation History of current and previous authorizations, including any service limits Authorization is approved, denied, or pended (if additional information is needed) Copy of authorization decision is forwarded to provider listed on the SA request 53
54 Services Authorized by Magellan Magellan Medicaid Administration (MMA) oversees the pharmacy program including service authorizations and billing. Certain medications require an authorization to be covered by Alaska Medical Assistance The Division of Health Care Services maintains the Prior Authorized Drug List and Interim Prior Authorized Drug List Drug lists and authorization forms are available online at SA forms can also be requested from MMA Only the prescriber may request medications, unless otherwise indicated on the either listing, by: calling the MMA Clinical Call Center at or faxing the appropriate completed request form to
55 Prior Authorization Medication List by Category 55
56 Preferred Drug List 56
57 Services Authorized by Qualis Health Qualis Health authorizes certain facility stays, procedures, and outpatient imaging as part of utilization management for Alaska Medical Assistance. Inpatient acute care hospital admissions exceeding three days Long-term acute care facility admissions and continued stays Inpatient and Residential psychiatric services Outpatient imaging Magnetic resonance imaging (MRI) Positron emission tomography (PET) Magnetic resonance angiography (MRA) Single-photon emission computed tomography (SPECT) Select inpatient and outpatient diagnoses, procedures, and transplants, regardless of length of stay Identified in Select Diagnoses and Procedures Pre-certification List and Outpatient Imaging, available under Review Guidelines at 57
58 Services Authorized by Qualis Health Three-Day Stay Guidelines (Inpatient Hospital) A medical necessity review must be obtained if patient is not discharged by the third day (day of admission is day one) Review must occur on or before day four of the stay Only exception to standard three-day stay guidelines are maternal and newborn stays related to childbirth 58
59 Qualis Health Contact Qualis business hours are 6:30am 5:00pm AKST, Monday Friday, excluding scheduled holidays. Qualis Health Provider Portal (QHPP), a secured web-based utilization review system providers must use to submit review requests For more information, refer to Utilization Review Phone: Fax: Physician Hotline (Peer-to-Peer Conversations)
60 Qualis Health Review Submission Deadlines Providers must use the QHPP to submit review requests Untimely review requests will not be considered unless extenuating circumstances exist. Providers must adhere to the following submission deadlines: Review Type Pre-service Urgent review* Submission Deadline Within 1 working day of service begin date Pre-service Non-urgent review* Minimum 7 calendar days prior to scheduled service date and up to 4 weeks prior Concurrent Urgent review* (inpatient only) Concurrent Non-urgent review* (inpatient only) On or before 4 th day after admission and/or intervals determined by Qualis after initial concurrent review On or before 4 th day after admission; non-urgent concurrent reviews are generally limited to one extension up to 15 days as determined by Qualis Retrospective Review As soon as eligibility is established up to 365 calendar days from service begin date; contact Qualis for request instructions if greater than 365 days from service begin date *Deadlines still apply for weekend and holiday requests, including emergency admissions. 60
61 Qualis Health Review Determinations Review Type Pre-service Urgent review Pre-service Non-urgent review Concurrent Urgent review Concurrent Non-urgent review Retrospective Review Determination Timeframe 3 calendar days 15 calendar days 3 calendar days 3 calendar days 30 calendar days Timelines are based on reviews where all necessary clinical information has been received and no referral for clinical peer review is needed When additional information is required to complete the review, the timeline is adjusted accordingly Urgent reviews are performed when a case involves urgent care and the time required for non-urgent review could: Seriously jeopardize the member s life, health or their ability to regain maximum function Subject the member to severe pain that could not be adequately managed without requested treatment 61
62 Qualis Health Peer-to-Peer Conversation When a non-certification decision is made, providers may request a peer-to-peer conversation with Qualis staff Peer-to-peer conversation allows the attending provider the opportunity to discuss the request and possibly prevent the need to appeal The attending physician must call Qualis Health Physician Hotline at by 5:00 pm AKST the day following notification of the potential non-certification If not able to call within this timeframe, notify Qualis Health within the timeframe to request an extension 62
63 Division of Senior and Disabilities Services Long-term care admission and level of care determination Swing bed and administrative-wait beds Personal Care Attendant services Waiver services DSDS forms are available at Contact for further information: Anchorage office at or (toll-free) Juneau office at or (toll-free) Fairbanks office at or (toll-free) 63
64 Authorization Request Common Errors Common errors made on SA requests include: No date(s) of service indicated Invalid procedure codes Missing attachments Insufficient details provided Failure to verify eligibility for the date of service Retroactive services do not meet criteria SA requested for service that does not require SA Incorrect form used 64
65 Additional Resources Alaska Medicaid Health Enterprise website at Information necessary for successful billing Includes provider-specific Medicaid billing manuals and fee schedules You may also call: Eligibility only , Option 1,2 or (toll-free), Option 1,1,2 All other inquiries , Option 1,1 or (toll-free), Option 1,1,1 66
66 2016 Conduent Business Services, LLC. All rights reserved. Conduent and Conduent Design are trademarks of Conduent Business Services, LLC in the United States and/or other countries.
