T M A V e r s i o n TABLE OF CONTENTS PART AUTHORIZED PROVIDERS
|
|
|
- Patrick Cameron
- 5 years ago
- Views:
Transcription
1 (a) General. 1 (1) Listing of provider does not guarantee payment of 1 benefits. (2) Outside the United States or emergency situations 1 within the United States. (3) Dual Compensation/Conflict of Interest. 1 (4) [Reserved] 2 (5) Utilization review and quality assurance. 2 (6) Exclusion of beneficiary liability. 2 (7) Provider required. 2 (8) Participating providers. 2 (i) Mandatory participation. 2 (ii) Voluntary participation 3 (A) Total claims participation: The participating provider 3 program. (B) Claim-specific participation. 3 (iii) Claim-by-claim participation. 3 (9) Limitation to authorized institutional provider 3 designation. (10) Authorized provider. 3 (11) Balance billing limits. 3 (i) In general. 3 (ii) Waiver. 4 (iii) Compliance. 4 (12) Medical records. 4 (13) Participation agreements. 4 (14) Implementing instructions. 5 (15) Exclusion. 5 (b) Institutional providers 5 (1) General. 5 (i) Preauthorization. 6 (ii) Billing practices. 6 (2) Nondiscrimination policy. 6 (i) Emergency care. 6 (ii) Care rendered before finding of a violation. 6 (iii) Other facility not available. 6 Interim Final Rule/FR Vol 67, No 114 i C-10, June 13, 2002
2 (3) Procedures for qualifying as a CHAMPUS-approved institutional provider. 6 (i) JCAH accreditation status. 6 (ii) Required to comply with criteria. 7 (iii) Notice of peer review rights. 7 (iv) Surveying of facilities. 7 (v) Institutions not in compliance with CHAMPUS 7 standards. (vi) Participation agreements required for some hospitals which are not Medicare-participating. 7 (4) Categories of institutional providers. 7 (i) Hospitals, acute care, general and special. 7 (ii) Organ transplant centers. 8 (iii) Organ transplant consortia. 8 (iv) Hospitals, psychiatric. 8 (v) Hospitals, long-term (tuberculosis, chronic care, or 9 rehabilitation). (vi) Skilled nursing facility. 10 (vii) Residential treatment centers. 11 (A) Organization and administration. 11 (1) Definition. 11 (2) Eligibility. 11 (3) Governing body. 12 (4) Chief executive officer. 12 (5) Clinical Director. 12 (6) Medical director. 12 (7) Medical or professional staff organization. 13 (8) Personnel policies and records. 13 (9) Staff development. 13 (10) Fiscal accountability. 13 (11) Designated teaching facilities. 13 (12) Emergency reports and records. 13 (B) Treatment services. 13 (1) Staff composition. 13 (2) Staff qualifications. 13 (3) Patient rights. 13 Final Rule/FR Vol 67, No 122 ii
3 (4) Behavioral management. 14 (5) Admission process. 14 (6) Assessments. 14 (7) Clinical formulation. 14 (8) Treatment planning. 14 (9) Discharge and transition planning. 14 (10) Clinical documentation. 15 (11) Progress notes. 15 (12) Therapeutic services. 15 (13) Ancillary services. 15 (C) Standards for physical plant and environment. 15 (1) Physical environment. 15 (2) Physical plant safety. 15 (3) Disaster planning. 15 (D) Standards for evaluation system. 15 (1) Quality assessment and improvement. 16 (2) Utilization review. 16 (3) Patient records review. 16 (4) Drug utilization review. 16 (5) Risk management. 16 (6) Infection control. 16 (7) Safety. 16 (8) Facility evaluation. 16 (E) Participation agreement requirements. 16 (F) Other requirements applicable to RTCs. 18 (viii) Christian Science sanatoriums. 18 (ix) Infirmaries. 18 (x) Other special institution providers. 19 (A) General. 19 (B) Types of providers. 20 (1) Free-standing ambulatory surgical centers. 20 (2) [Reserved] 20 (xi) Birthing centers. 20 (A) Certification requirements. 20 (B) CHAMPUS birthing center standards. 21 Final Rule/FR Vol 67, No 122 iii
