2016 MDwise HIP Medical Services that Require Prior Authorization
|
|
|
- Michael Lambert
- 6 years ago
- Views:
Transcription
1 2016 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance transport (non-emergent transport) Air Ambulance Elective/emergent/urgent medical, surgical inpatient admissions, and skilled nursing facility services Inpatient Rehabilitation With the exception of ER, Ambulance, Urgent Care Center services, Immunizations, Family planning services, chiropractic services, podiatry, and ologists, except if service is otherwise listed on PA list. A0426 & A0428 A0430, A0435 A0431, A0436 Subacute admission POS 21 Transplants Accidental dental services (other than ER) Bariatric Surgery including the work up/ evaluation for transplant Cochlear Implants surgery (See DME for device) General anesthesia for dental procedures D D9248 POS 21, 22, 24, 51, Maternity stays are notification only and no prior authorization number is issued. POS 21 or 61 and accommodation codes 024, POS 21 or POS 61. Revenue code 024 POS 21 - For outpatient need to have the following: S9975, Solid: Heart/lung Liver Pancreas Bone Marrow: Heart valve tissue transplants: 33933, Stem cell: Pancreas: Intestine: , D0100-D0999. Please contact Dentaquest for prior authorization of dental services Roux-en-Y , Gastroplasty , Gastric banding sleeve , 43771, 43772, 43773, Gastrectomy , 43847, 43848, 43886, 46887, Duodenal switch , 43775, 43844, Revised September 1, 2016
2 Hysterectomy 51925, , , , , Mastectomy reconstructive surgery Same as breast reconstruction below Maxillofacial surgeries/tmj -including Arthroplasty, Arthroscopy, Reconstruction, Discectomy (with or without disc replacement), trigger point injections, Arthrocentesis, and mandibular orthopedic repositioning appliances (MORA) 21010, , 21050, 21060, 21070, 21073, 21116, , , 21255, 29800, 29804, S8262 Non-cosmetic reconstructive surgery Included in potentially cosmetic Potentially cosmetic procedures in addition to other procedures listed separately: blepharoplasty, septoplasty/rhinoplasty, port wine stain removal, otoplasty, breast reconstruction, breast enlargement, breast reduction/mammoplasty, mammoplasty for gynecomastia, breast implant removal, excision of excess skin due to weight loss including panniculectomy/abdominoplasty, lipectomy or excess fat removal, varicose vein treatment, cleft lip/palate surgery, congenital craniofacial anomaly surgery, surgical treatment of congenital chest wall deformity (pectus excavatum), breast congenital anomaly (i.e. polymastia) 11200, 11201, , , , , 15847, , , 19300, , , 30520, , 30520, , 37785, , , 54660, , 67730, 67974, 67975, 69300, or diagnosis or S2066, S2067,S2068, 19301, 19302, 19303, 19304, 19304, 19305, 19306,19307, Breast congenital anomaly (i.e. polymastia) Included in Breast Reconstruction Breast enlargement (same as Augmentation) Same as Augmentation above Congenital craniofacial anomaly surgery Included in Maxillofacial above Tonsillectomy & Adenoidectomy Uvulopalatoplasty including laser assisted Vision surgery - Laser in-situ keratomileusis (LASIK), laser epithelial keratomileusis (LASEK), Photorefractive Keratectomy (PRK), Photostigmatic keratectomy (PARK/PRK-A), Epikeratoplasty 42820, 42821, 42825, 42826, 42830, 42831, 42835, S0800, S0810, S0812, Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy Replacement or repair of thoracic unit of a total replacement heart system (artificial heart) Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit 0051T 0052T 0053T
3 Insertion or replacement of permanent subcutaneous defibrillator system/ Insertion of subcutaneous implantable defibrillator electrode/ Removal of subcutaneous defibrillator electrode/ Repositioning of previously implanted subcutaneous implantable defibrillator electrode/programming device evaluation (in person)/ Interrogation device evaluation (in person)/electrophysiologic evaluation of subcutaneous implantable defibrillator Home health services 33270, 33271, 33272, 93260, 93261, POS 12 with the following codes, G0151, G0152, G0153, G0155, 99600, TE, TD, 99601, 99602, 92610, S9349, S9127, 97001, 97003, Initial evaluation codes for PT, OT, ST in home and all subsequent therapy visits in home requires PA. Home IV infusion S9349 Tocolytics, Home oxygen Hospice (inpatient and outpatient) Nutritionals and Supplements, Enteral/Parenteral Nutrition and services Outpatient ST/OT/PT Outpatient Pulmonary rehab, regardless of total claim cost The initial evaluation does not require prior auth. Prior authorization is required for PT or OT exceeding the 12 hours or visits per discipline within 30 calendar days. No PA required for ST for the first 12 visits or hours within a calendar year. A4615- A4616, A7046, E0424-E0455, E0460, E0461, E0463, E1352-E1392, E1405, E1406, K0738 All POS 34, For POS 12, the following should pend: 651, 652, 655 and 656 with HCPCS codes Q5001-Q5010 B4034 -B9998 Cochlear Implants (device) L8614- L8619 Durable Medical equipment Electric breast pump all DME and supplies >$500 (total claim) including rental or purchase requires prior authorization, rental or purchase of $500 or more per claim PT - Revenue codes - 420, 421, 422, 423, 429, and 97002, 97004, , OT - Revenue codes , 439 ST - Revenue codes 440,-443, 449, 92507, 92508, 92520, 92521, 92522, 92523, 92524, 92525, ST - Revenue codes 440, 441, 442, 443, 449, 92507, 92508, 92520, 92521, 92522, 92523, 92524, 92525, ALL DME codes. Please also refer to the orthotics category of this document for other items that may be considered DME that require prior authorization.
