Outpatient Specialty Referral Request Types

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

All TRICARE West Region referral and authorization requests must be submitted online.

A Wholly-Owned Subsidiary of Centene Corporation CareAffiliate Guide Using CareAffiliate at www.tricare-west.com Use this guide to assist you in using CareAffiliate Health Net Federal Services, LLC s (HNFS

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

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

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

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

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

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

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

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

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

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

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

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

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

MEDICAL & RX BENEFIT MATRIX. American Environmental Group/PPO Plan HSB Customer Service: EFFECTIVE DATE: MEDICAL & RX BENEFITS

MEDICAL & RX BENEFIT MATRIX American Environmental Group/PPO Plan HSB Customer Service: EFFECTIVE DATE: 01-01-2011 MEDICAL & RX BENEFITS SCHEDULE OF BENEFITS MEDICAL BENEFITS COVERED SERVICE/PLAN IN-NETWORK

Excellus BluePPO Signature Hybrid 5

Excellus BluePPO Signature Hybrid 5 Drug Coverage Excluded Benefit Time Period: 01/01/2017-12/31/2017 Trinity Health - Syracuse Essential General Cost Sharing Expenses - Single Domestic - $1,000 $2,500

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

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

IMPORTANT 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

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

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,

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

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

Benefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information

Excellus BluePPO Benefit Time Period: 01/01/2016-12/31/2016 COLGATE UNIVERSITY Cost Sharing Expenses Deductible - Single $250 $750 Deductible - Family $750 $2,250 0% 30% Annual Out of Pocket Maximum -

REVENUE CODE LIST REQUIRING CPT/HCPCS CODES FOR OUTPATIENT FACILITY CLAIMS

REVENUE CODE LIST REQUIRING CPT/HCPCS CODES FOR OUTPATIENT FACILITY CLAIMS For Providers Effective July 15, 2018 Revenue Code Description 240 All inclusive ancillary, general 250 Pharmacy 251 Drugs, generic

Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2017

HOSPITAL INPATIENT SERVICES Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2017 About this chart: This chart is to be used as a guide only and does not contain

*** 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

not require PA. review. MHT

IMPORTANT NOTICES This document is updated quarterly. Pleasee check this document prior to PA submission as codes may be removed or added. Alll codes listed require PA unless there is a Plan spec cific

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

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

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

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

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

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

Arizona Clover Health Choice PPO (040) 2019 Medical Benefits

Arizona 2019 Medical Benefits Effective Date: 1/1/2019 Version 1.0 Part D Deductible For Part D Copay information, see page 26. /year for Part D prescription drugs /year for Part D prescription drugs 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

IN-NETWORK MEMBER PAYS. Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services)

HMO-OA-CAL-15-15-0-0-03 HMO Open Access Calendar Year Plan Benefit Summary This is a brief summary of benefits. Refer to your Membership Agreement for complete details on benefits, conditions, limitations

Medicaid & Market Place Prior Auth (PA) Code Matrix Effective Q1, 2018

Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services Medicaid Inpatient, Residential Treatment, Partial Hospitalization, Electroconvulsive Therapy (ECT), Applied Behavior Analysis (ABA)

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $2,000 Individual $4,000 Family In-Network expenses include coinsurance/copays and deductibles.

Excellus BluePPO Signature Deduct 3

Excellus BluePPO Signature Deduct 3 Drug Coverage Excluded Benefit Time Period: 01/01/2017-12/31/2017 Trinity Health - Syracuse HSA General Cost Sharing Expenses - Single Domestic - $1,300 $2,500 $3,500

IMPORTANT NOTICES. To search this document, use [Ctrl + F] keys; enter Service or Code in search navigation pane at left; press Enter.

