SERVICES REQUIRING PRIOR AUTHORIZATION
|
|
- Polly Ford
- 5 years ago
- Views:
Transcription
1 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 Services Department. For elective admissions, prior authorization is required for the procedure and the hospitalization. Ambulatory Surgery LTC EMERGENCY ADMISSIONS While the admission for emergencies does not require prior approval, hospitals MUST notify Gold Coast Health Plan Health Services department within 24 hours or the next business day of the patient admission. All days will be reviewed for medical necessity. All Outpatient surgeries require pre-authorization. All Long Term Care and Skilled Nursing Services require authorization. Genetic Testing S0265 S3713 S3800 S3818-S3855 S3860-S3862 S3865-S3866 Home Health Care S9127-S S9490-S9810 S5180-S5181 S9208-S9214 S9122-S9124 S9125-S9131 T1021-T1022 Z6900, Z6902, Z6904, Z6906, Z6908, Z6910, Z6920 Effective: 2/1/2016 Page 1 of 5
2 Outpatient Diagnostic Studies (MRI, CT Scan, PET Scans, Nuclear Medicine Imaging, Trans-cranial Doppler, Sleep Studies) Pain Management All Speech Therapy X4300-X4320 X4544 Z5918-Z5920 Z5962 V5362 X4544 Occupational Therapy (Authorization required after 10 visits. Includes 1 evaluation and 9 visits.) Podiatry Services Z7600-Z G0398-G X4100 X4120 All services with provider type PO require authorization with the exception of services for the following: Pregnant members Members under the age of 21 Members who reside in a Long Term Care Facility Effective: 2/1/2016 Page 2 of 5
3 Physical Therapy (Authorization required after 10 visits includes 1 evaluation and 9 visits.) Chiropractic Services Only covered for the following members: Members 20 years of age and under. Members in a skilled nursing facility (long term care). Members who are pregnant. Chiropractic Services are also covered for adults when performed at a Federally Qualified Health Center (FQHC) or a Rural Health Center (RHC) (No prior-authorization required for first 2 visits per calendar month. Authorization required for any additional visits per calendar month.) Out of Network Services All OON services require authorization X3900-X Exceptions include: Family planning services (including pregnancy testing) Sexually transmitted disease testing and treatment HIV testing Abortion services Emergency Room services (facility and professional) Non-Participating Facility services require authorization. Non-Participating Provider services require authorization. These services do not require authorization and can be provided to members by any willing Medi-Cal provider. Renal, Hemo, and Peritoneal Dialysis Phototherapy (All Phototherapy requires authorization.) DME Dental Anesthesia No prior-authorization required E0202 S9098 S0812 Hyperbaric Oxygen Chamber A4575 C1300 Authorization required for purchase > $500 and rental > $200 per month. All dental anesthesia and IV sedation requires authorization when performed by a medical anesthesiologist. Effective: 2/1/2016 Page 3 of 5
4 Supplies Home Infusion Therapy S5035-S5036 S5497-S5523 S9325-S9368 S9370-S9379 S9400-S9404 S9490-S9810 S9494-S9497 Non Emergent Transportation Enteral Nutrition No prior-authorization required. Transportation covered by Ventura Transit. B4102-B4104 B4149 B4150-B4155 B4157-B4162 Prosthetics and Orthotics Prior authorization required only for services/equipment costing > $200. Hearing Devices L8614 V5140 V5030 V5150 V5040 V5170 V5050 V5180 V5060 V5190 V5070 V5210 V5080 V5220 V5120 V5230 V5130 V5265-V5275 V5928 Therapies: (Sclerotherapy, Proton Beam, Neutron Beam, MEG, IMRT) S2202 G G6015 Effective: 2/1/2016 Page 4 of 5
5 Injectables J2325 J1568 J0775 J1569 C9257 J1572 J7312 J3490 J7311 J3590 J3262 J0585-J0588 J0490 J7321 J0129 J7323 J1459 J7324 J1556 J7325 J1557 J7326 J1559 J1561 J1562 J1566 Hospice In-Network but Out of Area Z7106 Authorization required for all out of Ventura County providers including those who have contracts with GCHP. Exceptions include contracted DME and medical supply vendors. *The following services do not require authorization and can be provided to members by any willing Medi-Cal provider. Family planning services (including pregnancy testing) Sexually transmitted disease testing and treatment HIV testing Abortion services *Preventive and pre-natal care do not require prior-authorization but must be delivered by in-network providers. Effective: 2/1/2016 Page 5 of 5
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.)
More informationCovered 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
More informationMedi-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
More informationCovered 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
More informationA. 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
More informationA. 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
More informationNEIGHBORHOOD 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
More informationKaiser 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
More informationCUSTODIAL 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
More informationFACILITY 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
More informationFACILITY 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
More informationKY Medicaid Co-pays Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following:
This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant
More informationKY Medicaid Co-pays. Acute admissions medical Per admission diagnoses $0 Acute health care related to. Per admission substance abuse and/or for
This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant
More informationBenefit 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
More informationBenefit 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
More informationBenefit 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
More informationAND 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
More informationCovered 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
More informationWhat you need to know about your benefits Gold Coast Health Plan (GCHP) Combined Evidence of Coverage (EOC) and Disclosure Form MEMBER HANDBOOK
What you need to know about your benefits Gold Coast Health Plan (GCHP) Combined Evidence of Coverage (EOC) and Disclosure Form 2018 MEMBER HANDBOOK 2 Other languages and formats Other languages You can
More informationCovered Benefits Rhody Health Partners
Covered s Rhody Health Partners s Covered by UnitedHealthcare Community Plan As member of UnitedHealthcare Community Plan, you are covered for the following services. (Remember to always show your current
More informationCovered (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
More informationThis 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.