4 Hearing Aids Orthotics Prosthetics TENS (see pain management) Bone Density study for members under 65 years of age Botox Injections Chiropractic Clinical trials for cancer treatment Dialysis Genetic testing for orthotics of $250 or more of $500 or more per claim Left and Right ear- V5030, V5040, V5050, V5060, V5070, V5080, V5095, V5100, V5120, V5130, V5140, V5150, V5170, V5180, V5190, V5210, V5220, V5230, V5242-V5261, V5263, V5267 Bilateral- V5100, V5120, V5130, V5140, V5150, V5248, V5249, V5250, V5251, V5252, V5253, V5258, V5259, V5260, V5261 L0100-L4631 L5000 L9900 A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731, A4290 G G HX CP CP CP J0585, J0586, J0587, J0588 Please refer to worksheet titled Drugs requiring PA , 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, , 97039, 97110, 97112, 97113, 97116, 97124, 97139, Rev codes 082x, 083x, 084x-, 085x 81228, 81229, 88230, 88367, 88291, 80502, 88262, 88289, 88230, 72090, Hyperbaric oxygen 413, 99183,C1300, A4575, E0446 PET Scan- All MRA- ALL MR Spectroscopy , 404, G0219-G0235, 78459, 78491, 78492, 78608, 78609, , 73225, 71555, 70544, 70545, 70546, 73725, 70547, 70548, 70549, 72198, (billed under MRI revenue codes) MRI- Abdomen 74181, 74182, MRI - Pelvis 72195, 72196, 72197
5 MRI - Lower Extremity MRI- 3D MRI - Brain MRI - Chest 71550, 71551, 71552, MRI - Cervical, Thoracic, lumbar spine , MRI - Breast CT scan - Cervical, Thoracic, lumbar spine CT scan -Thorax CT-Scan -Abdomen CT scan - maxillofacial 70486, 70487, CT Scan -Pelvis 72191, 72192, 72193, D CT scans 77061, 77062, 77063, Podiatry (also described as routine foot care per HIP 2.0 benefit plans), after 6 visits Pulse generator 61885, The following radiation therapy requires prior auth: IMRT Vision training therapy Routine OB Ultrasounds PICC line insertion for OB services (i.e. hyperemesis gravidarum) Pain management- including trigger point injection, facet joint and/or facet joint nerve injection, Epidural steroid injection, transcutaneous electric nerve stimulator Sacral nerve, Neuro or Spinal Cord stimulator Behavioral Health Podiatry visits require prior authorization AFTER the 6th visit. All services rendered during the visit unless otherwise noted on this prior authorization list are included in the visit limit without authorization and 77386, more than 2 OB ultrasounds require prior auth the following require prior authorization (TENS) with Diagnosis codes Z34.00, Z34.80, Z34.90, Z33.1, O09.00-O09.93, Z36, O00-O99, P05.00-P with diagnosis of O21-O21.8, O20-O21.9, O44-O47, O67-O68 A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731, A4290, , 62310, 62311, , 72275, 77003, , , 64561, 64581, E0744- E0749, E0762, E0766, L8679-L , 64454, 64455, (for implant) 43647, (for electrodes) Coding PA requirement as outlined on the following pages.
