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.
|
|
|
- Junior Henry
- 5 years ago
- Views:
Transcription
1 , 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. Office visits and/or procedures at PAR/Network Providers do not require PA (unless noted In Any Setting ). 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 non-covered codes. MDHHS - Fee Schedule 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 during the claim review. To search this document, use [Ctrl + F] keys; enter Service or Code in search navigation pane at left; press Enter MHM_PA Code Matrix (Eff OCT 2016 ) Page 1
2 , PA Code Matrix Table of Contents IMPORTANT NOTICES... 1 Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services... 3 Cosmetic, Plastic & Reconstructive Procedures (in ANY setting)... 3 Durable Medical Equipment (DME)... 3 Experimental/Investigational... 5 Genetic Counseling & Testing... 6 Habilitative Therapy... 6 Home Health Care & Home Infusion... 7 Hyperbaric Therapy... 7 Imaging Advanced & Specialty... 7 In-Patient Admissions... 8 Long Term Services & Support... 8 Neuropsychological & Psychological Testing... 8 Non-Par Offices/Providers/Facilities... 9 Office Based Procedures... 9 Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures... 9 Pain Management Procedures Pregnancy and Delivery Prosthetics & Orthotics Radiation Therapy & Radio Surgery Sleep Studies Speech Therapy Specialty Pharmacy Drugs (Injectable) Transplant Services (Including Solid Organ and Bone Marrow) Transportation Services (Non-Emergent AIR) Unlisted/Miscellaneous Codes MHM_PA Code Matrix (Eff OCT 2016 ) Page 2
3 , PA Code Matrix 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 is not a covered benefit for MI Child please direct to their local Community Mental Health Department H0031^ H2017^ T1023^ N/A N/A N/A H0032^ H2018 T1025^ H0046 H2019^ T1026^ H2012 H2020 T1027^ H2013 S0201 T1028^ H2014^ S5111 T2013^ 204 H0012^ H2015 S5150^ T2040^ 901 H0017 H2016 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] Cosmetic, Plastic & Reconstructive Procedures (in ANY setting) N/A N/A N/A Durable Medical Equipment (DME) A7025 E0983 E2295 E2614 K0835 E0445 S1034 N/A N/A E0194 E0984 E2310 E2615 K0836 E0481 S1035 E0255 E0986 E2311 E2616 K0837 E0483 S1036 E0256 E0988 E2312 E2617 K0838 E0651 S1037 E0260 E1002 E2313 E2620 K0839 E0261 E1003 E2321 E2621 K0840 E0265 E1004 E2322 E2622 K MHM_PA Code Matrix (Eff OCT 2016 ) Page 3
4 , PA Code Matrix E0266 E1005 E2325 E2623 K0842 E0277 E1006 E2326 E2624 K0843 E0292 E1007 E2327 E2625 K0848 E0293 E1008 E2328 E2626 K0849 E0294 E1012 E2329 E2627 K0850 E0295 E1010 E2330 E2628 K0851 E0296 E1014 E2340 E2629 K0852 E0297 E1020 E2341 E2630 K0853 E0300 E1029 E2342 E2631 K0854 E0301 E1030 E2343 K0008 K0855 E0302 E1035 E2351 K0009 K0856 E0303 E1036 E2361 K0010 K0857 E0304 E1161 E2366 K0011 K0858 E0328 E1225 E2367 K0012 K0859 E0329 E1226 E2368 K0014 K0860 E0371 E1227 E2369 K0108 K0861 E0372 E1230 E2370 K0606 K0862 E0373 E1232 E2373 K0800 K0863 E0462 E1233 E2374 K0801 K0864 E0465 E1234 E2375 K0802 K0868 E0466 E1235 E2376 K0806 K0869 E0483 E1236 E2377 K0807 K0870 E0691 E1237 E2378 K0808 K0871 E0692 E1238 E2397 K0813 K0877 E0693 E1296 E2500 K0814 K0878 E0694 E1298 E2502 K0815 K0879 E0747 E1310 E2504 K0816 K0880 E0748 E1399 E2506 K0820 K0884 E0749 E1700 E2508 K0821 K0885 E0760 E2201 E2510 K0822 K0886 E0762 E2202 E2511 K0823 K0890 E0764 E2203 E2605 K0824 K0891 E0782 E2204 E2606 K0825 K0900 E0783 E2227 E2607 K0826 S1040 E0784 E2228 E2608 K0827 V2530 E0785 E2291 E2609 K0828 V2531 E0786 E2292 E2611 K0829 E0849 E2293 E2612 K0830 E0855 E2294 E2613 K MHM_PA Code Matrix (Eff OCT 2016 ) Page 4
5 Experimental/Investigational, PA Code Matrix T 0268T 0335T 0402T 0329T 0438T 0438T T 0269T 0336T 0403T 0330T 0439T 0439T T 0270T 0337T 0404T 0331T 0442T 0442T T 0271T 0338T 0405T 0332T 0443T 0443T T 0272T 0339T 0406T 0333T 0444T 0444T T 0273T 0340T 0407T 0437T 0437T 0019T 0200T 0274T 0342T 0408T 0441T 0441T 0042T 0201T 0275T 0347T 0409T 0445T 0445T 0051T 0202T 0278T 0348T 0410T 0440T 0440T 0052T 0205T 0281T 0349T 0411T 0053T 0206T 0282T 0350T 0412T 0054T 0207T 0283T 0351T 0413T 0055T 0208T 0284T 0352T 0414T 0058T 0209T 0285T 0353T 0415T 0071T 0210T 0286T 0354T 0416T 0072T 0211T 0287T 0355T 0417T 0075T 0212T 0288T 0356T 0418T 0076T 0213T 0289T 0357T 0419T 0085T 0214T 0290T 0358T 0420T 0095T 0215T 0291T 0359T 0421T 0098T 0216T 0292T 0360T 0422T 0100T 0217T 0293T 0361T 0423T 0101T 0218T 0294T 0362T 0424T 0102T 0219T 0295T 0363T 0425T 0106T 0220T 0296T 0364T 0426T 0107T 0221T 0297T 0365T 0427T 0108T 0222T 0298T 0366T 0428T 0109T 0228T 0299T 0367T 0429T 0110T 0229T 0300T 0368T 0430T 0111T 0230T 0301T 0369T 0431T 0126T 0231T 0302T 0370T 0432T 0159T 0234T 0303T 0371T 0433T 0163T 0235T 0304T 0372T 0434T 0164T 0236T 0305T 0373T 0434T 0164T 0237T 0306T 0374T 0435T 0169T 0238T 0307T 0392T 0435T 0171T 0249T 0308T 0393T 0436T 0172T 0253T 0309T 0394T Q T 0254T 0310T 0395T Q T 0255T 0312T 0396T Q T 0263T 0313T 0397T Q MHM_PA Code Matrix (Eff OCT 2016 ) Page 5
