National Accounts Utilization Management Requirements New York based Accounts

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Dana Palmer
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1 National Accounts Utilization Management Requirements New York based Accounts The table below reflects our National Accounts standard Utilization Management (UM) requirements. For precertification, please contact the toll free number located on the back of the Member s ID card. For benefits to be paid, the member must be eligible on the date of service and the service must be a covered benefit under the policy. Foreign, Medicare and coordination of benefits (COB) does not require prior authorization. Utilization Management (UM) Requirements National Accounts Inpatient Admissions Elective Admissions Emergency Admissions (required Plan notification is within 48 hours) OB-related Medical Stays (OB complications; excludes childbirth. Precertification is needed if the maternity stay exceeds 48 hours for a normal delivery or 96 hours for a cesarean section.) Newborn Stays beyond Mother s discharge Inpatient Skilled Nursing Facility Admissions Inpatient Rehabilitation Facility Admissions Inpatient Hospice Admissions Human Organ and Bone Marrow/Stem Cell Transplants All Inpatient Organ and Tissue Transplants All Outpatient Organ and Tissue Transplants Outpatient Services Home Health Care Services Home Infusion Therapy Transportation Services Air Ambulance services (emergency and scheduled) Mental Health/Substance Abuse (MH/SA) Vendor may vary. If Anthem Behavioral Health performs UM, then the following services require authorization. Inpatient Mental Health Admissions Although Outpatient Mental Health and Substance Abuse services Inpatient Substance Abuse Admissions do not require precertification, it is recommended to call to ensure that the provider is in-network or participating. For details on Pharmacy Precertification Requirements, please visit our pharmacy website at wellpointnextrx.com.

2 Group #: Applicable Services: Standard UM requirements plus the following services: Ambulatory Surgery (only possible reconstructive/cosmetic, outpatient transplants and vision related procedures.) Cardiac Rehabilitation (outpatient) MRI/MRA s Speech Therapy Standard UM requirements plus the following services: Physical Therapy after the 40 th visit Occupational Therapy after the 40 th visit Speech Therapy after the 40 th visit Standard UM requirements plus the following services: Ambulatory surgeries Standard UM requirements plus the following services: Physical Therapy after the 40 th visit Hearing Therapy after the 10 th visit Vision Therapy after the 10 th visit Standard UM requirements plus the following services: DME, Prosthetics and Orthotics over $5, Standard UM requirements plus the following services: Physical Therapy after 30 th visit Occupational Therapy after 30 th visit Speech Therapy after 30 th visit Chiropractic after 30 th visit Standard UM requirements plus the following services: Chiropractic after the 10 th visit Physical Therapy after the 10 th visit Occupational Therapy after the 10 th visit Speech Therapy after the 10 th visit.

3 Standard UM requirements plus the following services: Chiropractic after the 20 th visit Occupational and Speech Therapy after the combined 30 th visit Standard UM requirements plus the following services: Chiropractic after the 10 th visit Physical Therapy after the 10 th visit Occupational Therapy after the 10 th visit Speech Therapy after the 10 th visit Standard UM requirements plus the following services: Physical/Occupational/Speech and Hearing after combined 90 th visit over the age of Standard UM requirements plus the following services: Physical Therapy after 40 th visit Occupational Therapy after 40 th visit Speech Therapy after 40 th visit Standard UM requirements plus the following services: Standard UM requirements plus the following services: Standard UM requirements plus the following services: Education therapy for morbid obesity Diabetic Education DME over $500 Orthotics over $500 Occupational therapy after the 10 th visit Physical therapy after the 10 th visit Speech/Hearing therapy after the 10 th visit Vision therapy after the 10 th visit TMJ treatment (surgical) Outpatient Mental Health and Substance Abuse for visits 11 through 30.

4 Standard UM requirements plus the following services: Education therapy for morbid obesity Diabetic Education DME over $500 purchase or cumulative rental Orthotics over $500 Occupational therapy after the 20 th visit Physical therapy after the 20 th visit Speech/Hearing therapy after the 20 th visit Vision therapy after the 20 th visit TMJ treatment (surgical) Standard UM requirements plus the following services: Chiropractic Physical Therapy Occupational Therapy Speech Therapy Standard UM requirements plus the following services: DME and Prosthetics over $1, Standard UM requirements plus the following services: DME Purchases only over $1, Standard UM requirements plus the following services: Standard UM requirements plus the following services: DME Prosthetics and Orthotics over $1, Standard UM requirements plus the following services: Standard UM requirements plus the following services: Standard UM requirements plus the following services: Standard UM requirements plus the following services:

5 Standard UM requirements plus the following services: Standard UM requirements plus the following services: Standard UM requirements plus the following services: Standard UM requirements plus the following services: Physical Therapy visits Standard UM requirements plus the following services: Physical Therapy after 30 th visit Occupational Therapy after 30 th visit Speech Therapy after 30 th visit Chiropractic after 30 th visit Standard UM requirements plus the following services: Chiropractic after the 10 th visit Physical Therapy after the 10 th visit Occupational Therapy after the 10 th visit Speech Therapy after the 10 th visit Standard UM requirements plus the following services: Occupational, Speech/Hearing Therapy after the combined 30 th visit Standard UM requirements plus the following services: Physical Therapy after the 45 th visit Occupational Therapy after the 45 th visit Speech/Hearing Therapy after the 45 th visit Standard UM requirements plus the following services: Standard UM requirements plus the following services: Standard UM requirements plus the following services:

6 Non-Standard Applicable Groups Standard UM requirements plus the following services: DME Purchases over $500 Physical Therapy after max covered benefit Occupational Therapy after max covered benefit Speech Therapy after max covered benefit Vision Therapy after max covered benefit Standard UM requirements plus the following services: Standard UM requirements plus the following services: Standard UM requirements plus the following services: Accidental dental only DME over $1,250 CAT and PET Scans Cardiac Computed Tomography Cardiac CT angiography MRI s Standard UM requirements plus the following services: Standard UM requirements plus the following services: Education therapy for morbid obesity Diabetic Education DME over $500 purchase or cumulative rental Orthotics over $500 Occupational therapy after the 30 th visit Physical therapy after the 30 th visit Speech/Hearing therapy after the 30 th visit Vision therapy after the 30 th visit TMJ treatment (surgical) Cosmetic/Reconstructive surgery Investigational/Experimental surgery Standard UM requirements plus the following services: DME purchases over $5,000 & rentals over $500

7 Occupational Therapy after the 30 th visit Speech Therapy after the 30 th visit. after the 20 th visit Standard UM requirements plus the following services: Standard UM requirements plus the following services: DME purchases or rentals over $ Standard UM requirements plus the following services: Standard UM requirements plus the following services: Physical Therapy after the 60 th visit Occupational Therapy after the 10 th visit Speech Therapy after the 60 th visit. after the combined 52 nd visit Standard UM requirements plus the following services: Accidental dental services DME purchases over $1,000 Enteral, parenteral and oral feeding Morbid obesity procedures regardless if Empire is primary or secondary. Occupational Therapy after the 30 th visit Speech Therapy after the 30 th visit. Reconstructive procedures Standard UM requirements plus the following services: before the 11 th visit DME over $5, Standard UM requirements plus the following services: DME Prosthetics and Orthotics over $1,000 MRI/MRA s CAT Scans Standard UM requirements plus the following services: Physical Therapy after the 60 th visit

8 Occupational Therapy after the 60 th visit Speech Therapy after the 60 th visit Standard UM requirements plus the following services: Prosthetics over $1, Standard UM requirements plus the following services: Standard UM requirements plus the following services: All in-network outpatient Mental Health and Substance Abuse services require precert after the 12 th visit/member/provider/calendar year. All out-of-network outpatient mental health and substance abuse services require precert Standard UM requirements plus the following services: Physical Therapy after the 24 th visit Occupational Therapy after the 24 th visit Standard UM requirements plus the following services: DME, Prosthetics, Orthotics and Medical Supplies over $5,000 Physical Therapy after the 20 th visit Occupational Therapy after the 20 th visit Speech Therapy after the 20 th visit Standard UM requirements plus the following services: Ambulatory Surgery (precert is only required for possible cosmetic/reconstructive, outpatient transplants, optical procedures and morbid obesity procedures.) Cardiac Rehabilitation (outpatient) DME, Prosthetics and Orthotics MRI/MRA s Standard UM requirements plus the following services: Physical Therapy all visits Occupational Therapy all visits Speech Therapy all visits Standard UM requirements plus the following services:

9 Standard UM requirements plus the following services: Accidental dental services DME purchases over $1,000 Enteral, parenteral and oral feeding Morbid obesity procedures Occupational Therapy after the 30 th visit Speech Therapy after the 30 th visit. Reconstructive procedures Standard UM requirements plus the following services: Occupational Therapy after the 20 th visit Speech Therapy after the 20 th visit Hearing Therapy after the 60 th visit Standard UM requirements plus the following services: Reconstructive procedures Accidental dental services Standard UM requirements plus the following services: Standard UM requirements plus the following services: Standard UM requirements plus the following services: Advanced Reproductive Technology services.

2016 Rochester Regional Health PPO Medical Plan Summary

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