Schedule of Benefits for General Practitioners

Transcription

1 Schedule of Benefits for General Practitioners Aviva Health Insurance Ireland Limited

2 SCHEDULE OF BENEFITS FOR GENERAL PRACTITIONERS FROM AVIVA HEALTH INSURANCE IRELAND LIMITED Welcome to Aviva s schedule of benefits. This book displays the professional fees for procedures and tests covered by health insurance from Aviva, as set out in the rules of Aviva Health Insurance Ireland. To improve both your efficient payment and the member s experience, can you please provide your patient with the name and code of the procedure (where possible) to enable your patient to establish the level of cover their plan provides for the particular procedure from the Aviva customer care agent. For further information or queries; please contact us: By telephone at By us on provider.support@avivahealth.ie Our dedicated provider website In writing to Provider Affairs, Aviva Health Insurance Ireland Limited, One Park Place, Hatch Street, Dublin 2 Thank you, Colm O Sullivan Provider Affairs Aviva Health Insurance Ireland Limited Aviva Health Insurance Ireland Limited is regulated by the Central Bank of Ireland. Terms & conditions apply. The information contained in this book is correct at the time of going to print (October 2013).

3 General Practitioners Fee rates October 2013 to AUGUST Destruction of lesion(s) by any method, genital/anal warts (e.g. condyloma, papilloma, molluscum contagiosum, herpetic vesicle); per session () Haemorrhoids, injection and/or banding () Proctoscopy or sigmoidoscopy () Hydrocele (tapping) Cyst or benign tumour of cheek or mouth, excision of () Cyst or benign tumour on lip, excision of () Abscess, incision and drainage of Sclerosing operation on vein(s), one leg () Treatment of Spider/Thread veins and telangiectasia are excluded Sclerosing operation on veins, both legs () Treatment of Spider/Thread veins and telangiectasia are excluded Abscess, cyst or tumour, aspiration of () Biopsy of skin, subcutaneous tissue and/or mucous membrane including simple closure () Foreign body, removal of Skin abscess, (superficial) incision and drainage of () Excision of pigmented naevi, one or more, maximum benefit per six months () Schedule of Benefits for General Practitioners 3

4 26 Excision of sebaceous cyst(s) (single or multiple) () Wounds and sinuses, curettage of Basal cell carcinoma/sqamous cell carcinoma, simple excision () Copy of the histology report must be included with claim Epistaxis, anterior packing and/or cautery () Foreign body, removal of, from conjunctiva Foreign body, removal of, from cornea Nail, removal of Whitlow, incision and drainage Ganglion, removal of, aspiration Avulsion of nail plate, partial or complete, simple Breast cyst(s) aspiration/fine needle biopsy (diagnostic or therapeutic) () Destruction by cryosurgery of actinic keratosis with or without surgical curettement, one lesion () Repeat visits will not be paid at 'One Lesion' Rate. Claim must be made at the end of a cours of treatment Destruction by cryosurgery of actinic keratoses with or without surgical curettement, two or more lesions () Claim must be made at the end of a course of treatment Excision of chalazion, papilloma, dermoid or other cyst or lesion, single, involving skin, lid margin, tarsus, and/ or palpebral conjunctiva () Excision of chalazions, papillomas, dermoids or other cysts or lesions, one or both eyelids, involving skin, lid margin, tarsus and/or palpebral conjunctiva (), Side Room Destruction by cryotherapy of warts with or without surgical curettement, one lesion () Repeat visits will not be paid at One Lesion Rate. Claim must be made at the end of a course of treatment Schedule of Benefits for General Practitioners

5 51 Destruction by cryotherapy of warts with or without surgical curettement, two or more lesions () Claim must be made at the end of a course of treatment Enucleation of lipoma () Excision of sebaceous cyst(s) of face, single or multiple () Wounds greater than 7.5cm in total length, suture of with one layer repair of the epidermis, dermis or subcutaneous tissues with suture Benefit includes wound closures by tissue adhesives (e.g. 2-cyanoacrylate) either singly or in combination with sutures or staples or in combination with adhesive strips. Wound closures utilising adhesive strips as the sole repair material may not be claimed Ingrowing toe nail, removal of nail and nail bed Plantar warts, surgical excision, or local application, one or more per course of treatment on same or different days Per course of treatment on same or different days Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst (e.g. fingers, toes) () Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst (e.g. temporomandibular acromioclavicular, wrist, elbow or ankle, olecranon bursa) () Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g. shoulder, hip, knee joint, subacromial bursa) () Wounds up to 2.5cm in total length, suture of with one layer repair of the epidermis, dermis or subcutaneous tissues with suture Benefit includes wound closures by tissue adhesives (e.g. 2-cyanoacrylate) either singly or in combination with sutures or staples or in combination with adhesive strips. Wound closures utilising adhesive strips as the sole repair material may not be claimed Schedule of Benefits for General Practitioners 5

6 67 Wounds from 2.6cm to 7.5cm in total length, suture of with one layer repair of the epidermis, dermis or subcutaneous tissues with suture Benefit includes wound closures by tissue adhesives (e.g. 2-cyanoacrylate) either singly or in combination with sutures or staples or in combination with adhesive strips. Wound closures utilising adhesive strips as the sole repair material may not be claimed Therapeutic phlebotomy for patients with polycythemia rubra vera or haemochromatosis Benefit is payable when the following are confirmed: 1. Hereditary haemochromatosis with evidence of iron overload (serum ferritin in excess of 450 micro gram per litre). 2 Hereditary haemochromatosis with evidence of iron overload on at least 2 consecutive occasions 6 months apart 3. Secondary iron overload with serum ferritin in excess of 350 micro gram per litre. 4 Polycythaemia rubra vera Schedule of Benefits for General Practitioners

