Office visits and office-based surgical procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA.
|
|
|
- Evan Freeman
- 5 years ago
- Views:
Transcription
1 IMPORTANT NOTICES The codes listed in this document are for outpatient services only. All Inpatient services require authorization. This document is updated quarterly. Please check this document prior to PA submission as codes may be removed or added. All codes listed require PA unless there is a Plan-specific exception*. Office visits and office-based surgical procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA. Some services listed may not be covered by CMS or your local State Medicaid or Marketplace agency; please refer to your regulatory agency for specific noncovered codes. Prior authorization is not a guarantee of payment for services. Payment is made in accordance with a determination of the member s eligibility, benefit limitation/exclusions, and evidence of medical necessity and other applicable standards during the claim review. To search this document, use [Ctrl + F] keys. Enter Service or Code in search navigation pane; press Enter. *Refer to Molina Plan Exceptions section starting on page 23 MHT 2018 PA Code Matrix Page 1
2 Codification Document Change Tracking... 3 Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services... 5 Costmetic, Plastic & Reconstructive (In ANY Setting)... 6 Durable Medical Equipment (DME)... 6 Experimental/Investigational... 7 Genetic Counseling & Testing... 7 Habilitative Therapy... 8 Home Health Care & Home Infusion... 8 Hyperbaric Therapy... 8 Imaging Advanced & Specialty... 9 In-Patient Admissions... 9 Long Term Services & Support..9 Neuropsychological & Psychological Testing... 9 Non-Par Providers/Facilities Office Based 10 Occupational Therapy Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Pain Management Physical Therapy Prosthetics & Orthotics..12 Radiation Therapy & Radio Surgery Sleep Studies Speech Therapy Specialty Pharmacy Drugs (Injectable).13 Transplant Services (Including Solid Organ and Bone Marrow) Transportation Services (Non-Emergent)..14 Unlisted/Miscellaneous Codes..14 Texas Additional Exceptions MHT 2018 PA Code Matrix Page 2
3 Codification Document Change Tracking Received Date Effective Date 2018 Q1 Molina Healthcare of Texas, PA Code Matrix Specialty/Service Change/Update Description Exceptions/Notes 11./21/16 01/01/17 Behavioral Health Removed/NC Codes: 1001, 1002 Applies to Medicare only. 10/04/16 01/01/17 Genetic Genetic Counseling & Testing Required: 0009M, 11/15/16 01/01/17 Genetic Counseling & testing 11/15/16 01/01/17 Genetic Counseling & testing 11/15/16 01/01/17 Genetic Counseling & testing 10/4/16 01/01/17 Home Health Care & Home Infusion 11/15/16 01/01/17 Home Health Care & Home Infusion 11/17/16 01/01/17 Home Health Care & Home Infusion Added/PA Required: 0009M, 81420, Added/PA Required: 81235, 88261, Removed/Termed Codes: 81280, 81281, Removed/No PA Required: 0010M Added/PA Required: G0490, G9679, G9680, G9681, G9682*, G9683*, G9684* Added/PA Required : S5130, S5135, S5151, S947, T1000, T1002, T1003, T1005, T1022, T1030, T1031 Removed/No PA Required: S9977 Applies to all Plans all LOBs. Applies to all Plans (All LOB) Applies to all Plans (All LOBs) Applies to all Plans (All LOBs) Applies to all Plans (All LOBs) Applies to all Plans (All LOBs) Applies to Medicare only. 10/4/16 01/01/17 Imaging Removed Termed Code: S8032 Applies to all Plans/All LOBs. Use G0297 already in Matrix). 10/4/16 01/01/17 Out-Patient Hospital/ASC Added/PA Required: 55970, /4/16 01/01/17 Specialty Pharmacy Added/PA Required: C9139, C9481, C9483, J0287, J2504, J9045, J9265, Q0138, Q0139, Q9970, S /4/16 01/01/17 Specialty Pharmacy Removed/No PA Required: J0882, J2788, J2790, J2791, J2792, J8499, J8530, J /15/16 01/01/17 Out-Patient Hospital/ASC Added/PA Required: 43886, 43887, Applies to MKPL only. Applies to all Plans (All LOBs) Applies to all Plans (All LOBs) Applies to all Plans (All LOBs) 3/20/17 04/01/17 Home Health Care & Home Infusion Removed/No PA Required: G9679, G9680, G9681, G9682, G9683, G9684 Applies to /All LOBs. 3/20/17 04/01/17 Out-Patient Hospital/ASC Removed/No PA Required: Applies to ; all LOBs. 3/21/17 07/1/17 Specialty Pharmacy Added/PA Required: C9484 Applies to, NC for MKP 5/07/17 05/9/17 Therapy Services Added/PA Required: Nursing Facility membership require prior authorization post evaluation. 5/12/17 5/12/17 Nursing Facility Membership and Behavioral Health Removed: 90791, 90792, 99211, 99212, 99213, 99214, /22/17 7/1/17 Specialty Pharmacy Added/PA Required: C9485*, C9486*, C9487*, C9488*, J1750, J1756, J2916, J3145, J7320 Applies to MHT This applies for Nursing Facility Rate Group population in Texas only for BH requests. 3/23/17 7/1/17 OutPatientHospital/ASC 4/4/17 7/1/17 OutPatient Hospital/ASC 5/20/17 7/1/17 Cosmetic, Plastic and Reconstructive Added/PA Required: C9739, C9740 Removed/No PA Required: 22853, 22854, PA Update: No PA Required with breast CA Dx: 19300, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19396, 11900, 11901, (Medicaid/Marketplace) 06/1/17 07/1/17 Anesthesia Dental Anesthesia children 0-6 years old Added/ PA Required: MHT Medicaid Only (STAR) MHT 2018 PA Code Matrix Page 3