4 (1) Environment. 21 (2) Policies and procedures. 21 (3) Informed consent. 22 (4) Beneficiary care. 22 (5) Medical direction: 22 (6) Admission and emergency care criteria and 22 procedures. (7) Emergency treatment. 22 (8) Emergency medical transportation. 22 (9) Professional staff. 22 (10) Medical records. 22 (11) Quality assurance. 23 (12) Governance and administration. 23 (xii) Psychiatric partial hospitalization programs. 23 (A) Organization and administration. 23 (1) Definition. 23 (2) Eligibility. 23 (3) Governing body. 23 (4) Chief executive officer. 24 (5) Clinical Director. 24 (6) Medical director. 24 (7) Medical or professional staff organization. 24 (8) Personnel policies and records. 24 (9) Staff development. 24 (10) Fiscal accountability. 25 (11) Designated teaching facilities. 25 (12) Emergency reports and records. 25 (B) Treatment services. 25 (1) Staff composition. 25 (2) Staff qualifications. 25 (3) Patient rights. 25 (4) Behavioral management. 25 (5) Admission process. 26 (6) Assessments. 26 (7) Clinical formulation. 26 Final Rule/FR Vol 67, No 122 iv
5 (8) Treatment planning. 26 (9) Discharge and transition planning. 26 (10) Clinical documentation. 26 (11) Progress notes. 26 (12) Therapeutic services. 27 (13) Ancillary services. 27 (C) Standards for physical plant and environment. 27 (1) Physical environment. 27 (2) Physical plant safety. 27 (3) Disaster planning. 27 (D) Standards for evaluation system. 27 (1) Quality assessment and improvement. 27 (2) Utilization review. 27 (3) Patient records. 28 (4) Drug utilization review. 28 (5) Risk management. 28 (6) Infection control. 28 (7) Safety. 28 (8) Facility evaluation. 28 (E) Participation agreement requirements. 28 (F) Other requirements applicable to PHPs. 30 (xiii) Hospice programs. 30 (xiv) Substance use disorder rehabilitation facilities. 31 (A) Organization and administration. 31 (1) Definition of inpatient rehabilitation center. 32 (2) Definition of partial hospitalization center for the 32 treatment of substance use disorders. (3) Eligibility. 32 (4) Governing body. 33 (5) Chief executive officer. 33 (6) Clinical Director. 33 (7) Medical director. 34 (8) Medical or professional staff organization. 34 (9) Personnel policies and records. 34 (10) Staff development. 34 Final Rule/FR Vol 67, No 122 v
6 (11) Fiscal accountability. 34 (12) Designated teaching facilities. 34 (13) Emergency reports and records. 34 (B) Treatment services. 34 (1) Staff composition. 34 (2) Staff qualifications. 35 (3) Patient rights. 35 (4) Behavioral management. 35 (5) Admission process. 35 (6) Assessment. 35 (7) Clinical formulation. 35 (8) Treatment planning. 36 (9) Discharge and transition planning. 36 (10) Clinical documentation. 36 (11) Progress notes. 36 (12) Therapeutic services. 36 (13) Ancillary services. 36 (C) Standards for physical plant and environment. 37 (1) Physical environment. 37 (2) Physical plant safety. 37 (3) Disaster planning. 37 (D) Standards for evaluation system. 37 (1) Quality assessment and improvement. 37 (2) Utilization review. 37 (3) Patient records review. 37 (4) Drug utilization review. 37 (5) Risk management. 37 (6) Infection control. 37 (7) Safety. 38 (8) Facility evaluation. 38 (E) Participation agreement requirements. 38 (F) Other requirements applicable to substance use disorder rehabilitation facilities. 39 (xv) Home health agencies (HHAs). 39 Final Rule/FR Vol 67, No 122 vi
7 (c) Individual professional providers of care 41 (1) General 41 (i) Purpose. 41 (ii) Professional corporation affiliation or association 41 membership permitted. (iii) Scope of practice limitation. 41 (iv) Employee status exclusion. 42 (v) Training status exclusion. 42 (2) Conditions of authorization 42 (i) Professional license requirement. 42 (ii) Professional certification requirement. 42 (iii) Education, training and experience requirement. 42 (iv) Physician referral and supervision. 42 (3) Types of providers. 43 (i) Physicians. 43 (ii) Dentists. 43 (iii) Other allied health professionals. 