STAR Kids Quick Reference Tool March 2017

Transcription

1 Driscoll Health Plan General Information Address: 615 N. Upper Broadway, Suite 1621 Corpus Christi, Teas Hours of Operation: 8 a.m. to 5 p.m. (CST), Mon Fri (Ecept State Holidays) Eligibility Verification: Call Member Services or access web: php Confirm eligibility of member prior to providing services or making a referral. Also verify membership information and effective dates on the ID Card. See Section 3 of Provider Manual for questions at: nual.pdf Claims Information Electronic claims are accepted through: EMDEON Payer ID For paper claims, send a completed claim form (CMS 1500 or UB04) to: Driscoll Health Plan P.O. Bo 3668 Corpus Christi, Teas Claims must be submitted within 95 days of the date of service. For questions regarding claims, call: Nueces Service Area (STAR Kids): Hidalgo Service Area (STAR Kids): Provider Services STAR Kids Nueces SA: STAR Kids Hidalgo SA: Member Services STAR Kids Nueces: STAR Kids Hidalgo: Authorization Status STAR Kids Nueces SA: STAR Kids Hidalgo SA: Behavioral Health Targeted Case Management Fa: STAR Kids Contact Information Prior Authorization for Acute Services Fa: Prior Authorization for LTSS: To be transferred to Service Coord Nueces Hidalgo Ophthalmology Services ENVOLVE Vision Vision Member Services STAR Kids: Medical Transportation STAR Kids: Disease Management Fa: Service Coordination: STAR Kids Nueces: STAR Kids Hidalgo: Waste, Abuse, and Fraud Hotline Interpreter Services Note: When you use this service, you will need to provide: Language Needed Member DHP ID Number Physician s First and Last Name Form #: DHP460 1

2 Behavior Health Service Request Forms (SRF) Fa: Pregnancy Notification Forms (PNF) or Delivery Notifications (DN) Fa: Hr. Behavioral Hotline STAR Kids Nueces: STAR Kids Hidalgo: ECI Individual Family Service Plans (IFSP) Fa: Pharmacy (Prior Authorization) NAVITUS Provider Authorization Guide: The information listed below ONLY applies to DHP STAR Kids Members. For CHIP Perinate Members, refer to the DHP CHIP Perinate QRT. For CHIP or STAR members, please refer to the DHP CHIP/STAR QRT. Please submit authorizations on line at or fa to All services must be medically indicated, evidenced by supporting clinical documentation. No authorization required for Emergency Medical Conditions. No Authorization required for Outpatient Behavioral Health Conditions unless specified below. For Members with other primary insurance coverage, please contact the Service Coordination Department at for coordination of benefits. No authorization required for Outpatient Acute services if member has other primary insurance. (Inpatient does require prior authorization.) Authorization is required for LTSS and LTSS-like services such as PCS and PDN if member has other primary insurance, unless specified in the authorization as Bill Primary Payer For questions regarding Acute Authorizations, call (STAR Kids Utilization Management). For questions regarding LTSS or LTSS-like Authorizations, call (Nueces area STAR Kids Service Coordination) or (Hidalgo area STAR Kids Service Coordination). Authorization requests received after hours or during holiday closures will be processed with a start date of the following business day. Unlisted CPT codes and CPT codes not listed on the Medicaid fee schedule are not benefits of Teas Medicaid and are not covered by Driscoll Health Plan. Unless otherwise specified below, all out-of-network services require prior authorization. Inpatient admissions/observations/outpatient Facility Surgeries/Office-based services Inpatient admissions (non-delivery) Observations (non-ob) OB Observations for diagnoses related to pregnancy( OB Observations for diagnoses unrelated to pregnancy (in-network or out of-network) Deliveries-routine (Submit delivery notification information via our website or fa to ) Out-of-Network and Out-of-State routine deliveries and well-baby admissions Deliveries etending beyond 4 days vaginal/6 days cesarean-section (allows for 2 laboring days) NICU admissions Nursery stays in which newborn remains inpatient after the mother discharges (boarder/detained babies) Outpatient facility-based surgeries Office visits for providers on Quick Referral List (QRL) All office-based services for providers on Quick Referral List (QRL) unless specified below NO Form #: DHP460 2