Appeal Process Information
First-Level Appeals Appeal Process Information Regulation 7 AAC 105.270 stipulates the length of time a provider has to submit a first-level appeal. Most firstlevel appeals must be filed within 180 days
More informationChoice PPO Retired Employees Health Program Non-Medicare Eligible Retired Members
Choice PPO Retired Employees Health Program Non-Medicare Eligible Retired Members DEDUCTIBLE (per calendar year) Annual in-network deductible must be paid first for the following services: Imaging, hospital
More informationPassport Advantage Provider Manual Section 5.0 Utilization Management
Passport Advantage Provider Manual Section 5.0 Utilization Management Table of Contents 5.1 Utilization Management 5.2 Review Criteria 5.3 Prior Authorization Requirements 5.4 Organization Determinations
More informationSection 4 - Referrals and Authorizations: UM Department
Section 4 - Referrals and Authorizations: UM Department Primary Care Referral Process 1 Referrals to In-Network Specialists 1 Referrals to Out-Of-Network Specialists 2 Consultation Referral Forms 2 Consultation
More informationManaged Care Referrals and Authorizations (Central Region Products)
In this section Page Overview of Referrals and Authorizations 10.1 Referrals 10.1! Referrals: SelectBlue only 10.1! Definition of referrals 10.1! Services not requiring a referral 10.1! Who can issue a
More informationUTILIZATION MANAGEMENT AND CARE COORDINATION Section 8
Overview The focus of WellCare s Utilization Management (UM) Program is to provide members access to quality care and to monitor the appropriate utilization of services. WellCare s UM Program has five
More informationPrivate Duty Nursing. May 2017
Private Duty Nursing May 2017 Overview Provider Enrollment Member Eligibility Private Duty Nursing Services Specialized Private Duty Nursing Services Billing Additional Information 2 Provider Enrollment
More informationKDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance. UM Retrospective Review Services.
KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance UM Retrospective Review Services Provider Manual August 2017 This page intentionally blank Table of Contents KDHE-DHCF:
More informationProvider Manual Section 7.0 Benefit Summary and
Provider Manual Section 7.0 Benefit Summary and Exclusions Table of Contents 7.1 Benefit Summary 7.2 Services Covered Outside Passport Health Plan 7.3 Non-Covered Services Page 1 of 7 7.0 Benefit Summary
More informationColoradoPAR Program Durable Medical Equipment. August 2015
ColoradoPAR Program Durable Medical Equipment August 2015 Agenda Introduction to eqhealth Solutions Scope of Services Overview of the PAR process eqsuite Contacts and resources at eqhealth Solutions Key
More informationHOME BANK - S2395 NON-GRANDFATHERED CONSUMER DRIVEN HEALTH PLAN BENEFIT SHEET
CONSUMER DRIVEN HEALTH PLAN BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 180 days from incurred Filing Limit date, except when 180 days would
More informationHOW TO GET SPECIALTY CARE AND REFERRALS
THE BELOW SECTIONS OF YOUR MEMBER HANDBOOK HAVE BEEN REVISED TO READ AS FOLLOWS HOW TO GET SPECIALTY CARE AND REFERRALS If you need care that your PCP cannot give, he or she will REFER you to a specialist
More informationCentennial Care Provider Notification Grid
Page 1 of 5 Ablative Procedure for Venous Insufficiency & Varicose Veins Accredited Residential Treatment Center (ARTC) Acute Inpatient Medical (incl. Detoxification services & LTACH)) Acute Inpatient
More informationWILLIS KNIGHTON MEDICAL CENTER S2763 NON GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Customized COB Dependents Children birth to 26 Filing Limit 12 months For employees that work in a WKHS location within the primary HealthPlus
More informationState of Alaska Department of Health and Social Services. Behavioral Health Inpatient Psychiatric Review Provider Manual
State of Alaska Department of Health and Social Services Behavioral Health Inpatient Psychiatric Review Provider Manual Revised October 2015 Alaska Medicaid Inpatient Psychiatric Review Provider ManualTable
More informationHOW TO GET SPECIALTY CARE AND REFERRALS
THE BELOW SECTIONS OF YOUR MEMBER HANDBOOK HAVE BEEN REVISED TO READ AS FOLLOWS HOW TO GET SPECIALTY CARE AND REFERRALS If you need care that your PCP cannot give, he or she will refer you to a specialist
