Inpatient ALL TEXAS REFERRAL / AUTHORIZATION FORMS MUST BE SIGNED BY THE PCP OR ORDERING PHYSICIAN THAT HAS A VALID REFERRAL FROM THE PCP.
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1 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 all previous Prior Authorization lists. ALL TEXAS REFERRAL / AUTHORIZATION FORMS MUST BE SIGNED BY THE PCP OR ORDERING PHYSICIAN THAT HAS A VALID REFERRAL FROM THE PCP. Inpatient Hospitalizations / inpatient admissions All elective admissions to a facility including acute, skilled, hospice, rehabilitation and partial hospitalization for behavioral health conditions. Exception: Well babies (who go home with their mothers in less than 3 days for vaginal deliveries or less than 5 days for c-section deliveries). All inpatient facility to facility transfers - the transferring facility is responsible for obtaining pre-certification prior to the transfer to the new facility All non-elective admission notification is required. Please submit inpatient notification along with clinical information for medical necessity for admission and level of care within one business day of the admission date. PROCEDURE DESCRIPTION PROCEDURE CODES In-office specialty care referrals Any non-urgent referral for out of network specialist office visits, regardless of specialty. Any non-covering primary care provider who is not the member s PCP on the date of service. Exception: Well child exams by any provider with an EPSDT TPI number Well Diagnosis Codes: Z00.110, Z00.111, Z00.129, Z Dermatologists Surgery skin Septal / intranasal dermatoplasty Surgery (Venous) Hematology and coagulation Office and other outpatient service Office and other outpatient consultations All neuropsych evaluations 96101, TX
2 PROCEDURE DESCRIPTION Diagnostic testing OB ultrasounds Ambulance Home Health care PROCEDURE CODES Brach Genetic testing , , All Other Genetic Testing (added 8/11/17) OB ultrasounds for CHIP Perinate ONLY (CHIP will allow one OB ultrasound without prior authorization and any additional requests require prior authorization). Non-emergent ambulance transportation air or ground Skilled nursing Rehabilitation / physical, occupational, speech therapy excluding initial evaluations and re-evaluations 3/1/18 Private duty nursing Infusion therapy Medical injectables in-office, outpatient setting, or home (including but not limited to): Home health aide / personal care assistant Growth hormone J2941, Q0515, S9558, IVIG J1561, J1562, J1566, J1568, J1569, J1572, Synagis S9562 Remicade J1745 Transplants Outpatient rehabilitation / habilitation / therapies 17 Alpha hydroxyprogesterone caproate (17P) J1725, J3410 All transplant work-ups and procedures All PT,OT,ST therapy codes require PA, excluding initial evaluations and re-evaluations (3/1/18)
3 PROCEDURE DESCRIPTION PROCEDURE CODES Outpatient procedures Removal of premalignant, malignant lesions Dental / oral maxillofacial / Orthognathic surgery procedures / osteotomies craniofacial 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21159, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, THSteps Therapeutic Dental- For member aged 0-6 years Cosmetic procedures (including but not limited to): with EP Modifier or U3 modifier for Medicaid Only (07/01/017) Reconstructive repairs, injection of filling material (including collagen) 11950, 11951, 11952, Excision of skin Removal of benign lesion Otoplasty 69300, Breast reconstruction 19350, 19355, 19357, 19361, 19364, 19366,19367, 19368, 19369, 19370, 19371, 19380,19396, S2066, S2067, S2068 Reconstructive repair of pectus excavatum or carinatum 21740, 21742, Reduction mammoplasty / gynecomastia 19316, 19318, 19324, 19325, 19328, 19330, 19340, Lipectomy 15876, 15877, 15878, Venous ligation 36475, 36476, 36478, 36479, 37204, 37700, 37718, 37722, 37735, 37760, 37765, 37766, 37780, Sclerotherapy 36468, 36469, 36470, Rhinoplasty 30120, 30400, 30410, 30420, 30430, 30435, 30450,30460, Blepharoplasty 15820, 15821, 15822, 15823, 21280,, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67916, 67917, Canthoplasty Cervicoplasty Rhytidectomy 15824, 15825, 15826, 15828, 15829
4 PROCEDURE DESCRIPTION PROCEDURE CODES Gastroplasty / gastric bypass 43644, 43645, 43647, 43648, 43659, 43770, 43771, 43772, 43773, 43774, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999, 49999, 43881, 43882, Uvulopalatopharyngoplasty (UP3 or LAUP) 42145, 42140, Circumcision in children over 1 year of age 54150, Durable medical equipment, supplies, prosthetics, orthotics All requests where the total amount of the request is greater than $1,000 (including but not limited to): Abortion , Hospital beds Electric scooter Customized braces / orthotics Upper limb prosthetics Lower limb prosthetics Wheelchairs Cranial molding helmets S1040 Hearing aids 3/15/18 Additions Code Description REMOVAL INTACT MAMMARY IMPLANT REMOVAL MAMMARY IMPLANT MATERIAL ARTHRP TMPRMAND JOINT W/PROSTHETIC REPLACEMENT OSTEOCHONDRAL AUTOGRAFT KNEE OPEN MOSAICPLASTY GSTRCT PRTL DSTL W/GASTRODUODENOSTOMY GSTRCT PRTL DSTL W/GASTROJEJUNOSTOMY GSTRCT PRTL DSTL W/ROUX-EN-Y RCNSTJ GSTRCT PRTL DSTL W/FRMJ INTSTINAL POUCH COCHLEAR DEVICE IMPLANTATION W/WO MASTOIDECTOMY SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN THER PX 1/GT AREAS EACH 15 MIN NEUROMUSC REEDUCA PHYS/QHP ATTN&SUPVJ HYPRBARIC OXYGEN TX/SESSION E0424 STATION COMPRS GASOUS O2 SYS RENT;FLWMTR HUMIDFR E0425 STATION COMPRS GAS SYS PURCH; FLWMTR HUMIDFR NEB E0439 STATION LQD O2 SYS RENT; FLWMTR HUMIDFR NEBULIZR E0440 STATION LQD O2 SYS PURCH;RESRVOR HUMIDFR NEBULZR E0617 EXTERNAL DEFIB W/INTEGRATED ECG ANALY