6 , PA Code Matrix 0179T 0264T 0314T 0398T Q T 0265T 0315T 0399T 0184T 0266T 0316T 0400T 0188T 0267T 0317T 0401T 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 S3800 N/A S S S S S S S S S M M M M M * G S3722 NOTES: *Including Oncotype DX Habilitative Therapy After initial evaluation plus six (6) visits for outpatient and home settings S9128 N/A S S9129 S MHM_PA Code Matrix (Eff OCT 2016 ) Page 6
7 , PA Code Matrix Home Health Care & Home Infusion After initial evaluation plus six (6) visits; PA may be required for medications associated with Home Infusion. G0151 G0159 G0300 N/A 023X 043X N/A G0152 G X 044X G0153 G X 055X G0155 G X 056X G0156 G X 057X G0157 G X 060X G0158 G X 062X Hyperbaric Therapy G N/A N/A N/A Imaging Advanced & Specialty N/A N/A N/A C C C C C C C C C C C C C C C C MHM_PA Code Matrix (Eff OCT 2016 ) Page 7
8 , PA Code Matrix C C C C C C C C G G In-Patient Admissions Acute Hospital, Skilled Nursing Facilities (SNF), Rehabilitation, Long Term Acute Care (LTAC) Facility All Codes All Codes All Codes All Codes Long Term Services & Support [Not a Medicare covered benefit] N/A S5100 S5126 N/A N/A S5101 S5102 S5105 S5125 S9122 T1019 T1020 T1021 Neuropsychological & Psychological Testing N/A N/A N/A MHM_PA Code Matrix (Eff OCT 2016 ) Page 8
9 , PA Code Matrix Non-Par Offices/Providers/Facilities Auth required for Non-Par Office Visits, Procedures, Labs, Diagnostic Studies, In-patient stays, except for: Emergency Department Services Professional fees associated with ER visit and approved Ambulatory Surgery Center (ASC) or in-patient stay Women s Health, Family Planning and Obstetrical Services Federally Qualified Health Center (FQHC) / Rural Health Center (RHC) / Tribal Health Center (THC) Child and Adolescent Health Center Services Local Health Department (LHD) services Other services based on State requirements Office Based Procedures PAR Physician/Provider office-based procedures do not require PA, see above for Non-PAR. There are no codes associated with Office Based Procedures for PAR Providers see codes listed below for Outpatient Hospital or Ambulatory Surgery Center requiring Prior Authorization. Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures PLEASE NOTE: Medicare - N/A & MKT PL - N/A MEDICAID MEDICARE - MEDICAID - MKT PL MHM_PA Code Matrix (Eff OCT 2016 ) Page 9
10 , PA Code Matrix MEDICAID MEDICARE - MEDICAID - MKT PL F MHM_PA Code Matrix (Eff OCT 2016 ) Page 10
11 Pain Management Procedures Acupuncture is not a Medicare covered benefit, PA Code Matrix G N/A N/A Pregnancy and Delivery Notification Only N/A N/A N/A N/A Prosthetics & Orthotics L0452 L1640 L1860 L2000 L2090 L3010 N/A N/A L0480 L1680 L1900 L2005 L2106 L3020 L0482 L1685 L1904 L2010 L2108 L1300 L0484 L1700 L1907 L2020 L2126 L8692 L0486 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 L1110 L1846 L1990 L2080 Radiation Therapy & Radio Surgery G0340 Q9950 N/A N/A N/A G G G0339 G MHM_PA Code Matrix (Eff OCT 2016 ) Page 11
12 Sleep Studies, PA Code Matrix N/A N/A N/A Speech Therapy After initial evaluation plus six (6) visits for outpatient and home settings S9128 N/A S9128 Specialty Pharmacy Drugs (Injectable) J1566 J7513 Q N/A J1568 J7515 Q C9132 J1569 J7516 Q9980 A9542 A9542 C9136 J1571 J7517 Q9981 A9543 A9543 C9257 J1572 J7525 S0073 C9137 C9137 C9441 J1573 J7527 S0145 C9138 C9138 C9461 J1575 J7639 S0148 C9293 C9293 C9470 J1595 J7682 C9399 J0289 C9471 J1599 J7686 J0180 J0364 C9472 J1602 J7999 J0221 J0592 C9473 J1645 J8499 J0596 J0637 C9474 J1650 J8530 J0597 J0641 C9475 J1652 J8562 J0598 J0725 C9476 J1675 J8655 J0638 J0878 C9477 J1725 J8999 J0800 J0882 C9478 J1744 J9019 J0833 J0894 C9480 J1745 J9032 J1290 J1453 J0129 J1786 J9035* J1300 J1740 J0135 J1826 J9039 J1322 J2020 J0178 J1830 J9042 J1324 J2425 J0202 J1833 J9047 J1458 J2562 J0205 J1930 J9202 J1640 J2724 J0207 J1950 J9207 J1743 J2783 J0215 J2170 J9212 J1931 J2788 J0220 J2212 J9213 J1955 J3355 J0256 J2278 J9214 J2315 J8520 J0257 J2315 J9216 J2504 J8521 J0480 J2323 J9217 J2724 J8700 J0485 J2353 J9218 J2793 J MHM_PA Code Matrix (Eff OCT 2016 ) Page 12