4 06/1/17 07/1/17 Behavioral Health Added/ PA Required: Residential Detox and Ambulatory Detox: H0016, H0050, H0012, H0031, H0047, and T /21/17 09/1/17 Therapy Services Added/PA Required: Therapy Services require authorization after initial evaluation MHT Only: CHIP/Medicaid Only MHT Only 06/14/ /1/2017 Specialty Pharmacy Add/PA Required: C9490, J7511, J0640, J1230, J1570, J7308, J9000, J9065, J9070, J9100, J9130, J9150, J9181, J9190, J9200, J9208, J9209, J9211, J9213, J9230, J9268, J9280, J9328, J9340, J9360, Q9985, Q9986, Q /28/ /1/2017 Specialty Pharmacy Remove Termed Code: C /28/ /1/2017 Out Patient Hospital/ASC 06/28/ /1/2017 Out Patient Hospital/ASC Added/PA Required: 37243, C2616, C9734, C9746, C9747 Added/PA Required: S2095 : (Medicaid/Marketplace) 06/28/ /1/2017 Specialty Pharmacy Added/PA Required: J /28/ /1/2017 Home Health Care Services Added/PA Required: G0495, G /29/ /1/2017 Genetic Counseling & 06/29/ /1/2017 Testing Experimental & Investigational 07/12/ /1/2017 Out Patient Hospital/ASC Added/PA Required: 0004U, 0005U Added/PA Required: 0469T, 0470T, 0471T, 0473T, 0474T, 0475T, 0476T, 0477T, 0478T Remove/No PA Required: /27/ /1/2017 OT, PT & ST PA Update: PA Required for all therapy services after initial eval. MTX: (: (Medicaid/Marketplace) 09/1/ /1/2017 Specialty Pharmacy PA Update: J added Dx-related ICD Codes. : (Medicaid/Marketplace) 09/7/ /1/2017 DME Added/PA Required: E /12/ /1/2017 Specialty Pharmacy PA Update: C9484, C9489 NC Codes 09/20/ /1/2017 Specialty Pharmacy Added/PA Required: C9491, C9492, C9493, C /25/ /1/2017 Genetic Counseling & Testing 10/2/ /1/2017 Out Patient Hospital/ASC 07/1/ /1/2018 Home Health Care Services 07/1/ /1/2018 Long Term Services & Support (LTSS) 7/1/2017 1/1/2018 Unlisted/Miscellaneous Codes Added/PA Required: 0008U, 0009U 0010U 0011U, 0012U, 0013U, 0014U, 0015U, 0016U, 0017U Removed/No PA Required: 95909, 95911, 95912, PA Update: PA required for all home health services after initial visit/eval, including home OT/PT & ST. (Plan contractual exceptions will remain in place) Removed LTSS codes listed under this section. Added statement under specialty: All LTSS services require PA regardless of code(s). LTSS not covered by Medicare. Removed codes listed under this section as Molina requires PA for all unlisted/ misc. codes. (see next line for exception). Medicaid/Marketplace Medicare Only 7/1/2017 1/1/2018 Unlisted/Miscellaneous No PA Required: Codes 9/22/2017 1/1/2018 Specialty Pharmacy Added PA Required: J3095, J3240 9/26/2017 1/1/2018 Prostetics & Orthotics Added PA Required: L0637, L0650, L8614, L5856 9/26/2017 1/1/2018 Out Patient Hospital/ASC Added PA Required: MHT 2018 PA Code Matrix Page 4
5 9/26/2017 1/1/2018 Long Term Services & Added PA Required: S5165 Medicaid and MarketPlace Support (LTSS) 10/12/2017 1/1/2018 Specialty Pharmacy Removed No PA required: /12/2017 1/1/2018 Pain Management PA Required: 62320, 62321, 62322, 62323, 64479, /1/2017 2/1/2018 Specialty Pharmacy Removed/No PA Required: L8605, Q9970 4/1/2017 2/1/2018 Specialty Pharmacy Added/PA Required: C9140*, J0570, J0594, J1439, J2430, J2469, J9027, J9040, J9060, J9178, J9185, J9250, J9260, J9370, J9390 4/1/2017 2/1/2018 Experimental/Investigati onal Out-Patient Hospital/ASC Pain Management Specialty Pharmacy Home Health Care 4/1/2017 2/1/2018 Out-Patient Hospital/ASC Removed Termed Codes: 0019T, 0169T, 0171T, 0172T, 0281T, 0282T, 0283T, 0284T, 0285T, 0286T, 0287T, 0288T, 0289T, 0291T, 0292T, 0336T, 0392T, 0393T, 22851, 28290, 28293, 28294, 62310, 62311, C9137, C9138, C9139, C9470, C9471, C9472, C9473, C9474, C9475, C9476, C9477, C9478, C9480, C9481, G0163, G0164, Q9980, Q9981 Added/PA Required: 22853, 22854, 22859, 22867, 22868, 22869, 22870, 28291, 28295, 62324, 62325, 62326, 62327, /1/2017 2/1/2018 Genetic Counseling & Testing Added/PA Required: 81413, 81414, 81422, /1/2017 2/1/2018 Specialty Pharmacy Added/PA Required: J1942, J2182, J2786, J2840, J7175, J7179, J7202, J7207, J7209, J8670, J9034, J9145, J9176, J9205, J9295, J9325, J9352 4/1/2017 2/1/2018 Home Health Care Services Added/PA Required: G0493, G0494 Anesthesia Dental Anesthesia on a Medicaid (STAR) members age 0-6 years old (Please include DMO Provider Determination Letter with the Prior Authorization request) proper modifier required Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services Inpatient, Residential Treatment, Partial Hospitalization, Day Treatment, Electroconvulsive Therapy (ECT), Applied Behavioral Analysis (ABA) for treatment of Autism Spectrum Disorder (ASD) PLEASE NOTE: Behavioral Health Rehabilitative Day Treatment is not a covered benefit for TX Medicaid; however is a benefit for CHIP. H H0012 H2019^ T1023^ H0016 H0050 N/A 0912 H0017 H2020 H2018 T1025^ H0031 H0047 T1007 MHT 2018 PA Code Matrix Page 5