6 Medical Benefit Drugs that Require Prior Authorization Therapeutic Category Brand Name Generic Name Applicable Code(s) Botulinum Toxins Botox onabotulinumtoxin A J0585 Dysport abobotulinumtoxin A J0586 Myobloc rimabotulinumtoxin B J0587 Xeomin incobotulinumtoxin A J0588 Endocrine Agents Enzyme Replacement Therapy Hormonal Modifiers Immune Globulins H.P. Acthar corticotropin J0800 Makena hydroxyprogesterone caproate None Cerezyme imiglucerase J1786 Elelyso taliglucerase J3060 Lumizyme alglucosidase alfa J0221 Myozyme alglucosidase alfa J0220 Vimizim elosulfase alfa None VPRIV velaglucerase J3385 Eligard, Lupron leuprolide J9217, J9218, J1950 Sandostatin octreotide J2354 Sandostatin LAR octreotide J2353 Trelstar LA triptorelin J3315 Zoladex goserelin J9202 Bivigam immune globulin, human J1556 Carimune immune globulin, human J1566 Flebogamma / Flebogamma DIF immune globulin, human J1572 GamaSTAN S/D immune globulin, human J1460 Gammagard S/D immune globulin, human J1566 Gammaplex immune globulin, human J1557 Privigen immune globulin, human J1459 Gammagard Liquid immune globulin, human J1569 Hizentra immune globulin, human J1559 Gamunex-C immune globulin, human J1561 Gammaked immune globulin, human J1561 Octagam immune globulin, human J1568 Hyqvia immune globulin, human with recombinant hyaluronidase None
7 Therapeutic Category Brand Name Generic Name Applicable Code(s) Immuno-modulators for Inflammatory Conditions Miscellaneous Immunomodulators Immuno-modulators for Multiple Sclerosis Metabolic Bone Disease Osteoarthritis Pulmonary Arterial Hypertension (PAH) Agents Actemra tocilizumab J3262 Benylsta belimumab J0490 Entyvio vedolizumab None Orencia abatacept J0129 Remicade infliximab J1745 Rituxan rituximab J9310 Simponi Aria golimumab J1602 Ilaris canakinumab J0638 Soliris eculizumab J1300 Sylvant siltuximab None Tysabri natalizumab J2323 Aredia pamidronate J2430 Boniva ibandronate J1740 Reclast zoledronic acid J3488 Prolia, Xgeva denosumab J0897 Zometa zoledronic acid J3487 Euflexxa sodium hyaluronate J7323 Gel-One sodium hyaluronate J7326 Hyalgan, Supartz sodium hyaluronate J7321 Monovisc sodium hyaluronate None Orthovisc sodium hyaluronate J7324 Synvisc, Synvisc-One sodium hyaluronate J7325 Flolan epoprostenol J1325 Veletri epoprostenol J1325 Aralast NP proteinase inhibitor J0256 Glassia proteinase inhibitor J0257 Prolastin, Zemaira proteinase inhibitor J0257 Respiratory agents Xolair omalizumab J2357 HIPP0208 (12/15) APP0229 (12/15)
2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services
MDwise HIP Prior Authorization and Drug List
MDwise HIP Prior Authorization and Drug List Services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services With the exception of ER, Ambulance, Urgent Care Center
2016 MDwise HIP Medical Services that Require Prior Authorization
2016 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Coding All Out of Network services Facility to facility ambulance transport
MDwise Community Health Network Hoosier Healthwise Medical Services that Require Prior Authorization
MDwise Community Health Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network
MDwise Hoosier Care Connect Medical Services that Require Prior Authorization
MDwise Hoosier Care Connect Medical Services that Require Prior Authorization Certain Indiana Health Coverage Programs (IHCP) services require prior authorization (PA) for members enrolled in the Hoosier
2017 MDwise HIP Medical Services that Require Prior Authorization
2017 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
2018 MDwise HIP Medical Services that Require Prior Authorization
2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
2018 MDwise HIP Medical Services that Require Prior Authorization
2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
2018 MDwise HIP Medical Services that Require Prior Authorization
2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
BCBS AZ ADV PLUS * CLASSIC * PREMIER For use with members associated with the BHN Network Prior Authorization List 2015