43 (A) Clinical psychologist. 43 (B) Doctors of Optometry. 43 (C) Doctors of Podiatry or Surgical Chiropody. 43 (D) Certified nurse midwives. 43 (E) Certified nurse practitioner. 44 (F) Certified Clinical Social Worker. 44 (G) Certified psychiatric nurse specialist. 44 (H) Certified physician assistant. 45 (I) Anesthesiologist Assistant. 45 (J) Certified Registered Nurse Anesthetist (CRNA). 46 (K) Other individual paramedical providers. 46 (iv) Extramedical individual providers. 46 (A) Certified marriage and family therapists. 47 (B) Pastoral counselors. 48 (C) Mental health counselor. 49 (E) Christian Science practitioners and Christian Science nurses. 50 Final Rule/FR Vol 69, No 99 vii C-23, May 21, 2004
8 (d) Other providers. 50 (1) Independent laboratory. 50 (2) Suppliers of portable x-ray services. 50 (3) Pharmacies. 50 (4) Ambulance companies. 50 (5) Medical equipment firms, medical supply firms, and Durable Medical Equipment, Prosthetic, Orthotic, Supplies providers/suppliers. 51 (6) Mammography suppliers. 51 (e) Extended Care Health Option Providers. 51 (1) General. 51 (2) ECHO provider categories-- 51 (i) ECHO inpatient care provider. 51 (ii) ECHO outpatient care provider. 51 (iii) ECHO vendor. 51 (3) ECHO provider exclusion or suspension. 52 (f) Corporate services providers. 52 (1) General. 52 (2) Conditions of authorization. 53 (3) Transfer of participation agreement. 53 (4) Pricing and payment methodology: 54 (5) Termination of participation agreement. 54 Final Rule/FR Vol 69, No 161 viii C-25, August 20, 2004
T M A V e r s i o n TABLE OF CONTENTS PART DEFINITIONS
(a) General. 1 (b) Specific definitions. 1 Abortion. 1 Absent treatment. 1 Abuse. 1 Abused dependent. 1 Accidental injury. 2 Active duty. 2 Active duty member. 2 Activities of daily living. 2 Acupuncture.
Place 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
2018 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc.
2018 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc. Welcome from Kaiser Permanente It is our pleasure to welcome you as a contracted provider (Provider) participating under
(3) The limitations and exclusions listed here are in addition to those described in OAR and in each of the Division chapter 410 OARs.
410-120-1210 Medical Assistance Benefit Packages and Delivery System (1) The services clients are eligible to receive are based upon the benefit package for which they are eligible. Not all packages receive
KY 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
KY 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
Medicaid Benefits at a Glance
Medicaid Benefits at a Glance Mountain Health Trust Benefits Children (0 up to 21 years) Ambulatory Surgical Center Services Any distinct entity that operates exclusively for the purpose of providing surgical
FACT SHEET Payment Methodology
FACT SHEET 01-11 Payment Methodology What is CHAMPVA? CHAMPVA (the Civilian Health and Medical Program of the Department of Veterans Affairs) is a federal health benefits program administered by the Department
Payment Methodology. Acute Care Hospital - Inpatient Services
Grid Medi-Pak Advantage generally reimburses deemed providers the amount they would have received under Original Medicare for Medicare covered services, minus any amounts paid directly by Original Medicare
Provider Enrollment and Change Process Required Document Checklist
Provider Enrollment and Change Process Required Document Checklist Provider Classification To avoid processing delays gather these items before you get started. If applying to network, complete the application
SECTION 2: TEXAS MEDICAID REIMBURSEMENT
SECTION 2: TEXAS MEDICAID REIMBURSEMENT 2.1 Payment Information............................................................. 2-2 2.2 Reimbursement Methodology....................................................