6 2106 H2012 H0031^ T1026^ H2013 H0032^ T1027^ H2017^ H2014^ H0046 T1028^ S5150^ H2015 S5111 T2013^ T2040^ H2016 S0201 NOTES: ^PA required for all plans only when submitted with Autism Dx. [IDC9: , , , , , , , and ICD10: F84.0, F84.2, F84.3, F84.4, F84.5, F84.8, F84.9] Nursing Facility Rate Grouped Members Behavioral Health Requests Below Require Authorization MEDICARE/MEDICAID Cosmetic, Plastic & Reconstructive (In ANY Setting) Note: PA Update: No PA Required with breast CA Dx: 19300, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19396, 11900, 11901, N/A N/A Durable Medical Equipment (DME) For Medicare Hearing Supplemental benefit: Contact AVESIS at *A9900 Does not require PA for Molina Healthcare of Texas MEDICAID & MKT PLACE MEDICAID ONLY MKT PL A7025 E0373 E0986 E1237 E2327 E2508 E2631 K0827 K0861 E0481 S1036 N/A A9900* E0465 E0988 E1238 E2328 E2510 K0008 K0828 K0862 S1034 S1037 A9901 E0466 E1002 E1296 E2329 E2511 K0009 K0829 K0863 S1035 E0194 E0462 E1003 E1298 E2330 E2605 K0010 K0830 K0864 E0255 E1012 E1004 E1310 E2340 E2606 K0011 K0831 K0868 E0256 E0483 E1005 E1399 E2341 E2607 K0012 K0835 K0869 E0260 E0691 E1006 E1700 E2342 E2608 K0014 K0836 K0870 E0261 E0692 E1007 E2201 E2343 E2609 K0108 K0837 K0871 E0265 E0693 E1008 E2202 E2351 E2611 K0606 K0838 K0877 E0266 E0694 E1010 E2203 E2361 E2612 K0800 K0839 K0878 E0277 E0747 E1014 E2204 E2366 E2613 K0801 K0840 K0879 E0292 E0748 E1020 E2227 E2367 E2614 K0802 K0841 K0880 E0293 E0749 E1029 E2228 E2368 E2615 K0806 K0842 K0884 E0294 E0760 E1030 E2291 E2369 E2616 K0807 K0843 K0885 E0295 E0762 E1035 E2292 E2370 E2617 K0808 K0848 K0886 E0296 E0764 E1036 E2293 E2373 E2620 K0813 K0849 K0890 E0297 E0782 E1161 E2294 E2374 E2621 K0814 K0850 K0891 E0300 E0783 E1225 E2295 E2375 E2622 K0815 K0851 K0900 MHT 2018 PA Code Matrix Page 6
7 For Medicare Hearing Supplemental benefit: Contact AVESIS at *A9900 Does not require PA for Molina Healthcare of Texas MEDICAID & MKT PLACE E0301 E0784 E1226 E2310 E2376 E2623 K0816 K0852 V2530 E0302 E0785 E1227 E2311 E2377 E2624 K0820 K0853 V2531 E0303 E0786 E1230 E2312 E2378 E2625 K0821 K0854 E0766 E0304 E0849 E1232 E2313 E2397 E2626 K0822 K0855 E0328 E0855 E1233 E2321 E2500 E2627 K0823 K0856 E0329 E0983 E1234 E2322 E2502 E2628 K0824 K0857 E0371 E0984 E1235 E2325 E2504 E2629 K0825 K0858 E0372 E1236 E2326 E2506 E2630 K0826 K0859 K0860 MEDICAID ONLY MKT PL Experimental/Investigational MEDICAID & MKT PLACE MEDICAID ONLY MKT PL 0165T 0213T 0268T 0301T 0352T 0397T 0425T 0444T 0329T 0333T N/A 0042T 0214T 0269T 0302T 0353T 0398T 0426T 0437T 0330T 0331T 0051T 0215T 0270T 0303T 0354T 0399T 0427T 0441T 0332T 0052T 0216T 0271T 0304T 0355T 0400T 0428T 0445T 0053T 0174T 0217T 0272T 0305T 0356T 0401T 0429T 0440T 0054T 0175T 0218T 0273T 0306T 0357T 0402T 0430T 0496T 0055T 0178T 0219T 0274T 0307T 0358T 0403T 0431T 0470T 0058T 0179T 0220T 0275T 0308T 0359T 0404T 0432T 0471T 0071T 0180T 0221T 0278T 0309T 0360T 0405T 0433T 0473T 0072T 0184T 0222T 0310T 0361T 0406T 0434T 0474T 0075T 0188T 0228T 0312T 0362T 0407T 0435T 0475T 0076T 0189T 0229T 0313T 0363T 0408T 0436T 0476T 0085T 0190T 0230T 0314T 0364T 0409T T 0095T 0191T 0231T 0315T 0365T 0410T T 0098T 0195T 0234T 0316T 0366T 0411T T 0196T 0235T 0317T 0367T 0412T T 0198T 0236T 0335T 0368T 0413T T 0200T 0237T 0290T 0369T 0414T T 0201T 0238T 0337T 0370T 0415T Q T 0202T 0249T 0338T 0371T 0416T Q T 0205T 0253T 0293T 0339T 0372T 0417T Q T 0206T 0254T 0294T 0340T 0373T 0418T Q T 0207T 0255T 0295T 0342T 0374T 0419T Q T 0208T 0263T 0296T 0347T 0420T 0346T 0126T 0209T 0264T 0297T 0348T 0421T 0438T 0159T 0210T 0265T 0298T 0349T 0394T 0422T 0439T 0163T 0211T 0266T 0299T 0350T 0395T 0423T 0442T 0164T 0212T 0267T 0300T 0351T 0396T 0424T 0443T Genetic Counseling & Testing PLEASE NOTE: Prenatal diagnosis of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations 0004M S3841 S3861 N/A 0006M S3842 S3865 S M S3866 S M S3870 S3840 S MHT 2018 PA Code Matrix Page 7