More informationAppeal Process Information
First-Level Appeals Appeal Process Information Regulation 7 AAC 105.270 stipulates the length of time a provider has to submit a first-level appeal. Most firstlevel appeals must be filed within 180 days
More informationIMPORTANT 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
More informationCLASSIC 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
More informationCovered 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
More informationSummary 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
More informationGeneral 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
More informationChoice 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
More informationThe 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
More informationSummary 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
More information2017 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
More informationIMPORTANT 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
More informationWILLIS 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
More information2017 Summary of Benefits
H5209 004_DSB9 23 16 File & Use 10/14/2016 DHS Approved 10 7 2016 This is a summary of drug and health services covered by Care Wisconsin Medicare Dual Advantage Plan (HMO SNP) January 1, 2017 to December
More informationServices Covered by Molina Healthcare
Services Covered by Molina Healthcare As a Molina Healthcare member, you will continue to receive all medically-necessary Medicaid-covered services at no cost to you. The following list of covered services
More informationI. 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
More informationStanislaus County Medical Benefits EPO Option. In-Network Benefits (Stanislaus County Partners in Out-of-Network Benefits
Stanislaus County Medical EPO Option The following summary of benefits is a brief outline of the maximum amounts or special limits that may apply to benefits payable under the Plan. For a detailed description
More informationAll 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,
More informationExcellus 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
More informationBlue 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
More informationRFS-7-62 ATTACHMENT E INDIANA CARE SELECT PROGRAM DESCRIPTION AND COVERED BENEFITS
The following services are covered by the Indiana Care Select Program. Dual-eligible members, those members eligible for both IHCP and Medicare, will not receive any benefits under Indiana Care Select,
More informationMust 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
More informationProvider 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
More informationNEVADA 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
More informationSummary 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
More informationCentennial Care Provider Notification Grid
Page 1 of 5 Ablative Procedure for Venous Insufficiency & Varicose Veins Accredited Residential Treatment Center (ARTC) Acute Inpatient Medical (incl. Detoxification services & LTACH)) Acute Inpatient
More informationMyHPN 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
More informationBasic Covered Benefits and Services
Basic Covered Benefits and A prior authorization is when UnitedHealthcare Community Plan gives the doctor permission to perform certain services. Bed Liners Coverage Covered for members age 4 and up; Prior
More informationIrvine Unified School District ASO PPO /50
An Independent member of the Blue Shield Association Irvine Unified School District ASO PPO 500 90/50 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) THIS
More informationExcellus 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
More informationBlueOptions - Healthy Rewards HRA Plan
BlueOptions - Healthy Rewards HRA Plan Schedule of Benefits Plan 03359 Important things to keep in mind as you review this Schedule of Benefits: This Schedule of Benefits is part of your Benefit Booklet,
More informationMolina 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
More informationPreauthorization Program Effective Date: 01/01/2015 PPO, COMP, POS
SERVICES REQUIRING PREAUTHORIZATION Members should present their identification card to their health care provider when medical services or items are requested. When members use a participating provider
More informationSummary 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
More informationSummary 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
More informationMMA 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
More informationServices Covered by Molina Healthcare
Services Covered by Molina Healthcare Because you are covered by Medicaid, you pay nothing for covered services. As a Molina Healthcare member, you will continue to receive all medically necessary Medicaid-covered
More informationSISC Blue Shield of California 90% Plan C $10 Copayment Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix)
SISC Blue Shield of California 90% Plan C $10 Copayment Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE
More informationKaiser 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.
More informationUB-82 AND UB-92 CONVERSION TABLE - TO BE USED FOR REPORTING NON-INSTITUTIONAL HCSRS
6010.50-M, MAY 1999 DATA REQUIREMENTS CHAPTER 2 ADDENDUM H UB-82 AND UB-92 CONVERSION TABLE - TO BE USED FOR REPORTING NON-INSTITUTIONAL HCSRS The revenue codes listed below are authorized by the National
More informationCO-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
More informationMedicare 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
More informationCovered 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
More informationBlue 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
More informationFLEX RETIREE MAP (Over 65 Flex Retirees) 2018 Benefits PROFESSIONAL SERVICES. Visit to a physician, physician assistant or nurse practitioner at a PPG
PROFESSIONAL SERVICES Visit to a physician, physician assistant or nurse practitioner at a PPG Periodic health evaluations/preventive services - Applies when the only service(s) provided is a Medicare
More informationSERVICES 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
More informationMEDICAL 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
More informationCovered 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
More informationSummary of Benefits Report SENIOR CARE PLUS: VALUE BASIC PLAN (HMO)-009 January 1, 2015 December 31, 2015 WASHOE COUNTY, NEVADA
SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare).