Prior Authorization List 2015 Participating providers are responsible to furnish or arrange health care services with other participating healthcare facilities or providers. Prior authorization requests
Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015
J0129 Injection, abatacept (Orencia ), 10 J0178 Injection, aflibercept (Eylea ), 1 J0256 J0257 J0585 J0586 J0587 J0588 J0597 J0641 J0717 J0800 Injection, alpha 1-proteinase inhibitor, human (Aralast NP,
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services
Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List
Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List Code Drug Name Effective and/or Term Date J0129 Injection, abatacept (Orencia ), 10 mg J0178 Injection, aflibercept (Eylea
MedStar Medicare Choice Pharmacy Services
Pharmacy Services 1 MedStar Medicare Choice Pharmacy Services Table of Contents At a Glance..page 2 Pharmacy Policies..page 4 Medicare Choice Pharmacy Programs..page 6 Where to Obtain Prescriptions..page
PA Category Name Code(s) Additional Notes ABA 0364T 0365T 0366T 0367T 0373T 0374T H G0396. Applied Behavioral Analysis stage 3*
ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0364T 0365T 0366T 0367T 0373T 0374T H2020 96116
Prior Authorization List for Physician Alliance of the Rockies, UnitedHealthcare Medicare Advantage Effective January 1, 2019
MEDICAL MANAGEMENT CONTACT INFO- MONDAY - FRIDAY FROM 8:00 AM TO 5:00 PM - (720) 445-9404 *ALL REFERRALS TO SPECIALISTS REQUIRE PRIOR AUTHROIZATION* *ALL OUT OF NETWORK SERVICES REQUIRE PRIOR AUTHROIZATION*
Prior Authorization List for Physician Alliance of the Rockies, UnitedHealthcare Medicare Advantage Effective April 1, 2018
Prior List for Physician Alliance of MEDICAL MANAGEMENT CONTACT INFO- MONDAY - FRIDAY FROM 8:00 AM TO 5:00 PM - (720) 445-9404 *ALL REFERRALS TO SPECIALISTS REQUIRE PRIOR AUTHROIZATION* *ALL OUT OF NETWORK
Oregon CPT Preapproval Grid
Not Applicable Home Health Stays - For all Initial Certification and Recertification periods Notes: Initial Certification review required effective 1/1/12. Not Applicable Skilled Nursing Facility Stays
New Billing Guidelines for Home Infusion, Enteral and Parenteral Therapies Home Infusion Fee Schedule Effective July 1, 2009
STAT Bulletin PO Box 80 Buffalo, New York 14240-0080 May 12, 2009 Volume 15:Issue 18 To: All Home Health Care and Home Infusion Therapy Providers Contracts Effected: All Lines of Business New Billing Guidelines
PA Category Name Code(s) Additional Notes ABA. Applied Behavioral Analysis stage 3*
ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0373T H2020 96116 96112 96113 96121 96130 96131
Prior Authorization List Effective February 2, 2015
Prior Authorization List Effective February 2, 2015 Prior authorization is required for the following services. Prior authorization is the responsibility of the provider ordering or rendering services
Oregon CPT Preapproval Grid
* The following grid only identifies items that require preapproval from. 11400-11471 Excision benign lesion 15820-15823 Blepharoplasty Notes: If Opthamologist requesting, pre-auth is not required 19316-19318
Effective April 7, 2014 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST IMPORTANT
Effective April 7, 2014 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST The following services require clinical review preauthorization for commercial managed care products, Medicare,
SPECIALTY PHARMACY Master Clinical Drug List
Abraxane J9264 Provider ONCOLOGY None NO Actemra J3262 Provider ARTHRITIS PA - all YES Acthar HP Gel J0800 Prov/Self Med/Pharm ENDOCRINE/METABOLIC PA - all YES Adagen J2504 Provider ENZYME DISORDERS None
Louisiana Revised Prior Authorization Requirements
Louisiana Revised Prior Requirements Contact: Ann Kay Logarbo, M.D. Chief Medical Officer, a_logarbo@uhc.com All non-emergency inpatient admissions, including planned surgeries, require prior authorization.