3 Allergy Services Allergy testing for children under the age of 2 Allergy injections for patients under the age of 5 Ambulance Services Ambulance transport for non-urgent/non-emergent medical transportation Behavioral Health Services Out-of-Network outpatient Behavioral Health Services (unless otherwise specified below) Psychological Testing Neuropsychological Testing Residential Treatment Center (considered Outpatient) and Outpatient Deto Services (H2035 and H0046) Behavioral Health related Observations/Inpatient Admissions Cardiology Services Electrocardiogram (ECG) >6 in a 12 month period require authorization Nuclear Stress Tests Chiropractic services Chiropractic services Dental Services Dental Anesthesia Dermatology Services Dermatology consults for treatment without previous treatment attempt by PCP Biopsies and cryosurgery in office UV light therapy Durable Medical Equipment (purchase or rental determinations will be made by DHP) Apnea monitors (See also Interpretation of apnea monitor readings (94774) under Other Services) DME purchases for items over $ in paid charges DME rentals for items over $300 in paid charges per month or for rentals longer than 90 days DME equipment or supplies over the benefit limitation (See TMHP Provider Procedures Manual) Incontinent supplies Diabetic supplies eceeding benefit limitation (See TMHP Provider Procedures Manual) Orthotics, braces, and AFO s (all L codes); to include modifications and alterations Enteral formulas and nutritional supplies Hearing Aids Electric Breast pump (non-hospital grade) E0603- greater than one per pregnancy or per 3 years whichever is greater Inhaler Spacers (S8101) Effective 7/1/15 authorization required if >1 per 180 days, any provider. ENT Diagnostic analysis of cochlear implants, cochlear implant surgery, device, and replacement parts Gastroenterology Services Upper GI Endoscopy Colonoscopy with or without biopsy Genetic Services Out-of-Network genetic services Genetic counseling Genetic testing done at any lab (to include in-network laboratories) (CPT codes: , 81170, , , , ,81235, , , , 81270, , , , , 81310, , , , , 81350, 81355, , , , 81450, 81455, 81507, 81519, 88230, 88233, 88235, 88237, , 88245, , , 88267, 88269, , 88280, 88283, 88285, 88289) Fetal Aneuploidy (81420) and Cystic Fibrosis testing in pregnancy (81220) ordered by a participating Maternal Fetal Medicine (MFM) or Geneticist AND performed at LabCorp Fetal Aneuploidy (81420) and Cystic Fibrosis testing in pregnancy (81220) ordered by a participating Maternal Fetal Medicine (MFM) or Geneticist but NOT performed at LabCorp, OR ordered by any other provider specialty NO Form #: DHP460 3 X X X

4 than ecluded above and performed at any laboratory Hematology-Oncology Services Chemotherapy (submit chemo protocol prior to treatment) Radiation Therapy Blood transfusions Bone marrow biopsies as outpatient Home Health Services Home Health Nursing/Skilled Nursing Visits/Private Duty Nursing/Hospice Laboratory Services In-network laboratory services (unless otherwise specified- see Genetic testing above) Out-of-network laboratory services Neurology EEG s ordered by Neurologist OB-GYN Services D&C's not related to miscarriages Sterilization/BTL (not a benefit for CHIP members) Colposcopies, biopsies, cryocautery, conization, endocervical curettage, hysteroscopies Hysterosalpingograms (HSG's) OB Ultrasounds -greater than 3 per pregnancy (note: limited to one per pregnancy) Transvaginal OB ultrasound for short cervi (CPT 76817) in addition to the 3 per pregnancy Biophysical Profile (BPP) with or without NST (fetal non-stress tests) Amniocentesis Cervical cerclage removal in office or facility Cervical cerclage placement as Observation or Outpatient status at hospital Cervical cerclage placement as Inpatient Status at hospital or as Outpatient status at free-standing surgical facility Office Visits PCP to Specialist referrals (unless provider(s) are on Quick Referral List (QRL)) Specialist to Specialist referrals Out-of-Network office visits (Behavioral Health and Substance Abuse visits do not require authorization) PCP to PCP Referrals Outpatient Diagnostic Services (Miscellaneous) Sleep studies Pneumograms Ophthalmology Services Effective August 1, For all Ophthalmology services- contact Envolve Vision for prior authorization by web at or by Fa at Optometry/Ophthalmology procedures performed in an out-of-network facility require prior authorization through Envolve Vision (via webhttps://visionbenefits.envolvehealth.com/logon.asp or by Fa at ). NO Oral Surgery Ecision of gum tumors or oral cysts Oral surgery, treatment of TMJ, Orthodontics Treatment of lip tumors/masses Orthopedic Services Cyst aspirations and ecisions Casting Pain Management Services Pain management services and epidural steroid injections Pharmacy Injectable drugs >$300 if not covered by Navitus Depo-Provera injections in office Rhogam injections at facilities Form #: DHP460 4

5 Plastic Surgery Plastic or potentially cosmetic procedures performed in-office or facility Podiatry Services Podiatry treatment for flat feet/pes planus in office or facility Podiatry office-based treatment of ingrown toenails, nail fungus, plantar warts, nail removal, foreign bodies, etc. Radiology Services Anesthesia/sedation for CT or MRI CT s and MRI s All Mobile radiology PET scans Swallow Studies Therapy Services (PT/OT/ST) Speech Therapy Evaluation, Re-evaluation, and treatment Physical Therapy Evaluation, Re-evaluation, and treatment Occupational Therapy Evaluation, Re-evaluation, and treatment Urology and Renal Services Cystoscopies, cystourethroscopies, stone removal Circumcisions Urodynamic Studies VCUG s Other Services Nutritional Counseling Interpretation of apnea monitor readings (94774) NO *Benefits listed below are unique ONLY for DHP STAR KIDS Members. Long Term Services and Support (LTSS) for those DHP STAR Kids members in the Medically Dependent Childrens Program (MCDP) are listed below.* For DHP STAR Kids members in other waiver programs (such as CLASS, HCS, THmL, and DBMD), please contact that State of Teas Waiver Program administrator - Department of Aging and Disability Services (DADS) - for LTSS prior authorization at toll free number Personal Care Service Personal Care Services Private Duty nursing Other Services Adaptive Aides Day Activity and Health Services (DAHS) for >18year old Minor Home Modification Community First Choice (CFC) Benefits: (Habilitation (HAB), Emergency Response System (ERS), Support management) Other Services (continued) Respite ( In home and out of home) Employment Services (Supported Employment and employment assistance) Financial Management services NO Form #: DHP460 5

6 Fleible family support services Transition Assistance Services NO Form #: DHP460 6