7 Rate Change 2 17 Destruction of lesion(s) by any method, genital/anal warts (e.g. condyloma, papilloma, molluscum contagiosum, herpetic vesicle); per session () Biopsy of skin, subcutaneous tissue and/ or mucous membrane including simple closure () Foreign body, removal of Skin abscess, (superficial) incision and drainage of () Wounds and sinuses, curettage of Epistaxis, anterior packing and/or cautery () Nail, removal of Whitlow, incision and drainage Avulsion of nail plate, partial or complete, simple Breast cyst(s) aspiration/fine needle biopsy (diagnostic or therapeutic) () Destruction by cryosurgery of actinic keratosis with or without surgical curettement, one lesion () Repeat visits will not be paid at 'One Lesion' Rate. Claim must be made at the end of a cours of treatment Destruction by cryosurgery of actinic keratoses with or without surgical curettement, two or more lesions () Claim must be made at the end of a course of treatment Destruction by cryotherapy of warts with or without surgical curettement, two or more lesions () Claim must be made at the end of a course of treatment Enucleation of lipoma () Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst (e.g. fingers, toes) () Schedule of Benefits for General Practitioners 7

8 63 64 Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst (e.g. temporomandibular acromioclavicular, wrist, elbow or ankle, olecranon bursa) () Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g. shoulder, hip, knee joint, subacromial bursa) () Wounds up to 2.5cm in total length, suture of with one layer repair of the epidermis, dermis or subcutaneous tissues with suture Benefit includes wound closures by tissue adhesives (e.g. 2-cyanoacrylate) either singly or in combination with sutures or staples or in combination with adhesive strips. Wound closures utilising adhesive strips as the sole repair material may not be claimed Wounds from 2.6cm to 7.5cm in total length, suture of with one layer repair of the epidermis, dermis or subcutaneous tissues with suture Benefit includes wound closures by tissue adhesives (e.g. 2-cyanoacrylate) either singly or in combination with sutures or staples or in combination with adhesive strips. Wound closures utilising adhesive strips as the sole repair material may not be claimed Therapeutic phlebotomy for patients with polycythemia rubra vera or haemochromatosis Benefit is payable when the following are confirmed: 1. Hereditary haemochromatosis with evidence of iron overload (serum ferritin in excess of 450 micro gram per litre). 2 Hereditary haemochromatosis with evidence of iron overload on at least 2 consecutive occasions 6 months apart 3. Secondary iron overload with serum ferritin in excess of 350 micro gram per litre. 4 Polycythaemia rubra vera Schedule of Benefits for General Practitioners

9 Procedure removed 11 Axillary or inguinal lymph nodes, incision of abscess Schedule of Benefits for General Practitioners 9

10 General Practitioner FEES for SURGICAL PROCEDURES 1. This Schedule outlines the General Practitioner benefits available from Aviva for patient services personally provided by the General Practitioner on or after 1st October The Professional Fee values identified as participating benefit in this Schedule apply to General Practitioners who personally perform the procedure/treatment in a doctor s surgery and who have agreed with Aviva to accept such benefits in full settlement of fees and, who charges Aviva patients accordingly, with no additional payment being sought or due from the Aviva member, and are registered with Aviva at time of performance of the procedure/treatment. 3. The benefit for procedures includes all care associated with the procedure, pre-operative assessment, the operative procedure, local or regional anaesthesia when administered by the General Practitioner and all necessary follow-up care, and where performed in a General practitioners surgery will include all associated costs for example costs of equipment, consumables and nursing practitioner assistance if required. 4. For General Practitioners who agree to operate the participating benefit schedule of fees, the fee will include any follow up visit which is necessary for the removal of suture(s) or other related care subsequent to or linked to the linked the remunerated intervention. 5. When multiple procedures are performed on different sites, benefit is payable for a maximum of 3 procedures as follows: a) 100% of the highest valued procedure b) 50% of the second highest valued procedure c) 25% of the third highest valued procedure 6. benefits apply in respect of General Practitioners who have personally performed the procedure and who have not agreed fees with Hibernian Aviva Health. 7. The benefits listed in the Schedule are only payable when carried out i in the General Practitioner s surgery. 10 Schedule of Benefits for General Practitioners

11 8. To ensure that the correct benefit is allowed in respect of your fees, it is necessary for us to have: a) A full description of the procedure(s)/treatment(s) included on the claim form, b) The procedure code. c) A fully completed Aviva claim form. d) Your fee account (or amount stated on the claim form) with your Aviva General Practitioner. 9. Benefit is not payable for surgery which is not medically necessary or where it is performed incidental to other therapeutic surgery. Medically necessary: Means treatment which in the opinion of our Medical Advisors is generally accepted by the medical profession as appropriate with regard to good standards of medical practice and is (i) consistent with the symptoms or diagnosis and treatment of the injury or illness; (ii) necessary for such a diagnosis or treatment; (iii) not furnished primarily for the convenience of the patient, doctor or other provider; and (iv) furnished at the most appropriate level which can be safely and effectively provided to the patient 10. A procedure marked (Independent Procedure) is reimbursed only when it is performed alone or independently and not when it is performed at the same time as another procedure. However, benefit is allowed for the higher valued procedure. 11. A General Practitioner is defined in the Aviva Member Handbook as a medical practitioner with a current full registration with the Irish Medical Council, who holds a primary medical qualification. 12. The inpatient attendance standard benefit is payable to a General Practitioner for services provided by him/her to the patient for each full day of the patients stay in hospital. Schedule of Benefits for General Practitioners 11

12 Aviva Health Insurance Ireland Limited is regulated by the Central Bank of Ireland. PV-166C