Provider Enrollment and Change Process Required Document Checklist
Provider Enrollment and Change Process Required Document Checklist Provider Classification To avoid processing delays gather these items before you get started. If applying to network, complete the application
Medi-Pak Advantage: Reimbursement Methodology
Medi-Pak Advantage: Reimbursement Methodology The information located on the following pages is intended to summarize the reimbursement methodologies for Medi-Pak Advantage: Medi-Pak Advantage reimburses
Covered 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
Benefits. 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
Subject: Member Pre-Authorization Page 1 of 5
Subject: Member Pre-Authorization Page 1 of 5 Objective: I. To ensure appropriate utilization of Tuality Health Alliance (THA) resources, including the resource networks available through Providence Health
Place of Service Codes (POS) and Definitions
2950 Robertson Ave, Suite 200 Cincinnati, OH 45209 (P): 513-281-4400 www.medicalreimbursementinc.com www.linkedin.com/company/medical-reimbursement-inc www.twitter.com/medreimburse www.facebook.com/medicalreimbursementinc
RFS-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,
Blue Cross provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.
HOPE COLLEGE - HOURLY ORANGE 007013084/0011/0012/0013/0014/0015/0016/0017 Simply Blue PPO HSA ASC Effective Date: On or after July 2018 Benefits-at-a-glance This is intended as an easy-to-read summary
Bylaws. of the. Medical Staff. Crouse Health Hospital, Inc. including amendments approved through June 28, 2016
Bylaws of the Medical Staff of Crouse Health Hospital, Inc. including amendments approved through June 28, 2016 Crouse Health Hospital, Inc. 736 Irving Avenue, Syracuse, New York 13210 {H1058039.33} MEDICAL
The Healthy Michigan Plan Handbook
The Healthy Michigan Plan Handbook Introduction The Healthy Michigan Plan is a health care program through the Michigan Department of Community Health (MDCH). The Healthy Michigan Plan provides health
TRICARE: Mental Health and Substance Use Disorder Treatment for Child and Adolescent Beneficiaries
TRICARE: Mental Health and Substance Use Disorder Treatment for Child and Adolescent Beneficiaries Clinical Support Division Condition-Based Specialty Care Section June 24, 2015 Medically Ready Force Ready
CHAPTER 26. Rules and Regulations for Medicaid. Covered Services
CHAPTER 26 Rules and Regulations for Medicaid Covered Services Section 1. Authority. This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W. S.
EMERGENCY RULES SFY 2013 REIMBURSEMENT RATE REDUCTIONS
EMERGENCY RULES SFY 2013 REIMBURSEMENT RATE REDUCTIONS In order to avoid a budget deficit in the Medicaid Program, the Department of Health and Hospitals has published Emergency Rules which will: 1) reduce
Central Care Plan Medical and Prescription Plan Comparison Grid
Medical Plan Carrier/Network Annual Deductible (Benefit Plan Year: 7/1-6/30) Coinsurance (Percent Copays) Note: Coinsurance s apply once the has been met. Flat Dollar Copays Central Care Plan $200 per
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
WORK PROCESS DOCUMENT NAME: Medical Necessity Review for Behavioral Health and Substance Use Disorder REPLACES DOCUMENT: RETIRED:
PAGE: 1 of 7 SCOPE: Coordinated Care Departments for Behavioral Health and Substance Use Disorder (SUD) Reviews for members enrolled in Integrated Managed Care and Behavioral Health Services Only PURPOSE:
Central Care Plan Medical and Prescription Plan Comparison Grid
Medical Plan Carrier/Network Annual Deductible (Benefit Plan Year: 7/1 6/30) Coinsurance (Percent Copays) Note: Coinsurance amounts apply once the has been met. Flat Dollar Copays $400 per member $800
CAH PREPARATION ON-SITE VISIT
CAH PREPARATION ON-SITE VISIT Illinois Department of Public Health, Center for Rural Health This day is yours and can be flexible to the timetable of hospital staff. An additional visit can also be arranged
Highlights of Program Integrity Provisions Managed Care Delivery System Subcommittee June 9, 2011
Patient Protection and Affordable Care Act: Highlights of Program Integrity Provisions Managed Care Delivery System Subcommittee June 9, 2011 1 Provider Screening and Other Enrollment Requirements Provider
Provider 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
Medicaid Fundamentals. John O Brien Senior Advisor SAMHSA
Medicaid Fundamentals John O Brien Senior Advisor SAMHSA Medicaid Fundamentals Provides medical benefits to groups of low-income people with no medical insurance or inadequate medical insurance. Federally
What Does Medicaid Do?
