Refer to. Where there is not a certified Hospice program available, regular Home Health Care Services benefits will apply. Refer to the Home Health Care Services/Home Intravenous Services and Supplies Section of this Agreement. Exclusion Clinical Preventive Health Services This benefit has one or more exclusions as specified in the Exclusions section. We will provide Coverage for Clinical Preventive Health Services without any Cost Sharing at an age and frequency as determined by your In-network Practitioner/Provider. Clinical Preventive Health categories: Services Coverage is provided for services under four broad Screening and Counseling Services Routine Immunizations Adult Preventive Services Childhood Preventive Services Preventive S rvices for Women
Refer to. What is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time for which the Authorization is valid, which in no event shall be for more than twenty-four (24) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them prior to the actual service or delivery of supplies. This does not apply to Benefits mandated by law. Authorization means our decision that a Health Care Service requested by your Practitioner/Provider or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is not obtained for services by Out-of-Network Practitioners/Providers, except for Emergency Care, the Member may be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization may not be Covered. Prior Authorization when In-network
Refer to. “LCMs shall be normally closed: Specification for a time-out feature to be added to the CEBus Load Control Module A time-out feature will be added to the CEBus Load Control Module (LCM) such that the LCM will reconnect its shed loads automatically after a time-out period has elapsed, when the load has been shed with a CEBus context 57 “off” command. Specifically the following functions will be implemented in the CEBus Load Control Module.
Refer to. Gateway must communicate and interface with a minimum of two thermostats: Constraints:
Refer to. Article 31.3 for information re: the impact of a leave of absence on the probationary period.
Refer to. Annual Leave Appendix 1, MOA, Page 58 Legal Actions Leave Appendix 1, MOA, Page 39 Administrative Leave Appendix 1, MOA, Page 39 Military Leave with Pay Appendix 1, MOA, Page 40 Call-up to Active Military Duty Appendix 1, MOA, Page 42 Leave of Absence without Pay Appendix 1, MOA, Page 46 Leave for Disaster Service Appendix 1, MOA, Page 49 Accident Leave Appendix 1, MOA, Page 50 Parental Leave Appendix 1, MOA, Page 54
Refer to. Anyone who knowingly presents a false or fraudulent claim for payment of a loss, or benefit or knowingly presents false information for services is guilty of a crime and may be subject to civil fines and criminal penalties. We may terminate your Coverage for any type of fraudulent activity. For further information regarding Fraud, refer to the General Provisions Section.
Refer to. Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. o Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day-Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not included with Outpatient services when calculating the total accumulated benefit usage. Exclusion Exclusion ➢ Skilled Nursing Facility Care This benefit has one or more exclusions as specified in the Exclusions section. • Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. • Refer to your Summary of Benefits and Coverage for your visit limitations. ➢ Smoking Cessation Counseling/Program This benefit has one or more exclusions as specified in the Exclusions section. • Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and pharmacotherapy. Medical services are provided by licensed Health Care Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: o Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. o Group counseling, including classes or a telephone Quit Line, are Covered through an In-network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted r...
Refer to. The following services and supplies require Prior Authorization In-network and Out-of- network. Refer to the Benefits Section for detailed information about these services. Call PCSC 000-000-0000 0-000-000-0000 Please Note: Due to the ever-changing nature of health care services, this is not an all- inclusive list. For access to the most current list, you may contact our Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or toll-free at 0-000-000-0000. Hearing impaired users may call the TTY line at 711. You may also visit our website at xxx.xxx.xxx. ➢ Acute Medical Detoxification ➢ All Hospital admissions, Inpatient non-emergent ➢ Bariatric Services and Surgery for the treatment of obesity ➢ Bone Growth Stimulator ➢ Cancer Clinical Trials (Investigational/Experimental) ➢ Certified Hospice Care ➢ Computed Axial Tomography (CAT) scans in an outpatient setting ➢ Durable Medical Equipment ➢ Electroconvulsive Therapy (ECT) ➢ Epidural Injections for Back Pain ➢ Foot Orthotics ➢ Genetic Testing ➢ Home Health Care Services/Home Health Intravenous Drugs ➢ Hyperbaric Oxygen ➢ Injectable Drugs, (includes Specialty Medications and Medical Drugs) ➢ Magnetic Resonance Imaging (MRI) in an outpatient setting ➢ Mental Health services - Inpatient, Partial Hospitalization and select outpatient services ➢ Mobile Cardiac Outpatient Telemetry and Real Time Continuous Attended Cardiac Monitoring Systems ➢ Newborn Delivery and Hospital Obstetrical services ➢ Non-emergency care when traveling outside the U.S. ➢ Nutritional Supplements ➢ Observation Services greater than 24 hours ➢ Organ transplants ➢ Orthotics ➢ Positron Emission Tomography (PET) scans in an outpatient setting ➢ Prescription Drugs/Medications ➢ Prosthetic Devices ➢ Proton Beam Irradiation ➢ Reconstructive and potentially cosmetic procedures ➢ Selected Surgical/Diagnostic procedures • Ankle Subtalar Arthroereisis • Blepharoplasty/Brow Ptosis Surgery • Breast implant removal and/or replacement and Capsulectomy • Breast Reconstruction following Mastectomy • Breast reduction for gynecomastia • Breast Reduction Mammoplasty for symptomatic breast hypertrophy • Cholecystectomy by Laparoscopy • Endoscopy Nasal/Sinus balloon dilation • Hysterectomy • Lumbar/Cervical Spine Surgery • Meniscus Implant and Allograft/Meniscus Transplant • Panniculectomy • Rhinoplasty • Septoplasty • Tonsillectomy • Total Ankle Replacement • Total Hip Replacement • Total Knee Replacement ➢ Skilled Nursin...