Jan 30, Dear Provider:
Jan 30, 2015 Dear Provider: Kern Health Systems strives to provide quality and timely services to our members. Recently, KHS made changes to the services included on Prior Authorization Needed list. The
Pre-authorization Form
Northwest Montana Schools Consortium 2014 Please verify services not listed below on the pre-authorization list with Benefits and Eligibility (Customer Service) to determine coverage. Preauthorization
January 2016 Topic of the Month
January 2016 Topic of the Month MedStar Family Choice Medicaid Updated Authorization Rules Effective March 1, 2016 To all of our valued practitioners of MedStar Family Choice Medicaid in Maryland and the
UnitedHealthcare Notification/Prior Authorization Requirements Effective October 1, 2016
General Information This list contains notification/prior authorization review requirements for participating care providers for inpatient and outpatient services, as referenced in the UnitedHealthcare
Premera Blue Cross Medicare Advantage Plans Medical Policy Updates
Premera Blue Cross Medicare Advantage Plans Medical Policy Updates Medical Policy and Criteria Premera Blue Cross Medicare Advantage reviews all medical policies and criteria annually. The following updates
Provider Alert. November 30, 2017
Provider Alert November 30, 2017 Summary of changes to the MedStar Family Choice MD HealthChoice Plan Quick Authorization Guide effective for claims received 01/01/2018 1. The following eye procedures
Inpatient ALL TEXAS REFERRAL / AUTHORIZATION FORMS MUST BE SIGNED BY THE PCP OR ORDERING PHYSICIAN THAT HAS A VALID REFERRAL FROM THE PCP.
Prior Authorization List for Participating Providers Effective January 1, 2018 Applies to: Parkland HEALTHfirst, KIDSfirst, CHIP Perinate and CHIP Perinate Newborn This Prior Authorization List supersedes
Outpatient Specialty Referral Request Types
What is a request type? Request types are templates created for use with Health Net Federal Services, LLC s (HNFS) online referral and authorization submission tools, available at www.tricare-west.com
PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
UnitedHealthcare Notification/Prior Authorization Requirements Effective July 1, 2017
General Information This list contains notification/prior authorization review requirements for participating care providers for inpatient and outpatient services, as referenced in the 2017 UnitedHealthcare
National Accounts Utilization Management Requirements New York based Accounts
National Accounts Utilization Management Requirements New York based Accounts The table below reflects our National Accounts standard Utilization Management (UM) requirements. For precertification, please
BCN Advantage SM requirements for drugs covered under the medical benefit
J0586 ABOBOTULINUMTOXINA Dysport X X X the medication is being used to treat J0178 AFLIBERCEPT Eylea X X X X X of Neovascular (Wet) -Related Macular Degeneration of Macular Edema following either central
sad EFFECTIVE DATE: POLICY LAST UPDATED:
Medical Coverage Policy Prior Authorization via Web-Based Tool for Procedures sad EFFECTIVE DATE: 09 01 2015 POLICY LAST UPDATED: 12 18 2018 OVERVIEW This policy documents the prior authorization request
2018 HDHP. Denver Health Medical Plan, Inc. Career Service Employees (CSE) and Denver Employee Retirement Plan (DERP) HighPoint Denver Plus Network
2018 HDHP Denver Health Medical Plan, Inc. Career Service Employees (CSE) and Denver Employee Retirement Plan (DERP) HighPoint Denver Plus Network HighPoint Denver Cofinity Network Out of Network Deductible
Participating Provider Non- Participating Provider Limitations & Exceptions. deductible applies. 75% of the Fund's fee schedule; deductible applies
Medical Benefits for eligible Pension Members and their eligible dependents who are not Eligible for Medicare effective 1/1/2019. NOTE $50,000.00 lifetime major medical maximum effective 1/1/2013 Out-of-network
Allergen specific, each allergen is covered up to 50 units per patient annually; additional units would require medically necessary review.
ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION () GRID FOR MEDICAL BENEFITS FOR DIRECTLY CONTRACTED PROVIDERS ONLY Effective 01/01/2019 Before services are provided, please check: Member
INJECTABLE MEDICINES. Resources, Links or Additional Information. J Code Brand Names Generic names Prior Authorization or Restrictions
J9190 5-FU fluorouracil None. J0401 ABILIFY MAINTENA aripiprazole i.v. J9264 ABRAXANE paclitaxel protein bound J3262 ACTEMRA IV tocilizumab Yes, through Navitus. Restricted to (in at least consultation
sad EFFECTIVE DATE: POLICY LAST UPDATED:
Medical Coverage Policy Prior Authorization via Web-Based Tool for Procedures sad EFFECTIVE DATE: 09 01 2015 POLICY LAST UPDATED: 12 19 2017 OVERVIEW This policy documents the prior authorization request
UNIVERSITY OF THE INCARNATE WORD, S2855 SILVER RBP PLAN GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address & PPO Company Remit claims to: Gilsbar, Inc., P.O. Box
UNIVERSITY OF THE INCARNATE WORD, S2855 PPO PLAN GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address & PPO Company Remit claims to: CIGNA Physicians & Hospitals
Medication Policy Manual. Policy No: dru408. Topic: Site of Care Review Date of Origin: July 10, 2015
Medication Policy Manual Policy No: dru408 Topic: Site of Care Review Date of Origin: July 10, 2015 Committee Approval Date: August 17, 2018 Next Review Date: August 2019 Effective Date: October 1, 2018
UNIVERSITY OF THE INCARNATE WORD, S2855 BRONZE RBP PLAN GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address Remit claims to: Gilsbar, Inc., P.O. Box 2947, Covington,
MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold
SECTION XXIV MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold COST-SHARING Deductible Individual Family Out-of-Pocket Limit Individual Family $0 $0 $7,150 $14,300 except as required for emergency
2018 Anthem Blue Cross Senior Secure HMO - Southern CA - Post 65 (Medicare Eligible)*
General Information Lifetime Maximum Benefit Annual Maximum Benefit Coinsurance Percentage Precertification Requirements Prior authorization is required for select services. Services must be coordinated
STAT Bulletin. Drug Therapy Guideline Updates. To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business
STAT Bulletin November 28, 2011 Volume 9: Issue 27 To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business Drug Therapy Guideline Updates Why you re receiving this Stat
Prior treatment with non-biologic Disease- Modifying Antirheumatic. Not to be used in combination with another biologic DMARD
Abatacept (Orencia) 1, 2, 7, 11, 13, 14, 18, 24, 31, 44, 48, 49, 51, 53, 55, 57 J0129 Alpha 1 - Proteinase inhibitor (Prolastin-C) 5, 6, 10, 12, 40 Medically Necessary (if all the following criteria apply):
Arkansas State Specific UM Statistics for Prior Authorizations
Arkansas State Specific UM Statistics for Prior Authorizations 2016 2017 Quarter One Quarter Two Quarter Three Quarter Four 2018 Quarter One Quarter Two Quarter Three Quarter Four 2016 Number of Prior
Specialty Referrals. Start of Code Range (Procedure Low Code) Request Request Profile Description. End of Code Range (Procedure High Code)
What is a request profile? profiles are templates created for use with specialty referral, outpatient authorization, and outpatient behavioral health service request submissions. Each request profile has
Essential Health Benefits Standard Specialty PA and QL List July 2016
Anti-infectives Antiretrovirals, HIV SELZENTRY (maraviroc) Cardiology Antilipemic Pulmonary Arterial Hypertension Central Nervous System Anticonvulsants Depressant Neurotoxins Parkinson's Sleep Disorder
Pharmacy and Medical Guideline Updates
STAT Bulletin PO Box 15013 Albany, New York 12212 August 2, 2010 Volume 8: Issue 19 To: All PCPs and Specialists Contracts Affected: All Lines of Business Pharmacy and ical Guideline Updates As a result
PHC TAR REQUIREMENTS
A. Hospitalization 1. The hospital must notify PHC of any admission within 24 hours of the admission. 2. Authorization for elective admission must be requested by the admitting physician prior to the admission.