8 G S U 0005U *Including Oncotype DX Habilitative Therapy After initial evaluation S9128 S9129 S9152 S9128 S S Home Health Care & Home Infusion For Medicaid and MarketPlace: Skilled Nursing after initial evaluation plus six (6) visits per calendar year; PA may be required for medications associated with Home Infusion. For Medicare after initial evaluation PA required. MEDICARE / MEDICAID & MKT PLACE MEDICAID ONLY MEDICARE ONLY MKT PLACE ONLY G0151 G0299 G0156 G0159 G0162 S X 034X 056X S G0152 G0155 G0157 G X X G0153 G0300 G0158 G X 043X 060X S9977 G0490 G0495 G9860 G X 044X 062X S5135 S5130 S5151 S9470 T X 055X T1001 T1002 T1003 T1005 T1022 T1030 T1031 G0496 G0493 G0494 Hyperbaric Therapy G MHT 2018 PA Code Matrix Page 8
9 Imaging Advanced & Specialty MEDICAID & MKT PLACE 2018 Q1 Molina Healthcare of Texas, PA Code Matrix MEDICAID ONLY MKT PLACE ONLY C N/A N/A C C C C C C C C C C C C C C C8918 G C8919 S C C C C C C G0288 C In-Patient Admissions Acute Hospital, Skilled Nursing Facilities (SNF), Rehabilitation, Long Term Acute Care (LTAC) Facility MEDICAID & MKT PLACE MEDICAID ONLY MEDICARE ONLY MKT PLACE ONLY All Codes All Codes All Codes All Codes Long Term Services & Support All LTSS services require PA regardless of code(s). [Not a Medicare covered benefit] Neuropsychological & Psychological Testing MHT 2018 PA Code Matrix Page 9
10 Non-Par Providers/Facilities Auth required for Non-Par Office Visits,, Labs, Diagnostic Studies, In-patient stays, except for: Emergency Department Services Professional fees associated with ER visit and approved Ambulatory Surgery Center (ASC) or inpatient stay Local Health Department (LHD) services Other services based on State requirements Office Based PAR Physician/Provider office visits and office-based procedures Do Not require PA, see above for Non-PAR. Occupational Therapy: After Initial Evaluation G0152 S9129 S G G G G G S8990 Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) MKT PLACE MEDICAID & MKT PLACE MEDICAID ONLY ONLY N/A N/A C MHT 2018 PA Code Matrix Page 10
11 MEDICAID & MKT PLACE C MEDICAID ONLY MKT PLACE ONLY Pain Management Except trigger point injections [Acupuncture is not a Medicare/Medicaid/Marketplace covered benefit] G Physical Therapy: After Initial Evaluation G0151 S9131 N/A G G G G MHT 2018 PA Code Matrix Page 11
12 G0329 S Prosthetics & Orthotics L0480 L1640 L1860 L2000 L2090 L8692 N/A L0482 L1680 L1900 L2005 L2106 L0484 L1685 L1904 L2010 L2108 L0486 L1700 L1907 L2020 L2126 L0452 L1710 L1920 L2030 L2128 L0622 L1720 L1940 L2034 L2232 L0640 L1730 L1945 L2036 L2800 L0700 L1755 L1950 L2037 L4631 L0710 L1834 L1960 L2038 L6026 L1000 L1840 L1970 L2050 L7259 L1005 L1844 L1980 L2060 S1040 L1110 L1846 L1990 L2080 L0637 L8614 L0650 L5856 Radiation Therapy & Radio Surgery MEDICAID & MKT PLACE G0339 G6015 G G0340 G6016 Q9950 MEDICAID ONLY MKT PLACE ONLY Sleep Studies PLEASE NOTE: Home Sleep Studies do not require auth. Molina of Texas: No PA Required TX allows only 2 Sleep Studies per year with no PA 95800* 95806* 95810* N/A N/A 95801* 95807* 95811* 95805* 95808* 95803* *MHTX No PA Required. Speech Therapy: After Initial Evaluation S9152 S9128 S9152 S9128 S MHT 2018 PA Code Matrix Page 12
13 Specialty Pharmacy Drugs (Injectable) Note: Pharmacy requests should be faxed to: (Medicaid/CHIP/MarketPlace) , (MMP/Medicare) MEDICAID & MKT PLACE MEDICAID ONLY MKT PLACE ONLY J0850 J1571 J2505 J7189 J9355 J9293 J0202 N/A N/A J0572 J1572 J2507 J7190 J7504 J9301 J0596 C9138 C9138 C9132 J0573 J1573 J2597 J J9302 J0695 C9136 J0574 J1595 J2778 J7192 J9171 J9306 J C9257 J0575 J1599 J2793 J7193 J9307 J0875 J2724 J9015 J2724 J9015 C9399 J0598 J1602 J2796 J7194 J7527 J9310 J1447 S S S0145 J0888 J1645 J2820 J7195 J7639 J9315 J1575 J9043 J9357 J9043 J9357 S0148 J0881 J1650 J9330 J7196 J7682 J9351 J1833 J0725 J3355 J0725 J3355 J0129 J0885 J1652 J2941 J7197 J7686 J9354 J2502 J2783 J2783 J0135 J1675 J9267 J7198 J2248 J9371 J2860 A9542 A9542 J0178 J0895 J1725 J3060 J7199 J8530 J9400 J3090 J0364 L8605 J0364 L8605 J0180 J0897 J1743 J3110 J7201 J9600 J3380 J9261 S0132 J9261 S0132 J0207 J1290 J1744 J7309 J9267 J7188 J0637 A9543 Q5102 J1300 J1745 J3262 J7310 J9019 J8521 J7205 S0128 J1640 J0220 J1322 J1786 J3285 J7311 J9035 Q2043 J7313 J9050 S0157 J0221 J1324 J1826 J3315 J7312 J9042 Q2050 J7328 J9098 J9160 J0256 J1325 J1830 J3357 J7316 J9047 Q3027 J7340 C9293 J2425 J0257 J1438 J1930 J3385 J7321 J9202 Q3028 J8655 J8520 J9125 J0401 J1442 J1931 J3396 J7323 J9207 Q4074 J9032 J0205 S0122 J0480 J1458 J1950 J9303 J7324 J9025 Q9977 J9039 J8700 J0485 J1459 J2170 J3489 J7325 J9041 J2020 J9271 J0490 J1460 J9262 J3490 J7326 J9214 Q4145 J9299 J0585 J1556 J9999 J3590 J7327 J9216 Q4149 J9308 J0586 J1557 J2315 J7181 J7330 J9217 Q5101 J0587 J9330 J2323 