Page 1 of 5 Texas Department of Health What Does Medicaid Do? Table 4.1 Medicaid Eligibility in Texas: 1998 TANF-Related Categories (dollar amounts = maximum income limit for eligibility: asset cap: $2000)
SERVICES COVERAGE LIMITS/ EXCLUSIONS Alcohol, Drug, and Substance Abuse Services
SERVICES COVERAGE LIMITS/ EXCLUSIONS Alcohol, Drug, and Substance Abuse Services Alcohol, drug, and substance abuse treatment services are provided by the Department of Alcohol and Other Drug Abuse Services
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
Institutional Handbook of Operating Procedures Policy
Section: Clinical Policies Subject: General Procedures Institutional Handbook of Operating Procedures Policy 09.13.09 Responsible Vice President: EVP and CEO Health System Responsible Entity: UTMB Health
MMA Benefits at a Glance
MMA Benefits at a Glance You must get covered services by providers that are part of the Molina plan. You must also make sure that approval is obtained if needed. Ambulance Art Therapy Assistive Care Services
Stanislaus 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
WHAT DOES MEDICALLY NECESSARY MEAN?
WHAT DOES MEDICALLY NECESSARY MEAN? Your Primary Care Provider (PCP) will help you get the services you need that are medically necessary as defined below. Medically Necessary means appropriate and necessary
Benefits Why AmeriHealth Caritas VIP Care Plus Was Created
Benefits Benefits Why AmeriHealth Caritas VIP Care Plus Was Created The Medicare Medicaid Plan, AmeriHealth Caritas VIP Care Plus, was created to coordinate Medicare and Medicaid services, simplify the
Member s Responsibility: Deductible, Copays, Coinsurance and Maximums
Benefits-at-a-Glance for GradCare 2018 This is intended as an easy-to-read summary. It is not a contract. Refer to the Your Benefits chapter in the Certificate for an official description of benefits.