13 , PA Code Matrix J0490 J2354 J9219 J3060 J9017 J0585 J2355 J9225 J3385 J9025 J0586 J2357 J9226 J3485 J9033 J0587 J2440 J9228 J3490 J9041 J0588 J2502 J9245 J7178 J9043 J0596 J2503 J9262 J7180 J9050 J0638 J2505 J9267 J7181 J9055 J0695 J2597 J9271 J7182 J9098 J0714 J2778 J9293 J7183 J9120 J0717 J2796 J9299 J7185 J9155 J0740 J2820 J9301 J7186 J9160 J0775 J2860 J9302 J7187 J9171 J0850 J2940 J9306 J7188 J9179 J0875 J2941 J9307 J7189 J9201 J0881 J3030 J9308 J7190 J9206 J0885 J3090 J9310 J7192 J9215 J0888 J3110 J9315 J7193 J9261 J0890 J3240 J9351 J7195 J9264 J0895 J3262 J9354 J7197 J9266 J0897 J3285 J9371 J7198 J9303 J1322 J3315 J9400 J7199 J9305 J1325 J3357 J9600 J7200 J9330 J1438 J3365 Q0515 J7201 J9355 J1442 J3380 Q2028 J7205 J9357 J1447 J3396 Q2043 J9041 J9395 J1459 J3487 Q2050 J9047 J9999 J1460 J3488 Q3027 JO834 L8605 J1556 J3489 Q3028 L8605 S0122 J1557 J3490 Q4074 S0017 S0126 J1559 J3590 Q4101 S0145 S0128 J1560 J7178 Q4139 S0148 S0132 J1561 J7183 Q4145 S0157 S0157 J1562 J7340 Q4149 S0157 S0157 J9035* NO PA Required for Ocular Conditions J9035* PA Required for Non-Ocular Conditions 2016 MHM_PA Code Matrix (Eff OCT 2016 ) Page 13
14 , PA Code Matrix Transplant Services (Including Solid Organ and Bone Marrow) Corneal Transplants do not require PA MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PL N/A S2053 S S2054 S S2055 S S2060 S S2061 S S2065 S S2140 S S2142 S S2150 S S2152 S2152 Transportation Services (Non-Emergent AIR) PA required for Non-Emergent Air Transportation. A0430 A0431 A0999 MEDICARE - MEDICAID - MKT PL Unlisted/Miscellaneous Codes Molina requires medical necessity documentation and rationale be submitted with the PA request for these codes: T5999 N/A T A A A B E E E J K K L L L L L MHM_PA Code Matrix (Eff OCT 2016 ) Page 14
15 , PA Code Matrix L L L L L Q Q Q V V V V MHM_PA Code Matrix (Eff OCT 2016 ) Page 15
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
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
Office visits and office-based surgical procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA.
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
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
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
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,
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
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
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
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
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
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
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
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
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
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
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.
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
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
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
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
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):
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
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
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
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
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
Covered Services and Any Limits
WellCare of South Carolina Covered Services and Any Limits Abortions and related Covered only in the case of rape or incest or if the member s life is in danger Allergy testing and treatment Ambulance
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
Covered Services and Any Limits
WellCare of South Carolina Covered Services and Any Limits Abortions and related Covered only in the case of rape or incest or if the member s life is in danger Allergy testing and treatment Ambulance
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
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
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
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
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
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,
Metallic Policy Prior Approval Guide
Metallic Policy Guide Inpatient Outpatient Pharmacy Prior Approval Diagnostic Imaging Durable Medical Equipment This guide is solely for Metallic policies with the following alpha prefixes: AEE, AXC, EXX,
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
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
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