*** NOTE *** ALL services subject to deductible, unless otherwise noted.
MEDICAL BENEFITS Fund Name: International Association of Machinists Motor City Revised: 3/14/18 MP Fund ID: 2800 SPD Version: 10/2004 Who is covered? Actives, Retirees, & their Dependents Tax ID: 38-1422403
Injectable Drugs Requiring Pre-Service Approval
Abatacept Orencia J0129, 10 mg 1500 FL LCD- L29051 1) For patients with rheumatoid arthritis with failure, intolerance or contraindications to methotrexate. Limit dosing to 40 mg Q 2 weeks. 2) For patients
Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018
Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018 Payment for Services Covered Services are reimbursed based on the Allowable Charge. Blue Cross
Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018
1 Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018 Payment for Services Covered Services are reimbursed based on the Allowable Charge. BlueCross
Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018
Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018 Payment for Services Covered Services are reimbursed based on the Allowable Charge. Blue Cross
MVP PREMIER PLUS SCHEDULE OF BENEFITS Gold 4 MVP Health Plan, Inc. Embedded Deductible Off Exchange
COST-SHARING Deductible Individual Family Prescription Drug Deductible Individual Family Out-of-Pocket Limit Individual Family OFFICE VISITS Primary Care Visits (or Home Visits) Specialist Visits (or Home
Medical Pre-Authorization and Notification Requirements
NOTICE CHANGE IN PRE-AUTHORIZATION PROCESS EFFECTIVE JANUARY 14, 2019 The Health Plan has entered into a partnership with Palladian Health to improve outcomes for musculoskeletal conditions and spine pain
NEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS
. (EV-4) 25/45/1000 w/access Rider NEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to the important advantages of the Neighborhood
New York Essential Plan cost-sharing matrix
New York Plan cost-sharing matrix On January 1, 2016, Empire BlueCross BlueShield HealthPlus (Empire) is offering a new comprehensive and affordable health insurance program. The Plan is a health benefit
Brand Generic J-Code 1 Billable. Exclusion Criteria. Information and Criteria. Unit
Affinity Health Plan Department Of Pharmacy (Medicaid, Child Health Plus, Family Health Plus, Medicare Part B) **Medications Requiring Authorization under Medical Benefit** Click Here For Medication Authorization
UnitedHealthcare SignatureValue TM Focus Offered by UnitedHealthcare of California
CALIFORNIA SMALL GROUP UnitedHealthcare SignatureValue TM Focus Offered by UnitedHealthcare of California HMO SCHEDULE OF BENEFITS PLATINUM FOCUS-2 $0 These services are covered as indicated when authorized
Molina Healthcare of Washington Member Services: (800) /TTY
Benefits At-A-Glance Our goal is to provide you with the best care possible. Abortion Involuntary pregnancy termination (miscarriage) Voluntary pregnancy termination Acupuncture Ambulance Transportation
sad EFFECTIVE DATE: POLICY LAST UPDATED:
Medical Coverage Policy Prior Authorization via Web-Based Tool for Procedures sad EFFECTIVE DATE: 09 01 2015 POLICY LAST UPDATED: 12 19 2017 FOR INTERNAL USE ONLY: An RSS was requested to remove prior
Medical Policies and Clinical Utilization Management Guidelines update
Medical Policies and Clinical Utilization Management Guidelines update Medical Policies update Summary: On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following
MEDICAL SCHEDULE OF BENEFITS
MEDICAL SCHEDULE OF BENEFITS Plan(s) 011 (F) All health benefits shown on this Schedule of Benefits are subject to the following: Lifetime and annual maximums, Deductibles, Co-pays, Plan Participation
Medical and claim payment policy activity
Medical and claim payment policy activity Commercial business The following pages list the policy activity for commercial business that we have posted to our Medical Policy Portal from January 24 February
Medical and claim payment policy activity
Medical and claim payment policy activity Commercial business The following pages list the policy activity for commercial business that we have posted to our Medical Policy Portal from. For the most up-to-date
2016 Rochester Regional Health PPO Medical Plan Summary
Out of Annual Deductible Annual Deductible includes co-pays, coinsurance. The amounts are combined across all s. None Single Two-Person EE + Children Family $1,800 $3,600 $5,400 $5,400 Annual Out of Pocket
GILSBAR GROUP HEALTH PLAN S2202 OPTION 2 NON-GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB The Plan will cover all dependent Dependents children up to age 26 Filing Limit 12 months from date of service Mailing Address
MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018
MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018 FOR MMP MEDICAID, PLEASE REFER TO YOUR STATE MEDICAID PA GUIDE FOR ADDITIONAL PA REQUIREMENTS Refer to Molina
April 4, 2016 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST
A nonprofit independent licensee of the BlueCross BlueShield Association April 4, 2016 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST The following services require clinical review
Benefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information
BluePoint 3 Benefit Time Period: 06/01/2015-05/31/2016 Broome County - Red HMO Plan General Information Cost Sharing Expenses Deductible - Single $0 Deductible - Two Person $0 Deductible - Family $0 Services
NEW YORK STATE TEAMSTERS COUNCIL HEALTH & HOSPITAL FUND APPENDIX A SCHEDULE OF BENEFITS SUPREME BENEFITS
BENEFIT GUIDE NEW YORK STATE TEAMSTERS COUNCIL HEALTH & HOSPITAL FUND APPENDIX A SCHEDULE OF SUPREME IN NETWORK FEATURES Primary Care Physician Not Required 2 Physician Referrals Not Required 2 Out of
HealthyBlue Living SM
Deductible, Copays and Dollar Maximums Deductible Fixed Dollar Copays Coinsurance Annual Coinsurance Maximum (ACM) Out of Pocket Maximum - applies to deductibles, copays and coinsurance amounts for all
Please refer to your Benefit Handbook for further information about how your In-Network and Out-of- Network coverage works.
