FACILITY BASED SERVICES

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1 CUSTODIAL NURSING HOME CARE Chiropratic Services Custodial Nursing Home Care DME Equipment and Supplies Incontinence Supplies: Diapers, briefs, wipes, gloves, pads Infusion (IV, Enteral) Services Outpatient Therapy Evaluation Only: OT, PT & Speech Therapy Outpatient Therapy Services (PT, OT, ST) Physician Services (Vision, Podiatry, PCP, Specialty Care) FACILITY BASED SERVICES Inpatient Hospital Care

2 Elective Inpatient Admission or Elective Inpatient Surgery Inpatient Rehabilitation Care Skilled Nursing Facility Admission Non-Custodial Nursing Home Care Long Term Acute Care (LTAC) Emergency Room Care Observation Care Must meet CMS/MDHHS Observation Criteria Urgent Care Allergy Testing/Injections OUTPATIENT SERVICES Ambulance-Emergency Services (Air)

3 Ambulance-Emergency Services (Land) Ambulance-Non Emergency Services Anesthesia for Outpatient Dental Procedures Angiography Bariatric Surgery Blepharoplasty (Eye lid surgery) Bone Density Breast Reconstruction Cardiac Catherization (Must meet medical necssity criteria) (Must meet medical necessity criteria) (Covered only after mastectomy for treatment of Breast Cancer) Cardiac Rehabilitation Cardiac Stress Testing/Imaging Chiropractic Care Cochlear Implant Cosmetic Procedures (Keloid & Scar Revision, Panniculectomy, Septoplasty/Rhinoplasty) (Must meet medical necssity criteria)

4 Dental Care MANAGED BY DELTA DENTAL CALL Diabetes Education (Certified Diabetic Educator) Diagnostic Imaging: CT Scan, MRI Diagnostic Imaging: PET Scan Dialysis: Hemodialysis & Peritoneal Dialysis Eye Exams and Glasses Family Planning Services (Including Vasectomy & Tubal Ligation) MANAGED BY HERITAGE OPTICAL CALL Genetic Testing Hearing Aids NOT COVERED Home Health Care (Skilled Nursing, PT, OT, Speech Therapy) Hospice (Community-Based) PLAN NOTIFICATION REQUIRED Hospice (Inpatient) Immunizations (CDC/ACIP Recommended)

5 Infusion & Injection Therapy (Remicaid, IVIG, Xolair, Embrel, Humera) Lab Services (Genetic Testing requires Prior Authorization) (Contact Medicare Health Services for Additional Meds) (Must have a prescription) Long Term Support Services Maternal Infant Health Program (MIHP) OB Care (Office Visits, Ultrasound, NSTs) Outpatient Diagnostic or Screening Procedures (Bronchospcopy,Colonoscopy, EGD, Hysteroscopy, Ultrasound, Doppler Studies, Echocardiograms, X-rays etc.) Outpatient Surgery (Knee Arthroscopy, Cataract, ORIF, D&C, etc.) (Does not include Outpatient Dental Surgery - See Dental) Outpatient Therapy Evaluation Only: OT, PT & Speech Therapy Outpatient Therapy: Physical Therapy, Occupational Therapy & Speech Therapy Outpatient Treatment (Chemotherapy, Radiation Therapy) Parenteral and Enteral Nutrition Podiatry Pulmonary Rehabilitation Reduction Mammoplasty (Females Only) (Must meet specific criteria)

6 Sleep Studies Second Surgical Opinion Specialty Care Transportation (Non-emergency) MANAGED BY HAP MIDWEST CUSTOMER SERVICES WITH 4 BUSINESS DAYS NOTICE. CALL Transplant Services: Organ Transplant, Bone Marrow Travel Vaccines Vein Procedures: Sclerotherapy, Stripping/Ligation, etc. Well Woman Care (Mammogram, Pap Smear, etc.) NOT COVERED (Must meet specific criteria) DURABLE MEDICAL EQUIPMENT (DME) Braces (arm, leg, back & neck) Canes (excludes white canes for the blind) Commode chairs Continuous passive motion (CPM) machine Crutches

7 Enteral nutrition equipment (feeding pump) Home oxygen equipment Hospital beds and Mattresses Infusion pumps Implantable Automatic Defibrillators INR (Home Monitoring) Insulin Pumps Life Vest (DME) Nebulizers and nebulizer medications Patient Lifts Pneumatic Compression Devices (Lymphedema Pump) Positive Airway Pressure Devices and supplies: (CPAP, BiPAP) Power Mobility Devices Prosthetics & Orthotics Seat Lift

8 Speech Generating Devices Suction pumps Stimulators: Bone, Electrical, Neuromuscular, Transcutaneous Electrical Nerve Stimulators (TENS) Therapeutic shoes or inserts Traction equipment Walkers Wheelchairs MEDICAL SUPPLIES Diabetic Supplies: Glucometers, strips, lancettes, syringes/needles, alcohol wipes. Supplies covered by Pharmacy Benefit Diabetic Insulin Pump Supplies Enteral nutrition (feeding) supplies Incontinence supplies: Diapers, briefs, wipes, gloves, pads Nebulizer supplies Ostomy & Tracheostomy supplies Oxygen supplies

9 Urology supplies Wound Care supplies BEHAVIORAL HEALTH SERVICES Inpatient Psychiatric Admission MANAGED PER PIHP CALL DETROIT WAYNE COUNTY MENTAL HEALTH AUTHORITY (800) OR MACOMB COUNTY COMMUNITY MENTAL HEALTH (586) (CAN CALL COLLECT) Outpatient Behavioral Health Services MANAGED PER PIHP CALL DETROIT WAYNE COUNTY MENTAL HEALTH AUTHORITY (800) OR MACOMB COUNTY COMMUNITY MENTAL HEALTH (586) (CAN CALL COLLECT) Behavioral Health Office Visits Substance Abuse Treatment MANAGED PER PIHP CALL DETROIT WAYNE COUNTY MENTAL HEALTH AUTHORITY (800) OR MACOMB COUNTY COMMUNITY MENTAL HEALTH (586) (CAN CALL COLLECT) MANAGED PER PIHP CALL DETROIT WAYNE COUNTY MENTAL HEALTH AUTHORITY (800) OR MACOMB COUNTY COMMUNITY MENTAL HEALTH (586) (CAN CALL COLLECT) Partial Hospitalization MANAGED PER PIHP CALL DETROIT WAYNE COUNTY MENTAL HEALTH AUTHORITY (800) OR MACOMB COUNTY COMMUNITY MENTAL HEALTH (586) (CAN CALL COLLECT)

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