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
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
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
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
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
Service Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note:
Service Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note: If you are a Medicaid beneficiary and have a serious mental illness, or serious emotional disturbance, or developmental
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
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
AmeriHealth Caritas North Carolina Provider Data Intake Form
AmeriHealth Caritas North Carolina Provider Data Intake Form Section 1 instructions: Please complete all fields below for the provider. Entity name (as written on W9): IPA name (if applicable): Category:
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
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
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
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
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
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
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
Good health is part of the plan.
Good health is part of the plan. Presbyterian Health Plan has a long tradition of providing quality health care to State of New Mexico employees and their families. For 108 years, Presbyterian has been
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
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
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
Integrity Accountability Collaboration Trust Respect
S REQUIRING PRIOR AUTHORIZATION Only valid codes will be reviewed. Please refer to CMS/MC guidelines to verify validity. All Hospital Admissions (All Place of service 21 services require authorization.)
Schedule of Benefits HDHP WITH HSA MASSACHUSETTS
Schedule of Benefits HDHP WITH HSA MASSACHUSETTS ID: MD0000017710_A9 X This Schedule of Benefits states any Benefit Limits and amounts you must pay for Covered Benefits. However, it is only a summary of
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
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
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
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
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
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
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:
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
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
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
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
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
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
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
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
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.
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
Behavioral Health Providers: Frequently Asked Questions (FAQs)
Behavioral Health Providers: Frequently Asked Questions (FAQs) Q. What has changed as far as behavioral health services? A1. Effective April 1, 2012, the professional and outpatient facility charges for
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
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
Provider Orientation Molina Healthcare of Ohio, Inc.
Provider Orientation Molina Healthcare of Ohio, Inc. Agenda Molina Healthcare Overview Ohio Managed Care Overview Molina Healthcare Members Eligibility Enrollment Benefits Health Care Services Prior Authorization
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
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
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
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
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
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
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
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
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.
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
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
Combined Evidence of Coverage and Disclosure Form
Access+ HMO Combined Evidence of Coverage and Disclosure Form Santa Barbara City College Group Number: HSC214 Effective Date: October 1, 2012 An Independent Member of the Blue Shield Association Medical