Covered Services Definitions Sample Clauses

Covered Services Definitions. For detailed definitions of services covered under the Demonstration, including provider qualifications, service limitations and prior authorization, applicable HCPCS and CPT coding, and service exclusions (See Exhibits 1 through 7). Covered services under the Demonstration fall into two broad categories: core and specialty (or “add-on” services, as described in STC 17). A brief summary of covered services definitions follows. A. Core services are those medically necessary services coverable under section 1905(a) of the Social Security Act which each participating provider is expected to provide or purchase on behalf of enrollees. Core services include both primary care and behavioral health care services. 1. Primary care services include primary care, preventive care, immunizations and influenza vaccines, laboratory and radiology, and care coordination. Primary care services are provided by licensed practitioners, including physicians, nurse specialists, nurse practitioners and physician assistants (See Exhibits 1 through 3). The primary care encounter rate also includes specialty care including medically necessary referral to and treatment by physicians with a designated specialty or subspecialty and specialty laboratory and radiology testing as defined in Exhibit 4 are covered. Specialty care is not covered without a referral from the eligible primary care provider and compliance with the provider’s prior authorization requirements in effect. 2. Behavioral health care services include mental health and/or substance abuse screening, assessment, counseling, treatment, medication management, laboratory, follow-up, and support services provided to enrollees (See Exhibits 5 and 6). Behavioral health care services are provided by licensed practitioners including psychiatrists, physicians, psychologists, social workers, and psychiatric nurse practitioners or are provided by other practitioners (e.g. behavior and addiction specialists) authorized to provide services directly or under supervision in authorized under Medicaid Mental Health Clinic policies to provide services directly or under supervision to the extent permitted by the practitioner’s scope of State licensure. Payments for behavioral health care services are differentiated based on whether or not the enrollee provided with the service meets the federal definition of Serious Mental Illness (SMI), including those who also have a co-occurring addictive disorder. All participating providers may provide...