Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 or toll-free at 0-000-000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx. Reconstructive Surgery Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section. Rehabilitation and Therapy Services requires Prior Authorization. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational 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. Coverage is subject to the following limitations: 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 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 accumulated benefit usage. included with Outpatient services when calculating the total Skilled Nursing Facility Care 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 Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and
Appears in 2 contracts
Samples: Subscriber Agreement, Subscriber Agreement
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can may pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt form. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to us a Provider for reimbursementany sums owed to the Provider by Presbyterian. The DMR Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Direct Member Reimbursement form together with and attach the itemized cash register receipt must contain and the prescription drug detail (pharmacy pamphlet) along with the following information: o · Patient’s name and ID number o Name and quantity · Patient’s Date of Birth · Name of the drug o · Quantity dispensed · NDC (National Drug Code · Fill Date purchased o · Name of Prescriber · Name and phone number of Practitioner/Provider o Name and phone number of the dispensing pharmacy o · Reason for the purchase (nature of emergency) o · Proof of Payment Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY number 711. Please follow the mailing instructions on the Direct Member Reimbursement form. The Presbyterian Health Plan Pharmacy Service Team is available 24 hours a day to providers, pharmacies, and Members to address pharmacy benefit questions. Please contact them at 711 (000) 000-0000 or toll-free at 0-000-000-0000 and follow the voice prompts and select Pharmacy.. A registered professional nurse or visit physician shall be immediately available by phone 24 hours a day, seven days a week to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free phone number to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate phone access 24 hours a day, seven days a week to their PCP or the Pharmacy page of our website at xxx.xxx.xxxprovider’s authorized on-call back-up provider. Reconstructive Surgery Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for When these providers are unavailable, a registered nurse or physician on the correction of functional disorders. Reconstructive Surgery utilization management staff must be prescribed available to respond to inquiries concerning emergency or Urgent Care. In the event medically necessary covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a Member’s Practitioner/Provider and requires Mastectomy and Prophylactic Mastectomy, refer specialist similar to the Women’s Health Care Section. Rehabilitation and Therapy Services requires Prior Authorization. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer type of specialist to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy and occupational therapy, provided in whom a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation referral is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational 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. Coverage is subject to the following limitations: 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 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 accumulated benefit usage. included with Outpatient services when calculating the total Skilled Nursing Facility Care 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 Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andrequested.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000505) 000923-0000 5678 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 (000) 000-0000 or toll-free at 0-(000-) 000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx. Reconstructive Surgery Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section. Rehabilitation and Therapy Services requires Prior Authorization. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational 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. Coverage is subject to the following limitations: 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 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 accumulated benefit usage. included with Outpatient services when calculating the total Skilled Nursing Facility Care 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 Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andSignificant
Appears in 1 contract
Samples: Subscriber Agreement
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000505) 000923-0000 5678 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 (000) 000-0000 or toll-free at 0-(000-) 000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx. ⮚ Reconstructive Surgery Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section. • Rehabilitation and Therapy Services requires Prior Authorization. • Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. • Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. 🖐 • Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational 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. Coverage is subject to the following limitations: 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 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 accumulated benefit usage. included with Outpatient services when calculating the total Skilled Nursing Facility Care 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 Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andSignificant
Appears in 1 contract
Samples: Subscriber Agreement
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursementForm. . Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. The DMR form together with the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain the following information: o Patient’s name and ID number o Patient’s Date of Birth o Name and quantity of the drug o Quantity dispensed o NDC (National Drug Code) o Fill Date purchased o Name of Prescriber o Name and phone number of Practitioner/Provider o Name and phone number of the dispensing pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Direct Member (copy of the check, credit card statement or a receipt showing that payment in full was received) DirectMember Reimbursement (DMR) forms are available by calling our Presbyterian Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 or toll-free at 0-000-000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx. ➢ Reconstructive Surgery Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section. ➢ Rehabilitation and Therapy • Rehabilitation and Therapy Services requires Prior Authorization. • Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. • Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational 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. Coverage is subject to the following limitations: 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 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 accumulated benefit usage. included with Outpatient services when calculating the total Skilled Nursing Facility Care 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 Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000505) 000923-0000 5678 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 (000) 000-0000 or toll-free at 0-(000-) 000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx. Reconstructive Surgery Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section. Rehabilitation and Therapy Rehabilitation and Therapy Services requires Prior Authorization. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational 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. Coverage is subject to the following limitations: 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 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 accumulated benefit usage. included with Outpatient services when calculating the total Skilled Nursing Facility Care 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 Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andSignificant
Appears in 1 contract
Samples: Subscriber Agreement