J7182 J9218 J9264 J9305 J0289 J0588 J1559 J2353 J7200 J J9017 Q9977 J0597 J1560 J2354 J7178 J9225 J1740 J0592 J0878 J0638 J1561 J9999 J7180 J9226 J0894 J9120 J1453 J0717 J1562 J2357 J7183 J9228 J9055 J9395 J9155 J9245 J1566 J2426 J7185 J0641 J9201 J9179 C9139 J0775 J1568 J2440 J7186 J7187 J9206 J1955 J0800 J1569 J2503 J7187 J2562 J9266 J9263 C9483 J0287 J2504 J9045 J9265 Q0138 Q0139 C9140 S0073 C9485 C9486 C9490 C9488 J1750 J1756 J2916 J3145 J7320 J7511 J0640 J1230 J1570 J7308 J9000 J9065 J9070 J9100 J9130 J9150 J9181 J9190 J9200 J9208 J9209 J9211 J9213 J9230 J9268 J9280 J9328 J9340 J9360 Q9985 Q9986 Q9989 J0571 C9484 C9489 J3095 J3240 J0570 J0594 J1439 J2430 J2469 J9027 J9040 J9060 J9178 J9250 J9260 J9370 J9390 J1942 J2182 J2786 J2840 J7175 J7179 J7202 J7209 J8679 J9034 J9145 J9176 J9205 J9295 J9325 J9352 *No PA required for ocular diagnoses Transplant Services (Including Solid Organ and Bone Marrow) S S S2053 S2140 S2053 S S2054 S2142 S2054 S S2055 S2150 S2055 S S2060 S2152 S2060 S S2061 S MHT 2018 PA Code Matrix Page 13
14 Transportation Services (Non-Emergent) A0426 A0428 A0430 A0431 S9960 S9961 S9960 S9961 A0999 Unlisted/Miscellaneous Codes PLEASE NOTE: Molina requires authorization on all Unlisted/Miscellaneous unless otherwised specified. Medical necessity documentation and rationale be submitted with the PA request for all Unlisted/Miscellaneous codes. Texas Additional Exceptions Refer to the TX Medicaid Fee Schedule for Non-Covered Code verification as codes can be updated monthly. PA Required Submit clinical information supporting use of these codes Texas Medicaid requires authorization on all feeding/nutrition products listed below. Specialty Pharmacy Drugs refer to the Vendor Drug Program and Texas Medicaid Provider Procedure Manual for pharmacy requests requiring prior authorization. Claims payment is dependent on payable National Drug Code upon claims submission. Incontinence Supplies/Diapers for Texas Medicaid require authorization on members 20 and under ONLY. Pain management requires authorization in any setting. Therapy Services: Require authorization after initial evaluation S A4554 T4525 T4537 T T4521 T4526 T4539 T G T4522 T4527 T4540 T G T4523 T4528 T4541 T G T4524 T4529 T4542 T B4034 T4530 T4543 T S1040 S B4103 B4035 B4036 B B4152 B4104 B4149 B4150 B4157 B4153 B4154 B4155 MHT 2018 PA Code Matrix Page 14
15 B4161 B4158 B4159 B4160 B4172 B4162 B4164 B4168 B4185 B4176 B4178 B4180 B4199 B4189 B4193 B4197 B9000 B4216 B5100 B5200 B9998 B9002 B9004 B9006 S9123 B9999 S9152 S9153 T1003 S9124 T1000 T1002 NO PA Required MEDICARE/ G A T Nursing Facility Rate Grouped Members Behavioral Health Requests Below Require Authorization MEDICAR/MEDICAID MHT 2018 PA Code Matrix Page 15
16 Cosmetic/Reconstructive J9035 Dx Related Codes No PA required for Dx of Breast CA No PA Required when used with Ocular Dx's ICD-10 Medicaid Marketplace ICD-9 ICD-10 Medicaid Marketplace C N N B39.4 N N C N N B39.5 N N C N N B39.9 N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N MHT 2018 PA Code Matrix Page 16
17 C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N C N N E N N D05.01 N N E N N D05.02 N N E N N D05.10 N N E N N D05.11 N N E N N D05.12 N N E N N D05.80 N N E N N D05.81 N N E N N D05.90 N N E N N D05.91 N N E N N D05.92 N N E N N DO5.00 N N E N N DO5.82 N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N MHT 2018 PA Code Matrix Page 17
18 E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N MHT 2018 PA Code Matrix Page 18
19 E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N MHT 2018 PA Code Matrix Page 19
20 E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N E N N H21.1X1 N N H21.1X2 N N H21.1X3 N N H21.1X9 N N H32 N N H N N H N N H N N H N N H N N MHT 2018 PA Code Matrix Page 20
21 H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H34.9 N N H35.00 N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N MHT 2018 PA Code Matrix Page 21
22 H N N H N N H N N H N N H N N H N N H N N H35.09 N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H35.20 N N H35.21 N N H35.22 N N H35.23 N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H N N H35.33 N N H N N H N N H N N H N N H35.81 N N MHT 2018 PA Code Matrix Page 22
23 H35.82 N N H40.50X0 N N H40.50X1 N N H40.50X2 N N H40.50X3 N N H40.50X4 N N H40.51X0 N N H40.51X1 N N H40.51X2 N N H40.51X3 N N H40.51X4 N N H40.52X0 N N H40.52X1 N N H40.52X2 N N H40.52X3 N N H40.52X4 N N H40.53X0 N N H40.53X1 N N H40.53X2 N N H40.53X3 N N H40.53X4 N N H40.89 N N H44.20 N N H44.21 N N H44.22 N N H44.23 N N MHT 2018 PA Code Matrix Page 23
IMPORTANT NOTICES. Office visits and/or procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA.
