Provider Alert. November 30, 2017

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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 and surgeries will be the responsibility of MFC to review for medical necessity and provide authorization. Blepharoplasty, Capsulotomy, Cataract removal, Ectropion repair, Entropion repair, Eyelid lesion excision/reconstruction, Ptsosis repair, Strabismus repair, Destruction of lesion of lid margin, insertion of intraocular lens prosthesis (secondary implant) not associated with concurrent cataract removal, radial keratotomy, corneal relaxing incision for correction of surgically induced astigmatism, corneal wedge resection for correction of surgically induced astigmatism, Implantation of intraocular devices and orbital prosthesis. 2. Gender reassignment surgery requires prior authorization. 3. The following Prenatal Genetic Testing processed by LabCorp will not require prior authorization. CPT 81220 Cystic Fibrosis, CPT 81401 Spinal Muscular Atrophy with ICD10 codes O 9.xx through O36.xx, O4.xx through O48.xx, Z34.xx and Z36.xx. CPT 81420 Trisomy/Aneuploidy screening with ICD10 codes O 9.511, O 9.512, O 9.513, O 9.521, O 9.522, O 9.523, O28.5 and Z82.79. *O= the letter O not zero and = zero* **If done by any other Lab/facility will require prior authorization.** 4. PET Scans: No longer requires authorization from a participating free-standing radiology facility and the following hospitals- MedStar Georgetown University Hospital, MedStar Southern Maryland Hospital Center, MedStar St Mary s Hospital, MedStar Union Memorial Hospital, and MedStar Washington Hospital Center. 5. Durable Medical Supplies (soft supplies, disposable items and enteral/parenteral supplies), the dollar limit increased from $500 to $750 per member/per vendor/per month, before authorization will be required.

INPATIENT elective procedures (in or out of network) Inpatient admission for a Psychiatric diagnosis when the Bed Type is for Psychiatric Services State of Maryland Carve Out service Any Out of Network Services. OUTPATIENT In-Network (practitioner AND facility), facility based procedures (includes outpatient Chemotherapy and Radiation Therapy). See exceptions below. No prior auth required, unless included below in 'Exceptions Requiring Prior Authorization.' For children <21, Univ. of MD Main Campus, Univ. of MD Midtown Campus Kernan and Sinai Hospitals do not require an authorization. Exceptions Requiring Prior Authorization Ambulance/Wheelchair/Van Transport except for Hospital to Hospital Transfers. No reimbursement to city/county Fire Departments, including DC Fire Department and others that indicate "911" service. Hospital to SNF, Hospital to Home call MA Transport. Abortions Elective Abortions not MCO liability. Refer to MDH (formerly DHMH) (877-463-3464) Not covered under the Self-Referral Services. Audiology Services for members <21 y/o Not MCO liability. Refer to MDH (formerly DHMH) (877-463-3464) for audiology services, and hearing aid appliances and supplies. Audiology Services for members >21 y/o Bariatric Surgery Program - Including OP Surgeries Cardiac Rehabilitation Audiology is not a covered benefit Vestibular testing by an audiologist requires prior authorization :

Chiropractic Services for members <21 years old Chiropractic Services for members >21 years old Cosmetic procedures for >10 visits per condition. Examples of cosmetic procedures include (but not limited to): septoplasty, rhinoplasty, sclerotherapy, septoplasty, skin tag removal, panniculectomy, breast reduction (male or female), Coumadin Clinics Authorization required for clinics in regulated space. (Prefer monitoring by physician with labs to LabCorp) Diabetes and Nutritional Counseling Office, Homecare or Hospital Based services, no authorization required for the first 3 visits. After 3 visits, an auth is required. Epidural injections (cervical and lumbar), Facet blocks, Rhizotomies Erectile Dysfunction Procedures Eye procedures and surgeries for: blepharoplasty, capsulotomy, cataract removal, ectropion repair, entropion repair, eyelid lesion excision/reconstruction, keratoplasty, ptosis repair strabismus repair, destruction of lesion of lid margin, insertion of intraocular lens prosthesis (secondary inplant) not associated with concurrent cataract removal, radial keratotomy, corneal relaxing incision for correction of surgically induced astigmatism, corneal wedge resection for correction of surgically induced astigmatism. Implantation of Intraocular devices, Orbital Prosthesis * Some eye procedure may be found under the Cosmetic Procedures * Genetic Counseling Genetic Testing Gender Reassignment Surgery The OB meets with the family and charges a regular office visit.

Heart Failure Clinics Home Health Care Hospice Care (IP and OP), Skilled Nursing Facility and Acute Rehab Facility Hyperbaric Oxygen Infertility Services Investigational Surgery, Emerging Technology, Services, Procedures Laboratory Services (excludes genetic testing) Mount Washington Pediatric Hospital Services (Weight Smart Program/Outpatient Feeding Program) Neuropsychological Testing Authorization required after first 6 visits with in network provider Includes Home Infusion Nursing (99601 and 99602) All Services No prior auth required if done at an In Network freestanding lab facility or at MedStar WHC and MedStar GUH Outpatient Rehabilitation Services (PT/OT/SLP) for members <21yo Not MCO liability. Refer to DHMH (877-463-3464) Outpatient Rehabilitation Services (PT/OT/SLP) for members >21yo PET Scans for >30 visits per injury, per service No authorization required if performed at participating free-standing facilities. Only hospital exceptions are: MS Union Memorial Hospital, MS St. Mary's Hospital, MS Southern Maryland, MedStar WHC and MedStar Georgetown Hospital. *see website for participating free standing facilities. Private Duty Nursing Pulmonary Rehabilitation Prior Authorization required

Radiology- CT Scans, MRI's, X-RAYS, nuclear medicine, and Sonograms, and digital mammography Sleep Studies and Polysomnograms Sterilization Reversals Transplants--Pre-Transplant testing No authorization required if performed at participating free standing facilities. Only hospitals: MS Union Memorial Hospital, MS St. Mary's Hospital and MS So. Maryland Hospital In DC, MS WHC and MS Georgetown Univ. Hospital *See website or contact member services for participating free-standing facilities. No authorization required if performed at a participating, free-standing facilities. Facilities not requiring an auth: MS St. Mary's Hospital, MS So. Maryland Hospital, and MS NRH. *see website for participating free standing facilities. HLA Testing for BMT auth required Other labs at MD Hospitals require an auth. Transplant DME - Durable Medical Equipment Braces, (Orthotics, Prosthetics) and Splints costing over $500.00 excludes foot orthotics Durable Medical Equipment Durable Medical Supplies (soft supplies and disposable items- includes enteral/participatingenteral supplies) for items billed over $500.00 Prior auth required for claims billed >$1000 or rental equipment over 90 days. *See website or contact Member Services for in network vendors. for billed amounts >$750, per member/per vendor/per month. *See website or contact Member Services for In Network vendors. Foot orthotics, custom shoes, diabetic orthotics or shoes, CAM Walking Boot Insulin Pumps or Continuous Glucose Monitors *Please contact Member Services at 888-404-3549 or go to our website at MedStarFamilyChoice.com for assistance with finding in network vendors, physicians or facilities for all plans. *** This is a Quick Authorization Guide. It is not meant to be all inclusive. Please contact MD MFC at : 1-800-905-1722.

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