Martin s Point US Family Health Plan Pre-Authorization Requirements

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1 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 for complete pre-authorization guidance. You may also visit: To confirm provider participation in our network* To download a pre-authorization request form To review a summary of covered benefits, limitations and exclusions Please fax completed pre-authorization request forms to or call (option 3). For pre-authorization of mental health/substance abuse services (in-patient or outpatient), call the Behavioral Health Care Program at Abrasion Treatment, Dermabrasion, Salabrasion Allergy Injections Ambulance s, Air Benefit limitations apply Ambulance s, Ground Medical necessity required Audiological/Audiometric Testing Routine screening not covered except as part of well child preventive benefit. Biofeedback Biopsy, Office Biopsy, Outpatient Hospital Bone Marrow Biopsy, Office Bone Marrow Biopsy, Outpatient Hospital Capsule Endoscopies Cardiac Catheterization including diagnostic procedures, stent insertion, drug eluting stent, and balloon angioplasty Cardiac Rehabilitation, Phase II Status change to observation or inpatient admission requires pre-authorization. Cataract Surgery, Outpatient Eyeglass frames and lenses postcataract surgery do not require preauthorization. Chemotherapy Regimen If treatment includes medication(s) listed under Prior Authorization Medications, specific pre-authorization for the medication(s) is required in addition to pre-authorization for chemotherapy. Colonoscopy, Diagnostic or Routine Screening, Office or Outpatient Hospital

2 Contact Lens Fitting Benefit is limited for treatment of disease. All other fitting of contact lenses is not covered. Dental Procedures and Dental Supplies, Adjunctive Only Developmental Evaluations and Testing Diabetes Education/ADEF Diagnostic Procedures, Office or Outpatient (e.g., EMG, nerve conduction, digestive endoscopy, EGD, urodynamic studies, endoscopic ultrasound) Diagnostic Tests, Office or Outpatient (e.g., lab work, x-rays, MRAs, MRIs, CAT scans, PET scans, SPECT, EEG, cardiac tests) Dialysis Treatment Routine dental care and supplies are not covered. Network facilities should be used for diagnostic testing whenever possible. Dietary Counseling See Nutritional Counseling. Durable Medical Equipment Please call Emergency Room s Status change to observation or inpatient admission requires preauthorization. Any follow-up services in ER require pre-authorization. Eye Examinations, Annual Routine Member may self refer to a participating provider without PCP referral. Eye Examinations, n-routine (e.g., diabetic, cataract, glaucoma) Foot Care, n-routine (e.g., treatment of injury or trauma to foot or toes) Foot Care, Routine (e.g., paring corns/ calluses, nails, debridement) Fracture Care, Office Gastric Bypass and all related services beyond initial consult Genetic Testing Hearing Evaluations (i.e., to diagnose hearing loss) Home Health s (e.g., skilled nursing, physical therapy, occupational therapy, speech therapy) Hospice s Routine foot care covered only for patients with systemic disease of lower extremity. Benefit limitations apply. Routine hearing screening not covered except for as part of well child care benefit. s relating to hearing aids are not covered except for patients enrolled in TRICARE Program For Persons With Disabilities.

3 Hospital Clinic (e.g., Pain Clinic, Wound Clinic, etc.) Immunizations and Vaccinations (preventive health) Immunizations for Travel Only covered for dependents of active duty military for required travel outside the US as a result of duty assignment. t covered for routine travel. Infertility and Impotence s Inpatient Facility (Hospital) Admissions IV Therapy, Outpatient Hospital Mammography, Medical Diagnosis Mammography Screening, Routine Annual routine mammography, regardless of age. Network facilities should be used for diagnostic testing whenever possible. Maternity s, Observation Stay or Inpatient Admission Maternity s, Pre-and Post-Natal Global OB pre-authorization does not include pre-authorization for observation or inpatient stay. Medications Requiring Pre-authorization in Office, Outpatient, or Home Neuropsychological Testing Nutritional Counseling for the treatment of patients with Diabetes Refer to separate list This list is reviewed quarterly. All other conditions Observation Stay Status change to inpatient admission requires pre-authorization. Occupational Therapy, Office/Clinic Office Visit, Primary Care Physician Office Visit, Specialist Consultative Visit Oncology s Organ Transplant Orthopaedic Braces, Customized Splints, Orthotic Devices Pacemaker Checks Pain Clinic s Physicals, Annual Routine Physical Therapy in an Office/Clinic Physician Visits Provided in Hospital Office Pool Therapy Proctosigmoidoscopy Diagnostic, Office or Outpatient Hospital Please call

4 Martin s Point US Family Health Plan Pulmonary Rehabilitation Radiation Therapy Sigmoidoscopy, Diagnostic or Routine Screening, Office or Outpatient Hospital Skilled Nursing Stay Speech Therapy, Office/Clinic Surgery, Inpatient Hospital Surgery, Office If the service includes plastic, cosmetic, reconstructive, or scar revisions, the US Family Health Plan must pre-authorize the services Surgery, Outpatient Hospital and Ambulatory Surgical Center Status changes to observation or inpatient admission requires preauthorization. Telemedicine Ultrasound, Diagnostic Ultrasound, Endoscopic, Office or Outpatient Urgent Care Center Members should notify the PCP within 48 hours. Any follow-up services at Urgent Care Center require preauthorization. Urodynamic Studies Wound Clinic s *Martin s Point US Family Health Plan Point-of- (POS) Option The US Family Health Plan Point-of- payment policy applies to most services rendered to our members by non-contracted (out-of-network) providers. Generally, US Family Health Plan members will pay a larger cost share for services rendered by an out-of-network provider than they would for the same services rendered by an in-network provider. The exceptions to this policy are the following health care services which are paid at the innetwork level and are not subject to Point of deductible and cost-share regardless of the provider s network status: Ambulance (ground only), Cardiac Catheterization, Cardiac Rehabilitation (Phase II only), Diagnostic Procedures Office or Outpatient - (e.g., EMG, nerve conduction, digestive endoscopy, EGD, urodynamic studies, endoscopic ultrasound), Emergency Room s, Home Health s; Mammography (Diagnostic or Routine), Urgent Care Center and Mental Health (first six visits only).

5 All other services rendered by non-contracted providers (even if pre-authorized) may be subject to the POS payment policy. Some non-contracted services may be pre-authorized to be paid at in-network rates based upon medical necessity or network adequacy. The US Family Health Plan has a comprehensive network of Primary Care Providers (PCPs), hospitals, and specialty providers that is continually expanding and changing. To determine if a provider is currently participating in our network, please refer to our online Provider Directory at: or call For the latest lists of health care services, procedures, equipment and medications requiring prior authorization by the US Family Health Plan, please visit: Revised March 2013