, PA Code Matrix IMPORTANT NOTICES This document is updated quarterly. Please check this document prior to PA submission as codes may be removed or added. All codes listed require PA unless there is a
This document is updated quarterly. Please check this document before a Prior Authorization (PA) submission since codes may be removed or added
This document is updated quarterly. Please check this document before a Prior Authorization (PA) submission since codes may be removed or added All codes listed require PA Non-PAR Providers require PA
This document is updated quarterly. Please check this document prior to PA submission as codes may be removed or added. All codes listed require PA.
, PA Code Matrix IMPORTANT NOTICES September 1, 2016 This document is updated quarterly. Please check this document prior to PA submission as codes may be removed or added. All codes listed require PA.
IMPORTANT NOTICES. To search this document, use [Ctrl + F] keys. Enter Service or Code in Navigation pane; press Enter.
![IMPORTANT NOTICES. To search this document, use [Ctrl + F] keys. Enter Service or Code in Navigation pane; press Enter.](/thumbs/89/97516388.jpg "IMPORTANT NOTICES. To search this document, use [Ctrl + F] keys. Enter Service or Code in Navigation pane; press Enter.")
IMPORTANT NOTICES These codes are for OP Services only. ALL IP services require PA. This Matrix is updated quarterly, please check this document prior to PA submission as codes may be removed or added.
2017 MHI PA Matrix Updates Log
2017 Q4 Updates 2017 MHI PA Matrix Updates Log Received Effective Specialty/Service Update Applies to LOB Notes 6/14/2017 10/1/2017 Specialty Pharmacy Add/PA Required: C9490*, J7511, J0640, J1230, J1570,
IMPORTANT NOTICES. All codes listed in this document require authorization, unless otherwise specified.
IMPORTANT NOTICES This document is updated quarterly. Codes requiring prior authorization may be added or deleted. Please check this document prior to submitting your prior authorization request as changes
Molina 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
MOLINA HEALTHCARE MEDICAID PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 6/1/2018
MOLINA HEALTHCARE MEDICAID PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 6/1/2018 THIS PRIOR AUTHORIZATION/PRE-SERVICE GUIDE APPLIES TO ALL MOLINA HEALTHCARE MEDICAID MEMBERS ONLY REFER TO MOLINA
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
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
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 REVISED 2/1/16 I. Inpatient Admissions-All inpatient admissions
Covered (blood, blood components, human blood products, and their administration) Covered (Some restrictions)
Washington Apple Health Medical Benefits Allergy Services (Antigen/Allergy Serum/Allergy Shots) Ambulance Services (Air Transportation) by FFS* Ambulance Services (Emergency Transportation) Ambulatory
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
I. Out of Network: There are no OON benefits. However for any medically necessary service not available in network, authorization will be provided
Essential Plan Authorization Grid FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION EFFECTIVE 1/1/2018 I. Out of Network: There are no OON
Super 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
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
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
Summary 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
Your Out-of-Pocket Type of Service
Calendar Year Deductible (CYD) 1 $3,000 single/ 3x family Out-of-Pocket Maximum - Deductibles and copays all accrue towards the out-of-pocket $6,200 single/ 2x family maximum. With respect to family plans,
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
Molina 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
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
Kaiser Permanente Washington - Pre-Authorization requirements:
Kaiser Permanente Washington - Pre-Authorization requirements: Kaiser Permanente Washington requires pre-authorization for most services to be covered. The information below outlines pre-authorization
The 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
Summary 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
2018 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
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
CO-PAYMENT BOOK Las Vegas Blvd. South Suite 107 Las Vegas, NV
CO-PAYMENT BOOK 1901 Las Vegas Blvd. South Suite 107 Las Vegas, NV 89104 702-733-9938 www.culinaryhealthfund.org Revised January 2018 (Replaces Co-Payment Book dated June 2017) TABLE OF CONTENTS 4 5 6
CLASSIC BLUE SECURE/BLUE CROSS BLUE SHIELD COMPLEMENTARY Monroe County Benefit Summary/Comparison (Over 65 Retirees)
WHO IS COVERED Enrollment Requirement Members must be enrolled in both Medicare Parts A and B Members must be enrolled in both Medicare Parts A and B Type of Tier Single only Single only Dependent/Student
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.