More informationState of Alaska Department of Health and Social Services. Community-Based Youth Residential Behavioral Health Services Review Provider Manual
State of Alaska Department of Health and Social Services Community-Based Youth Residential Behavioral Health Services Review Provider Manual February 2018 TABLE OF CONTENTS Section 1: Qualis Health Care
More informationMedical Management Program
Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent Fraud, Waste and Abuse in its programs. The Molina
More informationMolina Healthcare MyCare Ohio Prior Authorizations
Molina Healthcare MyCare Ohio Prior Authorizations Agenda Eligibility Medicare Passive Enrollment Transition of Care Definition Submission Time Frame Standard vs. Urgent How to Submit a Prior Authorization
More informationSection 7. Medical Management Program
Section 7. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs.
More informationPreauthorization Program Effective Date: 01/01/2015 PPO, COMP, POS
SERVICES REQUIRING PREAUTHORIZATION Members should present their identification card to their health care provider when medical services or items are requested. When members use a participating provider
More informationSuper Blue Plus 2000 WVHTC High Option-B (Non-Grandfathered) $200 Deductible
BENEFIT HIGHLIGHTS 1 Super Blue Plus 2000 WVHTC High Option-B (Non-Grandfathered) $200 Group Effective Date December 1, 2017 Benefit Period (used for and Coinsurance limits) January 1 through December
More informationMedicare Advantage 2014 Precertification Requirements
Medicare Advantage 2014 Precertification Requirements (Effective for Jan 1, 2014 to June 30, 2014) The precertification requirements filed with the Centers for Medicare & Medicaid Services remain in effect
More informationBlue Shield $0 Cost-Share HMO AI-AN
Blue Shield $0 Cost-Share HMO AI-AN This plan is only available to eligible Native Americans 1 Uniform Health Plan Benefits and Coverage Matrix Blue Shield of California Effective January 1, 2017 THIS
More informationMolina Healthcare of Illinois Prior Authorization Codification List Q ILUM182.1
Q3-2018 ILUM182.1 MOLINA HEALTHCARE OF ILLINOIS 2018 PRIOR AUTHORIZATION CODIFICATION LIST The Molina Healthcare of Illinois (Molina) is reviewed for updates quarterly, or as deemed necessary to meet the
More informationPlace of Service Code Description Conversion
Place of Conversion CMS Place of Code Place of Name The place of service field indicates where the services were performed Possible values include: Code Description Inpatient Outpatient Office Home 5 Independent
More informationPeachCare for Kids. Handbook
PeachCare for Kids Handbook Table of Contents What is PeachCare for Kids?...2 Who is eligible?...3 How do you apply for PeachCare for Kids?...3 Who will be your child s primary doctor?...4 Your child s
More informationMolina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800)
Utilization Management Program Molina Healthcare of Michigan s Utilization Management (UM) program utilizes a care management approach based upon empirically validated best practices, where experience
More informationStanislaus County Medical Benefits EPO Option. In-Network Benefits (Stanislaus County Partners in Out-of-Network Benefits
Stanislaus County Medical EPO Option The following summary of benefits is a brief outline of the maximum amounts or special limits that may apply to benefits payable under the Plan. For a detailed description
More informationCovered Benefits Matrix for Children
Medicaid Managed Care The matrix below lists the available for children (under age 21) enrolled in the West Virginia Mountain Health Trust and s. Ambulance Ambulatory surgical center services Some services
More informationCalifornia Children s Services (CCS) Program Medi-Cal Managed Care CCS Whole-Child Model Comparison Chart January 6, 2016
California Children s Services (CCS) Program Medi-Cal Managed Care CCS Whole-Child Model Comparison Chart January 6, 2016 Authorization for Services Plan to adjudicate authorization request. Authorization
More informationHMSA Physical and Occupational Therapy Utilization Management Guide