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 Plan-specific exception*

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

Pennslyvania Green (Plan 028) 2018 Medical Benefits

Pennslyvania Green (Plan 028) 2018 Medical Benefits Effective Date: 1/1/2018 Version 1.0 Part D Deductible For Part D Copay information, see page 25. $150/year for Part D prescription drugs Tiers 1 and

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

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

CPT-4 3 HCPCS AMBULANCE I A0021-A0999 C9000-C9010, C9105 J0120-J8999 Q3014, Q3017 AMBULATORY SURGERY

TRICARE ENCOUNTER DATA (TED) CHAPTER 2 ADDENDUM F DATA REQUIREMENTS - FOR TYPE OF SERVICE TYPE OF SERVICE DESP. FOR TYPE OF SERVICE 1 AMBULANCE I 93005-93041 A0021-A0999 C9000-C9010, C9105 Q3014, Q3017

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

Individual Market Schedule of Benefits

Individual Market Schedule of Benefits Deductible and Out-of-Pocket Maximum Plan Deductible Individual Family $150 per Member $300 per Family $8,000 per Member $16,000 per Family Out-of-Pocket Maximum

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

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

Georgia Green (Plan 026) 2018 Medical Benefits

Georgia Green (Plan 026) 2018 Medical Benefits Effective Date: 1/1/2018 Version 1.0 Part D Deductible For Part D Copay information, see page 26. Out-of-Pocket Max $100/year for Part D prescription drugs

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

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

See the benefits table below. None. $2,000 per Member per Calendar Year $4,000 per family per Calendar Year

Schedule of s Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM HMO MAINE ID: MD0000017741_A4 X This Schedule of s states any Limits and Member Cost Sharing amounts you must pay for Covered s. However,

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

Principal Benefits for Kaiser Permanente Traditional HMO (1/1/16 12/31/16)

Benefit Summary 128742, 35995 ACWA/JPIA Principal Benefits for Kaiser Permanente Traditional HMO (1/1/16 12/31/16) The Services described below are covered only if all of the following conditions are satisfied:

IN-NETWORK MEMBER PAYS. Contract Year Plan Deductible (Deductible is combined for health services and prescription drugs) $5,000 Individual

HMO-OA-CNT-HSA-5000I/10000F-07 Contract Year Benefit Summary (E) Point-Of-Service Open Access High Deductible Health Plan (HDHP) for use with a Health Savings Account (HSA) This is a brief summary of benefits.

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $3,500 Individual $7,000 Family In-Network expenses include coinsurance/copays and deductibles.

Individual Market Schedule of Benefits

Individual Market Schedule of Benefits Deductible and Out-of-Pocket Maximum Plan Deductible Individual Family $600 per Member $1,200 per Family $7,400 per Member $14,800 per Family Separate Prescription

See the benefits table below. $250 per Member per Calendar Year $500 per family per Calendar Year

Schedule of s HMO MASSACHUSETTS ID: MD0000017703_A9 X This Schedule of s states any Limits and the Member Cost Sharing amounts you must pay for Covered s. However, it is only a summary of your benefits.

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.

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

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) PLAN DESIGN & BENEFITS None Individual None Family $1,500 Individual $3,000 Family In-Network expenses include coinsurance/copays

Anthem Blue Cross High HMO

Anthem Blue Cross High HMO HMO HIGH SELECT NETWORK Modified Premier HMO 10/100% This Summary of Benefits is a brief overview of your plan's benefits only. For more detailed information about the benefits

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

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*

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

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,

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

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

PLAN FEATURES Deductible (per plan year) Out-of-Pocket Maximum (per plan year) None Individual None Family $250 Individual $500 Family In-Network expenses include coinsurance/copays and deductibles. Pharmacy

Summary of Benefits Chart for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/17 9/30/18)

SISC - KPSA $0 Summary of Benefits Chart for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/17 9/30/18) Plan Out-of-Pocket Maximum For Services subject to the maximum, you will not pay any

Principal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16)

Disclosure Form SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16) The Services described below are covered only if all of the following

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

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.

Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/15 9/30/16)

SISC - SELF-INSURED SCHOOLS OF CALIFORNIA Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/15 9/30/16) The Services described below are covered only if all of the following

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

PUBLICATIONS SYSTEM CHANGE TRANSMITTAL FOR TRICARE POLICY MANUAL (TPM), AUGUST 2002

OFFICE OFTHE ASSISTANT SECRETARY OF DEFENSE HEALTH AFFAIRS 16401 EAST CENTAETECH PARKWAY AURORA, COLORADO 80011 9066 TRICARE MANAGEMENT ACTIVITY MB&RB CHANGE 163 6010.54-M AUGUST 10, 2012 PUBLICATIONS

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

IMPORTANT NOTICES. To search this document, use [Ctrl + F] keys. Enter Service or Code in Navigation pane; press Enter.