Schedule of Benefits The Harvard Pilgrim Health Care of New England USNH-STAFF/FACULTY POS Services listed are covered when Medically Necessary. Please see your Benefit Handbook for details. UI, 10/09
2018 Anthem Blue Cross HMO*
General Information Lifetime Maximum Benefit Annual Maximum Benefit Coinsurance Percentage 100.00% Precertification Requirements Pre-certification is required for certain services. However, this is an
PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
MEDICAL & RX BENEFIT MATRIX. American Environmental Group/HSA Plan EFFECTIVE DATE: MEDICAL & RX BENEFITS
MEDICAL & RX BENEFIT MATRIX American Environmental Group/HSA Plan EFFECTIVE DATE: 01-01-2011 MEDICAL & RX BENEFITS SCHEDULE OF BENEFITS MEDICAL BENEFITS COVERED SERVICE/PLAN IN-NETWORK OUT-OF-NETWORK CATEGORY
Schedule of Benefits. Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM POS MAINE
Schedule of s Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM POS MAINE ID: MD0000017736_A6 X This Schedule of s states any Limits and amounts you must pay for Covered s. However, it is only a summary
Date - Current Version Implementation. Date - First Implementationby - CO 7/1/ /9/2012 7/1/2013 7/1/2013 4/16/2013 4/1/2016 1/1/2013 1/1/2013
State: Nevada Anthem Blue Cross and Blue Shield Approved and adopted corporate Clinical Utilization Management (UM) Guidelines NEVADA Updated January 2, 2018 NOTE: Any Clinical Guideline not included in
Billing for Infusion Services in an Outpatient Neurology Clinic. Christine Mann, MBA Director of Infusion Services Dent Neurologic Institute
Billing for Infusion Services in an Outpatient Neurology Clinic Christine Mann, MBA Director of Infusion Services Dent Neurologic Institute Overview of Infusion Billing Codes Current Procedure Terminology
Vivida Health Specialty Pharmacy Drugs (Injectable) Prior-Authorization Requirements Effective 1/1/19
Vivida Health Specialty Pharmacy Drugs (Injectable) Prior-Authorization Requirements Effective 1/1/19 All Non-Par Provider Requests Requires Authorization Regardless of Service J0178 J0180 J0202 J0205
Medical Policies and Clinical Utilization Management Guidelines
providers.amerigroup.com Medical Policies and Clinical Utilization Management Guidelines Amerigroup Community Care began using Anthem s nationally recognized, evidence-based Medical Policies and Clinical
MEDICAL POLICY No R10 INFUSION SERVICES & EQUIPMENT
INFUSION SERVICES & EQUIPMENT Effective Date: August 1, 2017 Review Dates: 10/95, 12/99, 12/01, 11/02, 11/03, 11/04, 10/05, 10/06, 10/07, 10/08, 10/09, 4/10, 4/11, 4/12, 4/13, 5/14, 5/15, 2/16, 2/17, 5/17
April 8, 2018 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST
A nonprofit independent licensee of the BlueCross BlueShield Association April 8, 2018 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST The following services require clinical review
MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018
MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018 FOR MMP MEDICAID, PLEASE REFER TO YOUR STATE MEDICAID PA GUIDE FOR ADDITIONAL PA REQUIREMENTS Refer to Molina
Schedule of Benefits PPO MASSACHUSETTS
Schedule of s PPO MASSACHUSETTS ID: MD0000017711_A5 X This Schedule of s states any Limits and the amounts you must pay for Covered s. However, it is only a summary of your benefits. Please see your Handbook
Benefit Name Domestic In Network Out of Network. Benefit Name Domestic In Network Out of Network. 30% Coinsurance Subject to Deductible
Excellus BluePPO $5/$45/$90 Integrated Rx Benefit Time Period: 01/01/2019-12/31/2019 Thompson Health General Cost Sharing Expenses Deductible - Single $1,350 $1,350 $2,700 Deductible - Family $2,700 $2,700
Cover Comparison for AAMI Health Insurance Basic Hospital Plus
Cover Comparison for AAMI Health Insurance Basic Hospital Plus Summary of changes effective 1 April 2019 Product AAMI Health Insurance Basic Hospital Plus (previously AAMI Health Insurance Starter Hospital)
Medical and claim payment policy activity
Medical and claim payment policy activity Commercial business The following pages list the policy activity for commercial business that we have posted to our Medical Policy Portal from. For the most up-to-date