HMSA Physical and Occupational Therapy Utilization Management Guide Published November 1, 2010 An Independent Licensee of the Blue Cross and Blue Shield Association Landmark's provider materials are available
More informationPhysician, Advanced Nurse Practitioner & Physician Assistant. January 2017
Physician, Advanced Nurse Practitioner & Physician Assistant January 2017 Overview Enrollment requirements Member information Covered and non-covered services Service authorization Reimbursement Claims
More informationSummary of Benefits CCPOA (Basic) Custom Access+ HMO
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits CCPOA (Basic) Custom Access+ HMO CCPOA Effective January 1, 2019 HMO Benefit Plan This Summary of Benefits
More informationDME Services Provider Manual. Effective Date: December 1, 2013
DME Services Provider Manual Effective Date: December 1, 2013 Revised Date: January 2017 Provider Manual Mississippi Division Table of Contents I. Introduction II. III. IV. Getting Started Helpful Tips
More informationState of Montana. Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES
State of Montana Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES FOR UTILIZATION MANAGEMENT January 31, 2013 Children s Mental Health
More informationMyHPN Solutions HMO Gold 7
MyHPN Solutions HMO Gold 7 HIOS ID: 95865NV0030074 Attachment A Benefit Schedule Calendar Year Deductible (CYD): $3,000 of EME per Member and $6,000 of EME per family. The Calendar Year Out of Pocket Maximum
More informationRSNA EMPLOYEE BENEFIT TRUST PLAN II S2502 NON GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to age 26 Filing Limit 1 year from date of service Mailing Address & PPO Company. Remit claims to:
More informationKY Medicaid Co-pays Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following:
This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant
More informationRE: Important Information Regarding Prior Authorization for High Tech Imaging Services
Name Address City, St Zip RE: Important Information Regarding Prior Authorization for High Tech Imaging Services Dear Provider: Blue Cross and Blue Shield of Louisiana and HMO of Louisiana, Inc., (HMOLA),
More informationBlue Care Network Physical & Occupational Therapy Utilization Management Guide
Blue Care Network Physical & Occupational Therapy Utilization Management Guide (Also applies to physical medicine services by chiropractors) January 2016 Table of Contents Program Overview... 1 Physical
More informationBlue Shield Gold 80 HMO
Blue Shield Gold 80 HMO Uniform Health Plan Benefits and Coverage Matrix Blue Shield of California Effective January 1, 2017 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND
More informationBest Practice Recommendation for
Best Practice Recommendation for Standard Notification Timeframes for Pre-Authorization Requests Version 4.6 Admin Simplification: A program of the Washington Healthcare Forum operated by OneHealthPort
More informationKY Medicaid Co-pays. Acute admissions medical Per admission diagnoses $0 Acute health care related to. Per admission substance abuse and/or for
This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant
More informationThe MITRE Corporation Plan
Benefit Type Plan Year Type Calendar Year Annual Medical Out of (for certain services) Employee Employee + 1 Family Annual Prescription Drug Out of Employee Employee + 1 Family Copayments: One copay per
More informationSummary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000
Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000 Group Plan PPO Savings Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this
More informationCA 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
More informationCONRAD INDUSTRIES, INC. S2489 NON GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children to age 26 Filing Limit 12 months from date of service Mailing Address & PPO Company. PPO Co.: PPO CIGNA
More informationCovered Services List and Referrals and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice
Covered Services Covered Services List and s and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice This chart tells you two things: 1. the covered services and benefits
More informationStandardized Prior Authorization Form Instructions