More informationMEDICAL 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
More informationBenefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information
Excellus BluePPO $5/$35/$70, $0 gen for kids Integrated Rx, No Ded Prev Rx Benefit Time Period: 01/01/2018-12/31/2018 NYSADA General Information Cost Sharing Expenses Deductible - Single $3,500 $3,500
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO 20 (20/0%) EFFECTIVE JULY 1, 2017 These services are covered as indicated when authorized through your Primary Care Physician
More informationAmeriHealth 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:
More informationServices That Require Prior Authorization
Services That Require Prior Authorization Some of the services listed in the Medical Benefits Chart are covered only if your doctor or other network provider gets approval in advance (sometimes called
More informationCovered 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
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California Performance HMO Schedule of Benefits (Package A, Network 1) 10/0% These services are covered as indicated
More informationY0021_H4754_MRK1427_CMS File and Use PacificSource Community Health Plans, Inc. is a health plan with a Medicare contract
Y0021_H4754_MRK1427_CMS File and Use 08262012 PacificSource Community Health Plans, Inc. is a health plan with a Medicare contract Section I - Introduction to Summary of s Thank you for your interest in.
More information2018 Summary of Benefits
2018 Summary of Benefits H5209-004_MDASB 9-13-17 Accepted 9/18/2018 DHS Approved 09/13/2017 This is a summary of drug and health services covered by Care Wisconsin Medicare Dual Advantage Plan (HMO SNP)
More informationGold 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
More informationBenefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information
Excellus BluePPO $5/$35/$70, $0 gen for kids Integrated Rx, No Ded Prev Rx Benefit Time Period: 01/01/2018-12/31/2018 NYSADA General Information Cost Sharing Expenses Deductible - Single $2,600 $2,600
More informationST. TAMMANY PARISH SCHOOL BOARD SCHEDULE OF BENEFITS
PLAN NAME ST. TAMMANY PARISH SCHOOL BOARD SCHEDULE OF BENEFITS St. Tammany Parish School Board Active Employee Plan PLAN'S ORIGINAL BENEFIT PLAN DATE PLAN'S AMENDED BENEFIT PLAN DATE GROUP NUMBER 78B03ERC
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California Performance HMO Schedule of Benefits (Benefit Package B, Network 2) 20/500A These services are covered
More informationThis plan is pending regulatory approval.
Bronze Full PPO 3000 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective October 1, 2015 THIS MATRIX IS INTENDED TO BE USED
More informationPROFESSIONAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare INPATIENT HOSPITAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare
PROFESSIONAL SERVICES PCP office visits Specialist office visits Annual physical exam/preventive care Physical, speech & occupational therapy Flu and pneumonia vaccinations Diagnostic services including
More informationGOLD 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
More informationSummary of Benefits Platinum 90 HMO Trio
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum 90 HMO Trio Individual and Family Plan HMO Benefit Plan This Summary of Benefits shows the
More informationJanuary 1, 2015 December 31, Maintenance Organization (HMO) offered by HEALTHNOW NEW YORK INC. with a Medicare contract)
BLUECROSS BLUESHIELD SENIOR BLUE 601 (HMO), BLUECROSS BLUESHIELD SENIOR BLUE HMO SELECT (HMO) AND BLUECROSS BLUESHIELD SENIOR BLUE HMO 651 PARTD (HMO) (a Medicare Advantage Health Maintenance Organization
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO Schedule of Benefits 20/250A These services are covered as indicated when authorized through your
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California Performance HMO Schedule of Benefits (Package A, Network 1) 10/0% These services are covered as indicated
More informationMHP 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
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO Schedule of Benefits 20/0% These services are covered as indicated when authorized through your Primary Care
More informationUnitedHealthcare 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
More informationSt Peter s Health Partners EPO Plan
St Peter s Health Partners - 2017 EPO Plan Plan Overview: The St Peter s Health Partners (SPHP) EPO plan offers an Exclusive Network of Facilities for plan participants to receive care. The network consists
More informationBlue 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
More informationBlue 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
More informationUnitedHealthcare SignatureValue TM Alliance Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Alliance Offered by UnitedHealthcare of California HMO Deductible Schedule of Benefits HRA-QUALIFIED DEDUCTIBLE HEALTH PLAN 35-50/20%/2000DED
More informationFor Large Groups Health Benefit Single Plan (HSA-Compatible)
Financial Features (DED 1 ) (PBP 2 ) (DED is the amount the member is responsible for before Florida Blue pays) Out-of-Network Inpatient Hospital Facility Services Per Admission (PAD) Coinsurance (Coinsurance
More informationST. MARY S HEALTHCARE SYSTEM, INC. Case # GA6476 BlueChoice HMO Benefit Summary Effective: January 1, 2018
ST. MARY S HEALTHCARE SYSTEM, INC. Case # GA6476 BlueChoice HMO Benefit Summary Effective: January 1, 2018 All benefits are subject to the calendar year deductible, except those with in-network copayments,
More informationMartin 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
More information