IMPORTANT NOTICES These codes are for OP Services only. ALL IP services require PA. This Matrix is updated quarterly, please check this document prior to PA submission as codes may be removed or added.

Schedule of Benefits - CENTRAL HMO Group CITY OF MARSHFIELD Benefit Year: January 1st through December 31st Effective Date: 01/01/2017

Security Health Plan certifies that you and any covered dependents have coverage as described in your Certificate and Schedule of Benefits as of the effective date shown on the letter you received with

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

MEDICAL BENEFITS. Eff. 1/1/15 Medicare Advantage is through HUMANA

Fund Name: Pipefitters Local 636 Fund ID: 7800 MEDICAL BENEFITS Revised: 10/30/18 MP Who is covered? Active Members and their Dependents HAP Po Box 02399 Detroit, MI 48202 800-957-4325 www.hap.org PRE-CERT

Subject to Routine Physical Exam benefit. Same as applicable participating provider office visit member cost sharing Allergy Testing

PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $2,000 Individual $4,000 Family Member cost sharing for certain services may not apply

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

II. BENEFITS AND SERVICES

II. S AND SERVICES A. HealthChoice Benefits This table shows the healthcare services and benefits that all HealthChoice enrollees can get when they need them. We offer other services not listed here. (See

Exhibit 2 - YHP Plan Changes Service YHP Benefit Aetna Durable Medical Equipment including orthotics Prosthetic Devices Home Health Care $ 100 ded/80% to $ 5,000 annual maximum 100% up to $5,000 max Agreed

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

MEDICAL CODING FUNDAMENTALS

Medical Coding Fundamentals Goldsmith, Susan ISBN-13: 9780073374987 Table of Contents MEDICAL CODING FUNDAMENTALS CHAPTER 1: MEDICAL TERMINOLOGY, ANATOMY, AND PHYSIOLOGY Word Elements Root Words Combining

SUMMARY OF P BENEFITS AND SCHEDULE OF COPAYMENTS

SUMMARY OF P-10-15-250 BENEFITS AND SCHEDULE OF COPAYMENTS THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD

Letter to the AMGA Board of Directors...1 Introduction...3

Table of Contents Letter to the AMGA Board of Directors...1 Introduction...3 Section I: Executive Summary Survey at a Glance...6 Participant Profile...10 Survey Methodology...18 How to Use This Report...21

Global Series Elite Executive Schedule of Medical & Dental Benefits Effective August May

STANDARD HEALTH BENEFITS FOR SERVICES AND SUPPLIES PROVIDED BY KEMH, MID-ATLANTIC WELLNESS INSTITUTE AND GOVERNMENT APPROVED TESTING FACILITIES IN BERMUDA Standard Health Benefits SP ON YOUR INSURANCE

Long-stay patients methodology Published by NHS England and NHS Improvement

Long-stay patients methodology Published by NHS England and NHS Improvement July 2018 1 Document Title: Long-stay patients methodology Version number: 1.0 First published: 9 July 2018 Updated: Prepared

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. Coverage Period: Beginning On or After 1/1/2018

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning On or After 1/1/2018 Blue Shield Gold 80 PPO 0/25 + Child Dental Coverage for: Individual

Global Series Schedule of Medical & Dental Benefits Effective July May

STANDARD HEALTH BENEFITS FOR SERVICES AND SUPPLIES PROVIDED BY KEMH, MID-ATLANTIC WELLNESS INSTITUTE AND GOVERNMENT APPROVED FACILITIES IN BERMUDA Standard Health Benefits PW OR SP OR PRIV ON YOUR INSURANCE

Anthem Blue Cross Your Plan: Custom Premier HMO 10/100% Your Network: Select HMO

Anthem Blue Cross Your Plan: Custom Premier HMO 10/100% Your Network: Select HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does

Revenue/Procedure Code Service Group Matrix

0 114 Room and Board- private psychiatric 0 118 Room and Board- private rehabilitation 0 124 Room and Board -semi private psychiatric 0 128 Room and Board - semi private rehabilitation 0 134 Room and Board