Standardized Prior Authorization Form Instructions The Standardized one-page Prior Authorization Request Form is to be used by all NH Medicaid Fee for Service (FFS) and Managed Care Organization (MCO)
More informationBlue Shield of California
An independent member of the Blue Shield Association City of San Jose Custom ASO PPO 100 90/70 Active Employees Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage
More informationCorCare PPO Provider Manual. Updated 12/19/2016
CorCare PPO Provider Manual 2017 Updated 12/19/2016 TABLE OF CONTENTS TABLE OF CONTENTS 1. Summary of Procedures, Resources, Claims Submissions... 3 2. Claims Completion... 4 3. Prepayment and Balanced
More informationEVIDENCE-BASED HEALTHCARE SOLUTIONS. CareCore National. Frequently Asked Questions Prepared for. Prepared for. October 23, 2009
EVIDENCE-BASED HEALTHCARE SOLUTIONS CareCore National Musculoskeletal CARECORE NATIONAL Management RADIOLOGY Program Physical BENEFIT Medicine MANAGEMENT and Therapy PROPOSAL Prepared for Prepared for
More informationSECTION 9 Referrals and Authorizations
SECTION 9 Referrals and Authorizations General Information The PAMF Utilization Management (UM) Program is carried out by the Managed Care department. The UM Program is designed to ensure that all Members
More informationServices That Require Prior Authorization
Services That Require Prior Authorization Some of the services listed in the Medical Benefits Chart are covered only if your doctor or other network provider gets approval in advance (sometimes called
More informationNEIGHBORHOOD HEALTH PARTNERSHIP POS SUMMARY OF BENEFITS
XV-2 $30/$60/$200/$1,000/80% R NEIGHBORHOOD HEALTH PARTNERSHIP POS SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to the Point of Service (POS) Plan you have with Neighborhood
More informationHome address City State ZIP Code
Member Appeal Form Date of Request PATIENT INFORMATION Last name First name MI Member ID # Date of birth (MM/DD/YYYY) Name of representative pursuing appeal, if different from above (See instructions,
More informationSummary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx]
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx] Group Plan HMO Benefit
More informationHMO West Pennsylvania Employees Benefit Trust Fund Benefit Highlights Active Eligible Members. Providers None $6,850 single / $13,700 family
Benefit Provision HMO Network Providers None $6,850 single / $13,700 family DEDUCTIBLE (Per Calendar Year) OUT-OF-POCKET MAXIMUM (includes costs for medical, mental health and substance abuse benefits
More informationCovered Services List
CAREPLUS Covered Services List For CeltiCare Health with MassHealth CarePlus Coverage This is a list of all covered services and benefits for MassHealth CarePlus enrolled in CeltiCare Health. The list
More informationBenefits. Benefits Covered by UnitedHealthcare Community Plan
Benefits Covered by UnitedHealthcare Community Plan As a member of UnitedHealthcare Community Plan, you are covered for the following MO HealthNet Managed Care services. (Remember to always show your current
More informationMedi-Cal Program. Benefit. Benefits Chart
Chart Please note that the table below is only a summary. More details about benefits can be found in the section of the Medi-Cal Evidence of Coverage booklet. All health care is arranged through your
More informationRFS-7-62 ATTACHMENT E INDIANA CARE SELECT PROGRAM DESCRIPTION AND COVERED BENEFITS
The following services are covered by the Indiana Care Select Program. Dual-eligible members, those members eligible for both IHCP and Medicare, will not receive any benefits under Indiana Care Select,
More informationBlue Shield High Deductible Plan
Blue Shield High Deductible Plan Benefit Booklet Stanford University Group Number: 170293, 976184 & 976185 Effective Date: January 1, 2014 An independent member of the Blue Shield Association Claims Administered
More informationPA/MND Review of Spine Surgery services Questions & Answers
PA/MND Review of Spine Surgery services Questions & Answers 1. What is the Musculoskeletal Program? Horizon BCBSNJ has expanded our Pain Management Program with evicore to include Pain Management and Spine
More informationPlan Overview. Health Net Platinum 90 HSP. Benefit description Member(s) responsibility 1,2