Summary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx]
![Summary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx]](/thumbs/86/94175655.jpg "Summary 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
CUSTODIAL NURSING HOME CARE
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
Summary 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
FACILITY BASED SERVICES
FACILITY BASED SERVICES Inpatient Hospital Care Elective Inpatient Admission or Elective Inpatient Surgery Inpatient Rehabilitation Care Skilled Nursing Facility Admission Non-Custodial Nursing Home Care
FACILITY BASED SERVICES
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
Excellus Blue PPO Signature Hybrid 1
Excellus Blue PPO Signature Hybrid 1 Drug Coverage Excluded Benefit Time Period: 03/01/2018-12/31/2018 Trinity Health - Syracuse Traditional General Cost Sharing Expenses Deductible - Single $250 $750
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
Service Rendered EBCBS GHI Health Plan Notes Alcohol Detox/Rehab (IP or OP) Submit to GHI. Submit to GHI
New York City Account Claim Submission Guide The purpose of this guide is to help determine which insurance carrier to send a claim to for certain hospital versus medical services. For instructions on
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
Martin s Point US Family Health Plan Pre-Authorization Requirements
Martin s Point US Family Health Plan Requirements Requirements described below are for covered benefits only and this information is provided for summary purposes only. Please call 1-888-732-7364 for complete
BCBSAZ Individual HMO Portfolio ZCS Plan Attachment Neighborhood Network On Exchange
BCBSAZ Individual HMO Portfolio ZCS Plan Attachment Neighborhood Network On Exchange 21016 0118 Suite E PLAN NETWORK Your Plan Network is the Neighborhood Network. The BCBSAZ provider directory of Neighborhood
General Preauthorization Overview Capital BlueCross Effective Date: October 1, 2015 Revised: September 30, 2015 Preauthorization Contact Information:
General Preauthorization Overview Capital BlueCross Effective Date: October 1, 2015 Revised: September 30, 2015 Preauthorization Contact Information: Clinical Management Behavioral Health (Magellan Health
Blue 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
Excellus BluePPO Signature Deduct 3
Excellus BluePPO Signature Deduct 3 Drug Coverage Excluded Benefit Time Period: 03/01/2018-12/31/2018 Trinity Health - Syracuse HSA General Cost Sharing Expenses - Single $1,500 $2,500 $3,500 - Two Person
Blue 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
Your Out-of-Pocket Type of Service
Calendar Year Deductible (CYD) 1 $0 single/ 3x family Out-of-Pocket Maximum - Deductibles, coinsurance and copays all accrue toward the outof-pocket maximum. With respect to family plans, an individual
Summary of Benefits Prominence HealthFirst Small Group Health Plan
POS Triple Choice 3000 Summary of Benefits Calendar Year Deductible (CYD) $3,000 Single / $9,000 Family $7,000 Single / $21,000 Family $21,000 Single / $63,000 Family Coinsurance 40% coinsurance 50% coinsurance
2016 Medical Plan Comparison Chart
2016 Medical Plan Comparison Chart WellStar Health System is committed to helping you control healthcare costs while providing more choices and personal control over your healthcare coverage through the
Medicare 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
Kaiser Foundation Health Plan, Inc. A NONPROFIT HEALTH PLAN - HAWAII REGION
Kaiser Foundation Health Plan, Inc. A NONPROFIT HEALTH PLAN - HAWAII REGION 2019 Summary of Important Changes for Contract Renewals for the Kaiser Permanente Group Plan (These changes are subject to regulatory
Blue 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
2018 MA Plan 006. Alternative Medicine:Acupuncture and Naturopathy. $250 maximum combined total of acupuncture and naturopathy services
Abdominal Aortic Aneurysm Screening $0 copay For planned preventive services that become diagnostic during the Alternative Medicine:Acupuncture and Naturopathy AIR Ambulance (Non-emergency) $300.00 copay
Passport 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
WILLIS 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
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
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
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
Telemedicine services $0 copay Not applicable Primary care provider (PCP) CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance
Calendar Year Deductible (CYD) 2 Plan includes an embedded individual deductible provision. An embedded deductible combines individual and family deductibles in $4,000 Single / $8,000 Family $12,000 Single
GOLD 80 HMO NETWORK 1 MIRROR
GOLD 80 HMO NETWORK 1 MIRROR Summary of Benefits Group An independent member of the Blue Shield Association (Intentionally left blank) Gold 80 HMO Network 1 Mirror Summary of Benefits The Summary of Benefits
UnitedHealthcare SignatureValue TM Advantage Offered by UnitedHealthcare of California HMO Schedule of Benefits GOLD ADVANTAGE 0
CALIFORNIA SMALL GROUP UnitedHealthcare SignatureValue TM Advantage Offered by UnitedHealthcare of California HMO Schedule of Benefits GOLD ADVANTAGE 0 These services are covered as indicated when authorized
GIC 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
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
Platinum 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
MEDICAL BENEFIT SUMMARY GRID: TUFTS HEALTH TOGETHER (MASSHEALTH) CAREPLUS
MEDICAL BENEFIT SUMMARY GRID: TUFTS HEALTH TOGETHER (MASSHEALTH) CAREPLUS ABBREVIATIONS BH = Behavioral health IN = In-network MM = Medical management team at Tufts Health Plan = Out-of-network PA = Prior
Benefits are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES Annual Deductible The maximum out-of-pocket limit applies to all covered Medicare Part A and B benefits including deductible. Hearing aid reimbursement does not apply to the out-of-pocket
Gold Access+ HMO $30 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix)
Gold Access+ HMO $30 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED
SERVICES REQUIRING PRIOR AUTHORIZATION
S REQUIRING PRIOR AUTHORIZATION All Hospital Admissions (All Place of service 21 services require authorization.) ELECTIVE ADMISSIONS All hospital admissions require review by Gold Coast Health Plan Health
COVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE
COVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE This is a list of all covered services and benefits for MassHealth Standard and CommonHealth members enrolled
MEDICAL BENEFIT SUMMARY GRID: TUFTS HEALTH TOGETHER (MASSHEALTH) FAMILY ASSISTANCE
MEDICAL BENEFIT SUMMARY GRID: TUFTS HEALTH TOGETHER (MASSHEALTH) FAMILY ASSISTANCE ABBREVIATIONS BH = Behavioral health IN = In-network MM = Medical management team at Tufts Health Plan = Out-of-network
Platinum Local Access+ HMO $25 OffEx
Platinum Local Access+ HMO $25 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED
All Out-of-Network hospitalizations, surgeries, procedures, referrals, evaluations, services and treatment require prior authorization.