UNIVERSITY OF MICHIGAN BZK Effective Date: 01/01/2018
UNIVERSITY OF MICHIGAN 68712000 0070051870000-06BZK Effective Date: 01/01/2018 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional
2017 Comparison of the State of Iowa Medicaid Enterprise Basic Benefits Based on Eligibility Determination
General Plan Provisions Benefits Available from Out-of-Network Providers 2017 Comparison of the State of Iowa Enterprise Cost Sharing: A variety of methods are used to share expenses between the state
FIDA. Care Management for ALL
Care Management for ALL In 2011, Governor Andrew M. Cuomo established a Medicaid Redesign Team (MRT), which initiated significant reforms to the state s Medicaid program. This included a critical initiative
Office of Children s Health Insurance Program (CHIP)
August 4, 2017 Dear CHIP (s): This letter is to inform you that the Department of Human Services (Department) is implementing the Affordable Care Act (ACA) 1 provision which requires that all providers
Meaningful Use FAQs for Behavioral Health
Netsmart is your Meaningful Use technology partner with all the solutions you need to meet all Stage 1 Meaningful Use criteria so you don t have to integrate products from multiple vendors. For more information,
Choice 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
CALIFORNIA Small Group HMO Aetna Health of California, Inc. Plan Effective Date: 04/01/2007. Aetna Value Network* HMO $30/$40
PLAN FEATURES Deductible (per calendar year) Member Coinsurance Lifetime Maximum Primary Care Physician Selection Referral Requirement PHYSICIAN SERVICES CALIFORNIA Small Group HMO Primary Care Physician
HEALTH PLAN BENEFITS AND COVERAGE MATRIX
HEALTH PLAN BENEFITS AND COVERAGE MATRIX THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR
BCBSNC Provider Application for Participation
BCBSNC Provider Application for Participation This application is to be used if you wish to become a participating provider facility with BCBSNC. This application is not a contract. Please follow the applicable
Major Dimensions of Managed Behavioral Health Care Arrangements Level 3: MCO/BHO and Provider Contract
Introduction To understand how managed care operates in a state or locality it may be necessary to collect organizational, financial and clinical management information at multiple levels. For instance,
OVERVIEW OF YOUR BENEFITS
OVERVIEW OF YOUR BENEFITS IMPORTANT PHONE NUMBERS Member Services Department (646) 473-9200 For answers to questions about your benefits or to be referred to another Benefit Fund department. Program for
Chapter 8 Section Infusion Drug Therapy Delivered In The Home
TRICARE Policy Manual 6010.60-M, April 1, 2015 Other Services Chapter 8 Section 20.1 Issue Date: September 7, 2011 Authority: 32 CFR 199.2 and 32 CFR 199.6(f) Copyright: CPT only 2006 American Medical
Organizational Provider Credentialing Application
Organizational Provider Credentialing Application New Mexico Organizational provider identification Legal business name (as reported to the IRS): Medicaid number: Doing Business As (DBA) name (if applicable):
1199SEIU Greater New York Benefit Fund OVERVIEW OF YOUR BENEFITS
1199SEIU Greater New York Benefit Fund OVERVIEW OF YOUR BENEFITS I HOSPITAL CARE This benefit is for the hospital s charge for the use of its facility only. Coverage for services rendered by doctors, labs,
Fidelis Care New York Provider Manual 22C-1
Fidelis (MAP) is for individuals who have Medicare and Medicaid coverage and who have a chronic illness or disability. Member Eligibility Fidelis provides managed long-term care services to members who:
Covered 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
Public Act No
Public Act No. 15-59 AN ACT CONCERNING SCHOOL-BASED HEALTH CENTERS. Be it enacted by the Senate and House of Representatives in General Assembly convened: Section 1. (NEW) (Effective October 1, 2015) (a)
A. All inpatient facility services - Medical, Substance Abuse, and Behavioral Health admissions require authorization.
Medicare Authorization Grid FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION EFFECTIVE 1/1/2017 I. Inpatient Admissions: All inpatient
SAMPLE CARE COORDINATION AGREEMENT
SAMPLE CARE COORDINATION AGREEMENT This sample Care Coordination Agreement is between a fictional Certified Community Behavioral Health Clinic (CCBHC), Behavioral Health Clinic, and a fictional hospital,
Advanced Practice Nurse Authority to Diagnose and Prescribe
Advanced Practice Nurse Authority to Diagnose and Prescribe Copyright protected information. Provided courtesy of the Illinois State Medical Society ADVANCED PRACTICE NURSES AUTHORITY TO DIAGNOSE AND PRESCRIBE
WYOMING MEDICAID PROVIDER MANUAL. Medical Services HCFA-1500
WYOMING MEDICAID PROVIDER MANUAL Medical Services HCFA-1500 Medical Services March 01,1999 Table of Contents AUTHORITY... 1-1 Chapter One... 1-1 General Information... 1-1 How the Billing Manual is organized...