PureCare HSP is available through Covered CA in Kings, Madera, Sacramento, and Yolo counties, and parts of El Dorado, Fresno, Nevada, Placer, and Santa Clara counties. Plan Overview Health Net Platinum
More informationSummary of Benefits Platinum Full PPO 0/10 OffEx
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum Full PPO 0/10 OffEx Group Plan PPO Benefit Plan This Summary of Benefits shows the amount
More informationMississippi Medicaid Inpatient Services Provider Manual
Mississippi Medicaid Inpatient Services Provider Manual Effective Date: November 2015 Revised: June 2016 Inpatient Services Provider Manual Introduction eqhealth Solutions (eqhealth) is the Utilization
More information2018 Authorization and Notification Requirements Medical Services
2018 Authorization and Notification Requirements Medical Services For the following plans: MSHO=Minnesota Senior Health Options MSC Plus=Minnesota Senior Care Plus Connect=Special Needs BasicCare Connect
More informationGold Access+ HMO 500/35 OffEx
An Independent Member of the Blue Shield Association Gold Access+ HMO 500/35 OffEx Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective
More informationCovered Benefits Matrix for Adults
Medicaid Managed Care The matrix below lists the available for adults (age 21 and older) enrolled in the West Virginia Mountain Health Trust and s. Ambulance Ambulatory surgical center services Some services
More informationPROVIDER APPEALS PROCEDURE
PROVIDER APPEALS PROCEDURE 1. The Provider or his/her designee may request an appeal in writing within 365 days of the date of service 2. Detailed information and supporting written documentation should
More informationAMERICAN INDIAN 638 CLINICS PROVIDER MANUAL Chapter Thirty-nine of the Medicaid Services Manual
AMERICAN INDIAN 638 CLINICS PROVIDER MANUAL Chapter Thirty-nine of the Medicaid Services Manual Issued December 1, 2009 Claims/authorizations for dates of service on or after October 1, 2015 must use the
More informationState of Montana. Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES
State of Montana Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES FOR UTILIZATION MANAGEMENT October 1, 2012 Children s Mental Health
More informationPlatinum Trio ACO HMO 0/20 OffEx
Platinum Trio ACO HMO 0/20 OffEx Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2017 THIS MATRIX IS INTENDED TO
More informationDepartment of Healthcare and Family Services (HFS) Medical and Dental Services
Department of Healthcare and Family Services (HFS) Medical and Dental Services Accessing Medical Services This presentation is designed to provide a general overview of Medical Assistance Program services
More informationIrvine Unified School District ASO PPO /50
An Independent member of the Blue Shield Association Irvine Unified School District ASO PPO 500 90/50 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) THIS
More informationKaiser Permanente Group Plan 301 Benefit and Payment Chart
301 Kaiser Permanente Group Plan 301 Benefit and Payment Chart 10119 CITY AND COUNTY OF SAN FRANCISCO About this chart This benefit and payment chart: Is a summary of covered services and other benefits.
More informationIPA. IPA: Reviewed by: UM program. and makes utilization 2 N/A. Review) The IPA s UM. includes the. description. the program. 1.
IPA Delegation Oversight Annual Audit Tool 2011 IPA: Reviewed by: Review Date: NCQA UM 1: Utilization Management Structure The IPA clearly defines its structures and processes within its utilization management
More informationPLAN DESIGN AND BENEFITS - PA POS 4.2 with $5/$15/$30 RX PARTICIPATING PROVIDERS
PLAN FEATURES Deductible (per calendar year) PHYSICIAN SERVICES Primary Care Physician Visits Specialist Office Visits Maternity OB Visits Allergy Treatment Allergy Testing PREVENTIVE CARE Routine Adult
More informationServices Covered by Molina Healthcare
Services Covered by Molina Healthcare As a Molina Healthcare member, you will continue to receive all medically-necessary Medicaid-covered services at no cost to you. The following list of covered services
More informationMedical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management
G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services
More informationAetna Health of California, Inc.