5 E0618 E0619 E1390 E1391 E1392 E1831 E2101 G0177 K0065 K0073 K0105 APNEA MONITOR WITHOUT RECORDING FEATURE APNEA MONITOR WITH RECORDING FEATURE O2 CONC 1 DEL PORT 85PCT /GT 02 CONC AT PRSC FLW RATE O2 CONC 2 DEL PORT 85PCT /GT O2 CONC PRSC FLW RATE EA PORTABLE OXYGEN CONCENTRATOR RENTAL STATIC PROGRESSIVE STRETCH TOE DEVICE BLD GLU MONITOR W/INTEGRATED LANCING/BLD SAMPLE TRN&ED REL CARE&TX PTS DISABL MENTL HLTH-SESS SPOKE PROTECTORS EACH CASTER PIN LOCK EACH IV HANGER EACH
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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
Payment Policy: Cosmetic Procedures Reference Number: CC.PP.024 Product Types: ALL
Payment Policy: Cosmetic Procedures Reference Number: CC.PP.024 Product Types: ALL Effective Date: 01/01/2014 Last Review Date: 06/20/2018 Coding Implications Revision Log See Important Reminder at the
Your 2010 Medical Benefit Chart PFFS Plan Xerox Effective 01/01/2010
Inpatient Services Inpatient hospital care Your 2010 Medical Benefit Chart PFFS Plan Xerox Effective 01/01/2010 Hospital days are unlimited. Covered services include, but are not limited to, the following:
Family Coverage Self-Only Coverage Amounts Per Accumulation Period (a Family of one Member) or more Members
Benefit Summary 128742 & 35995 ACWA JPIA Principal Benefits for Kaiser Permanente Traditional HMO Plan (1/1/18 12/31/18) Accumulation Period The Accumulation Period for this plan is 1/1/18 through 12/31/18
BCN HMO / BCN Advantage 2008 Clinical Review Program Medical Necessity Criteria / Benefit Review Requirements
Note: If service is retrospective, include reason for late notification in the e-referral Comments section. Examples: 1) Member received service without PCP referral. 2) Member received service with PCP
Unlimited except where otherwise indicated. Primary Care Physician Selection
PLAN FEATURES Deductible (per calendar year) None Individual None Family Out-of-Pocket Maximum (per calendar year) $2,000 Individual In-Network expenses include coinsurance/copays and deductibles. $4,000
Medical Services Requiring Prior Approval
Unless otherwise indicated, the following health plans do not require prior approval for the services within this list: o The State of Vermont Total Choice Plan (prefix FVT) o The ical Center Pre-65 and
Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (7/1/18 6/30/19)
Benefit Summary 35876D 35876 SCHOOLS INSURANCE GROUP #35876 Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (7/1/18 6/30/19) Plan Out-of-Pocket Maximum For Services subject
Principal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19)
Disclosure Form SISC - Self Insured Schools Of California Home Region: California Principal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19) Accumulation Period The Accumulation Period
PLAN DESIGN. Customer Name: High Desert & Inland Employee-Employer Trust. Effective Date: Plan: HMO Plan. Location(s): California
PLAN DESIGN Customer Name: High Desert & Inland Employee-Employer Trust Plan: HMO Plan Location(s): California Organization Name: Aetna PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum
Principal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17)
Benefit Summary SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17) The Services described below are covered only if all of the following
Tusculum College. Benefit Summary. $25 Copay. $25 Copay. after Deductible. 20% after Deductible 20% after Deductible
Benefit Plan Features: Annual Deductible Benefit Summary Your Cost In-Network Individual/Family $750/$1500 Annual Out-of-Pocket Maximum Individual/Family $3500/$7000 4th Quarter Carry-over Covered Services
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
Tusculum College. Benefit Summary Option/Quote: 2. 30% after Deductible. $35 Copay. 30% after Deductible
Benefit Plan Features: Annual Deductible Effective Date: 4/1/2018 Network: S Benefit Summary Option/Quote: 2 Your Cost In-Network Individual/Family $1250/$2500 Annual Out-of-Pocket Maximum Tusculum College
Anthem Blue Cross Your Plan: Premier HMO 20/200 admit/100 OP Your Network: California Care HMO
Anthem Blue Cross Your Plan: Premier HMO 20/200 admit/100 OP Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process.