MIT Student Extended Insurance Plan Benefit Description
Preferred Provider Plan A PPO Health Plan administered by Blue Cross and Blue Shield of Massachusetts, Inc. MIT Student Extended Insurance Plan Benefit Description Welcome! This benefit booklet provides
YORK HOSPITAL MEDICAL STAFF BYLAWS
YORK HOSPITAL MEDICAL STAFF BYLAWS Table of Contents ARTICLE I. NAME...4 1.1 NAME... 4 ARTICLE II. PURPOSES AND RESPONSIBILITIES OF THE MEDICAL STAFF.4 2.1 PURPOSES... 4 2.2 RESPONSIBILITIES... 4 ARTICLE
AND PROCEDURES WHICH REQUIRE AUTHORIZATION EFFECTIVE
Medicare Authorization Grid FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION EFFECTIVE 1/1/2018 I. Inpatient Admissions: All inpatient
Covered 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
Rural Health Clinic Overview
TrailBlazer Health Enterprises Rural Health Clinic Overview Steven W. Mildward Published March 2012 108724 2012 TrailBlazer Health Enterprises /TrailBlazer. All rights reserved. Important The information
Benefit Explanation And Limitations
Benefit Explanation And Limitations SFHP providers supply many medical benefits and services, some of which are itemized on the following pages. For specific information not covered in this table, please
Optima Health Provider Training Special Needs Plan (SNP) Optima Community Complete
Optima Health Provider Training Special Needs Plan (SNP) Optima Community Complete Subject Areas I. Background on SNP II. D-SNP Eligibility Requirements III. Description of Targeted Populations IV. D-SNP
Louisiana Medicaid Update
Louisiana Medicaid Update HFMA Region 9 Conference November 15, 2015 Origins of Medicaid Means tested entitlement program Established 1965 by Title XIX of the Social Security Act Public health coverage
MyHPN 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
Benefit Explanation And Limitations
Benefit Explanation And Limitations SFHP providers supply many medical benefits and services, some of which are itemized on the following pages. For specific information not covered in this table, please
CHAPTER 2 ADDENDUM OTHER SPECIAL PROCEDURE CODES M, MAY 1999
6010.50-M, MAY 1999 CHAPTER 2 ADDENDUM E FIGURE 2-E-1 PROCEDURE CODES FOR OUTPATIENT HOSPITAL, AMBULATORY SURGICAL CENTER, BIRTHING CENTER, AND HOSPITAL/OUTPATIENT BIRTHING ROOM CLAIMS Contractors are
MHP Service Codes Requiring Preauthorization - Effective July 1, 2018
McLaren Health Plan Medicaid/Healthy Michigan McLaren Health Advantage (PPO) McLaren Health Plan Community MHP Service Codes Requiring Preauthorization - Effective July 1, 2018 Auditory Procedures Oral
NEIGHBORHOOD 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
(b) Self-determination and participation. The resident shall have the right to:
Effective Date: 04/17/96 Title: Section 415.5 - Quality of life 415.5 Quality of life. The facility shall care for its residents in a manner and in an environment that promotes maintenance or enhancement
Benefits. Benefits Covered by UnitedHealthcare Community Plan
Benefits Covered by UnitedHealthcare Community Plan UnitedHealthcare provides all medically necessary covered services under Medicaid SSI. Some services may require a prior authorization. Specific covered
EXTERNAL QUALITY REVIEW COMPLIANCE MONITORING REPORT
Michigan Department of Health and Human Services (MDHHS) EXCERPTS Behavioral Health and Developmental Disabilities Administration Prepaid Inpatient Health Plans 2015 2016 EXTERNAL QUALITY REVIEW COMPLIANCE
Combined Evidence of Coverage and Disclosure Form
Access+ HMO 30-20B Combined Evidence of Coverage and Disclosure Form SISC 30-20% Zero Facility Deductible-Broad DP Effective Date: October 1, 2017 An independent member of the Blue Shield Association Blue
Summary 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
CHAPTER 6: CREDENTIALING PROCEDURES
We want to help you become or continue as a participating in-network provider for our members. Please refer to this chapter for information about: Provider credentialing Provider recredentialing Provider
NCD for Routine Costs in Clinical Trials (310.1)
NCD for Routine Costs in Clinical Trials (310.1) Publication Number 100-3 Manual Section Number 310.1 Version Number 2 Effective Date of this Version 7/9/2007 Implementation Date 10/9/2007 Benefit Category