2018 OptumCare Utah Contracted Provider Prior Authorization List Items listed below require prior authorization. Out-of-Network All Out-of-Network hospitalizations, surgeries, procedures, referrals, evaluations,
NEVADA HEALTH CO-OP SOUTHERN STAR/ESTRELLA GOLD 100% 34996NV
NEVADA HEALTH CO-OP SOUTHERN STAR/ESTRELLA GOLD 100% 34996NV003 0002 Attachment A Benefit Schedule Lifetime Maximum: Unlimited. Benefits apply when you obtain or arrange for Covered through a Nevada Health
Blue 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
Covered 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
HOW 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
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
Essential Health Benefits Addendum. Office of the Insurance Commissioner Washington State
Essential Health Benefits Addendum Office of the Insurance Commissioner Washington State 1 Details, details Classification of Services Classification of a service may affect the scope of the available
Must meet specific criteria. Prior authorization required. Must meet specific criteria
MIDWEST HEALTH Acupuncture NOT A BENEFIT NOT A BENEFIT NOT A BENEFIT Acute Care Observation Post Operative Emergency Room Allergy Testing/Allergy Injections Ambulance-Emergency Land Plan Notification Not
Kaiser Permanente (No. and So. California) 2018 Union
Kaiser Permanente (No. and So. California) General Information Lifetime Maximum Benefit Annual Maximum Benefit Coinsurance Percentage Precertification Requirements Precertification Penalty Health Savings
Yes, for all plans, see or call for a list of network providers.
Important Questions (Massachusetts ) (New England ) (National ) What is the overall $0.00 Are there other s for specific? Is there an out of pocket limit on my expenses? What is not included in the out
RSNA 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:
Quick Reference Card
Amerigroup District of Columbia, Inc. Quick Reference Card Precertification/notification requirements Important contact numbers n Revenue codes https://providers.amerigroup.com/dc DCPEC-0176-17 Important
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.
Gold 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
Blue 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
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
Summary of Benefits Prominence Preferred Health Insurance Small Group Health Plan
Calendar Year Deductible (CYD) 2 $1,000 Single / $3,000 Family $3,000 Single / $9,000 Family Coinsurance - Member responsibility 20% coinsurance 50% coinsurance Out-of-Pocket Maximum 3 - Deductibles, coinsurance
Benefit Name In Network Out of Network Limits and Additional Information. N/A Pharmacy. N/A Pharmacy
Excellus BluePPO Drug Coverage Excluded Benefit Time Period: 01/01/2018-12/31/2018 HOBART & WILLIAM SMITH COLLEGES General Information Cost Sharing Expenses Deductible - Single $0 $500 Deductible - Family
2014 Review of Habilitative and Mental/Behavioral Health and Substance Abuse Services
2014 Review of Habilitative and Mental/Behavioral Health and Substance Abuse Services Please note that a similar version of this summary was distributed on 9/13/2013 but did not include attachments. Please
Blue Cross Premier Bronze
An individual PPO health plan from Blue Cross Blue Shield of Michigan. You will have a broad choice of doctors and hospitals within BCBSM s unsurpassed statewide PPO network including nationwide coverage.
HOME 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
HOW 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
Precertification: Overview
Precertification: Overview Introduction Precertification determines whether medical services are: Medically Necessary or Experimental/Investigational Provided in the appropriate setting or at the appropriate
WV Bureau for Medical Services & Molina Medicaid Solutions
WV Bureau for Medical Services & Molina Medicaid Solutions On January 1, 2014, Medicaid eligibility was expanded to qualified individuals ages 19 to 64 making 138% of the Federal Poverty Level. 112,464
COVERED SERVICES FOR NHP MASSHEALTH MEMBERS
COVERED SERVICES FOR NHP MASSHEALTH MEMBERS Neighborhood Health Plan Covered Services for MassHealth Standard & CommonHealth, Family Assistance, and CarePlus Issued and effective October 1, 2015 nhp.org/member
Regence Engage Plan Highlights For Groups of /1/2016
Plan Features Provider choice: Members have direct access to their choice of providers. Category 1 are Preferred; Category 2 are Participating; and Category 3 are Non-contracted providers. Simplicity:
CONRAD 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
Covered Benefits Rhody Health Partners ACA Adult Expansion
Covered s Rhody Health Partners ACA Adult Expansion Abortion Services Adult Day Services AIDS Medical and Non-Medical Case Management Alcohol and Substance Abuse Treatment Cosmetic Surgery Dental Care
Provider Guide for Prime Healthcare EPO
Provider Guide for Prime Healthcare EPO Revised: 02012014 Page 1 Table of Contents INTRODUCTION... 3 OVERVIEW... 3 BENEFIT AND REIMBURSEMENT... 3 PLAN PARTICIPATION... 4 UTILIZATION MANAGEMENT AND REFERRAL
UNIVERSITY OF THE CUMBERLANDS MEDICAL BENEFITS SCHEDULE
November 1, 2016 UNIVERSITY OF THE CUMBERLANDS MEDICAL BENEFITS SCHEDULE NETWORK NON-NETWORK Lifetime Maximum Benefit Unlimited Unlimited Annual Deductible (Single/Family) $500/$1,000 $1,000/$2,000 Maximum