Easily locate PrimeCare participating providers at www.aetna.com/docfind/primecare PLAN FEATURES Deductible (per calendar year) Member Coinsurance Lifetime Maximum Primary Care Physician Selection Referral
More informationSummary of Benefits Platinum Trio HMO 0/25 OffEx
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum Trio HMO 0/25 OffEx Group Plan HMO Benefit Plan This Summary of Benefits shows the amount
More informationUtilization Review Determination Time Frames
Utilization Review Time Frames The purpose of this chart is to reference utilization review (UR) determination time frames. It is not meant to completely outline the UR determination process. Refer to
More informationPrecertification: Overview
Precertification: Overview Introduction Precertification determines whether medical services are: Medically Necessary or Experimental/Investigational Provided in the appropriate setting or at the appropriate
More informationBlue Choice PPO SM Provider Manual - Preauthorization
In this Section Blue Choice PPO SM Provider Manual - The following topics are covered in this section. Topic Page Overview E 3 What Requires E 3 evicore Program E 3 Responsibility for E 3 When to Preauthorize
More informationHealthcare Eligibility Benefit Inquiry and Response. 270/ Companion Guide
Healthcare Eligibility Benefit Inquiry and Response 270/271 5010 Companion Guide Table of Contents Purpose...1 Contact Information...1 Preparation and Testing Requirements...1 System Availability...2 Batch
More informationCITY OF SLIDELL S2630 NON-GRANDFATHERED BENEFIT SHEET
CITY OF SLIDELL S2630 BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 No later than 365 days after the Filing Limit date expenses are incurred
More informationSchedule of Benefits
Schedule of Benefits ANTHEM Small Business Health Options Program (SHOP) This is a brief schedule of benefits. Refer to your Anthem Certificate of Coverage (Booklet) for complete details on benefits, conditions,
More informationHMSA Physical and Occupational Therapy Utilization Management Authorization Guide
HMSA Physical and Occupational Therapy Utilization Management Authorization Guide Published Landmark's provider materials are available online at www.landmarkhealthcare.com. The online Physical and Occupational
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO 20 (20/0%) EFFECTIVE JULY 1, 2017 These services are covered as indicated when authorized through your Primary Care Physician
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO Schedule of Benefits 20/0% These services are covered as indicated when authorized through your Primary Care
More informationWyoming Medicaid- Provider Services Updates. Provider Workshops Summer 2017
Wyoming Medicaid- Provider Services Updates Provider Workshops Summer 2017 Facilities Update TITLE 25- Involuntary Hospitalization Effective August 1, 2016- Wyoming Medicaid began processing Title 25 claims
More informationMEDICAL ASSISTANCE BULLETIN
MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE ISSUE DATE EFFECTIVE DATE NUMBER September 8, 1995 September 8, 1995 1153-95-01 SUBJECT Accessing Outpatient Wraparound
More informationMEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF PUBLIC WELFARE
MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF PUBLIC WELFARE SUBJECT BY NUMBER: ISSUE DATE: September 8, 1995 EFFECTIVE DATE: September 8, 1995 Mental Health Services Provided
More informationBlue Shield Gold 80 HMO 0/30 + Child Dental INF
Blue Shield Gold 80 HMO 0/30 + Child Dental INF Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2017 THIS MATRIX
More informationDean Health Plan Physical Medicine Overview
Dean Health Plan Physical Medicine Overview Provider Training / Presented by: Leta Genasci Above and throughout this document, NIA Magellan refers to National Imaging Associates, Inc. Dean Health Plan
More informationGIC Employees/Retirees without Medicare
GIC Active Employees & Retirees without Medicare 7/1/18 GIC Employees/Retirees without Medicare HMO Summary of Benefits Chart This chart provides a summary of key services offered by your Health New England
More informationServices Covered by Molina Healthcare
Services Covered by Molina Healthcare Because you are covered by Medicaid, you pay nothing for covered services. As a Molina Healthcare member, you will continue to receive all medically necessary Medicaid-covered
More information