907 KAR 1:044. Coverage provisions and requirements regarding community mental health center behavioral health services.
907 KAR 1:044. Coverage provisions and requirements regarding community mental health center behavioral health services. RELATES TO: KRS 194A.060, 205.520(3), 205.8451(9), 422.317, 434.840-434.860, 42
VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION
VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION GENERAL INFORMATION Primary Practice Facility Location The type of application being submitted: Please choose facility type (check all that apply):
Master Table of Contents, pages 1 and 2 Master Table of Contents, pages 1 and 2
CHANGE 5 6010.59-M AUGUST 28, 2017 REMOVE PAGE(S) INSERT PAGE(S) Master Table of Contents, pages 1 and 2 Master Table of Contents, pages 1 and 2 CHAPTER 7 Section 2, pages 1 and 2 Section 2, pages 1 and
Optional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived 30% after deductible
PLAN FEATURES NON- Deductible (per calendar year) $500 Individual $750 Individual $1,500 Family $2,250 Family All covered expenses, excluding prescription drugs, accumulate toward both the preferred and
T A B L E O F C O N T E N T S. Medicare Hospice CoPs California Hospice Standards Title 22 Regulation Page No.(s) SAMPLE
TABLE OF CONTENTS.. [ Subpart A ] - 418.3 Definitions Article 1 - Definitions Article 1 - Definitions Hospice Hospice 74600. Home Health Agency 1 Hospice Care No Equivalent No Equivalent 2 No Equivalent
Member Handbook. COMMUNITY BLUE Preferred Provider Organization (PPO)
Member Handbook COMMUNITY BLUE Preferred Provider Organization (PPO) This contract is between you and Blue Cross Blue Shield of Michigan. Because we are an independent corporation licensed by the Blue
California 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
COMMUNITY BLUE GROUP BENEFITS CERTIFICATE SG
COMMUNITY BLUE GROUP BENEFITS CERTIFICATE SG This contract is between you and Blue Cross Blue Shield of Michigan. Because we are an independent corporation licensed by the Blue Cross and Blue Shield Association
AMERICAN 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
Chapter 13 Section 2. Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups
Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC) Chapter 13 Section 2 Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups Issue Date:
Medi-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
Optional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and
For Large Groups Health Benefit Single Plan (HSA-Compatible)
Financial Features (DED 1 ) (PBP 2 ) (DED is the amount the member is responsible for before Florida Blue pays) Out-of-Network Inpatient Hospital Facility Services Per Admission (PAD) Coinsurance (Coinsurance
CHANGE M OCTOBER 23, CHAPTER 5 Section 4, pages 1 and 2 Section 4, pages 1 and 2
CHANGE 149 6010.58-M OCTOBER 23, 2017 REMOVE PAGE(S) INSERT PAGE(S) CHAPTER 5 Section 4, pages 1 and 2 Section 4, pages 1 and 2 CHAPTER 7 Section 2, pages 3 and 4 Section 2, pages 3 and 4 CHAPTER 13 Section
Welcome to the County Medical Services Program!
Welcome to the! As an eligible member of the (CMSP), you will receive an Advanced Medical Management, Inc. (AMM) CMSP Identification (ID) Card and a State of California Benefits Identification Card (BIC).
Kaiser 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.
AMBULATORY SURGICAL CENTERS PROVIDER MANUAL Chapter Twenty-nine of the Medicaid Services Manual
AMBULATORY SURGICAL CENTERS PROVIDER MANUAL Chapter Twenty-nine of the Medicaid Services Manual Issued November 1, 2010 Claims/authorizations for dates of service on or after October 1, 2015 must use the
Managed 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