Office Visits. We cover medically necessary office visits provided they are reasonable in number and in the scope of the services rendered for the following: • office visits to primary care physicians; • office visits to specialists; • routine examinations; • consultations; • medication visits for outpatient mental illness; • office visits to oral and maxillofacial surgeons (OMS) for medical conditions; or • retail based clinics.
Office Visits. Benefits are available for office visits for the diagnosis and treatment of a medical condition, including care and consultation provided by primary care providers and Specialists.
Office Visits. Medical Care visits for the exam, diagnosis and treatment of an illness or injury by a Member’s Primary Care Physician. This also includes physical exams and routine child care, including well-baby visits. For the purpose of this benefit, Office Visits include Medical Care visits to a Member’s Primary Care Physician's office, during and after regular office hours, Emergency visits and visits to a Member's residence, if within Keystone's Limited Network Area.
Office Visits a. See all exclusions.*
b. Health education, except when:
1) Provided during an office visit for non-preventive health care services; or
2) It is counseling that is treated as a preventive health care service.
c. Any weight loss programs and related health care services, except as otherwise covered as preventive health care services.
d. Nutritional counseling, except when provided:
1) During a confinement as covered under the “Hospital Services” section of this contract; or
2) As outpatient self-management training and education for the diagnosis and treatment of diabetes by a certified, registered, or licensed health care professional working in a program consistent with the national standards of diabetes self-management education as established by the American Diabetes Association; or
3) Through a provider’s office, clinic system or hospital setting to a member who has been diagnosed by a
4) As counseling that is treated as a preventive health care service.
e. Marital counseling, relationship counseling, family counseling except as covered under this contract, or other similar counseling or training services.
f. Professional sign language and foreign language interpreter services in a provider’s office.
g. Exams, other evaluations and/or services for employment, insurance, licensure, judicial or administrative proceedings or research, except as otherwise covered under this section or treated as a preventive health care service.
h. Charges for duplicating and obtaining medical records from non-participating providers unless requested by PIC.
i. Genetic testing and associated health care services, except as covered under this contract.
j. Hypnosis and chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning.
k. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
l. Treatment of cleft lip and cleft palate, except for such treatment of a covered dependent child if treatment is scheduled or started prior to the covered dependent child reaching age 19.
m. Vision therapy/Orthoptics.
n. Health care services provided by an audiologist that are not provided in an office setting.
o. Counseling, studies, or services ordered by a court or law enforcement officer that are not determined to be medically necessary, except as covered under #11 and #12 of the “Office Visits” section of this contract.
p. Nutritional and food supplements, except for folic acid as...
Office Visits. The Plan provides Benefits for office visits to Providers. Office visits include visits to retail health clinics and walk-in centers and are covered as Office Visits. Services at a retail health clinic are limited to basic health care services to Members on a walk-in basis. These clinics are normally found in major pharmacies and retail stores. Services are typically provided by nurse practitioners or physician’s assistants and without an appointment. Services are limited to routine care and treatment of common illnesses for adults and children. Services rendered during an office visit, such as medical exams, management of therapy, injections, surgery and anesthesia, may be subject to additional charges beyond office visit Out-of-Pocket Costs. When available in the Member’s area, the Plan provides coverage that will include online visit services. Covered Services include a medical consultation. The Plan does not cover communications used for: reporting normal lab or other test results, office appointment requests, billing, insurance coverage or payment questions, requests for referrals to Providers outside the online care panel, benefit precertification, physician to physician consultation. Please refer to the “Telehealth” provisions for additional or different services available.
Office Visits. Physicians and other Providers who You see in an office setting will provide You with both primary care and specialty care services. These Covered Services may include annual examinations, routine immunizations, and treatment of non-emergency/acute illnesses and injuries. For preventive, routine or specialty care, call or make an appointment with Your Physician or other Provider. Your Provider will arrange for Preauthorization as needed. If You need a same day appointment or have an Urgent Illness, call Your Physician’s office to make an appointment. If Your Provider is unable to see You, You may be offered an appointment with another Physician, Certified Nurse Practitioner or Physician Assistant in his/her group. After hours, Your Physician may offer an answering service. When You arrive for Your appointment show Your Plan ID card to the receptionist. You may be required to make a Copay before receiving services. If You are unable to keep an appointment, cancel as soon as possible, as missed appointment charges may apply and those charges are not covered under the Plan. Telemedicine and telehealth services are Covered Services under this Contract at the same level and copayment amounts as other office visits. If you need an Ambulance, call 911 or a local Ambulance service. This service is covered if it is Medically Necessary because of an emergency. The Plan’s Medical Director determines this by reviewing Ambulance and medical records. Non-Emergency Ambulance transport requires Preauthorization from the Plan. If Ambulance services are not Medically Necessary and are not authorized by the Plan, You are responsible for payment.
Office Visits. The Plan provides Benefits for office visits to Providers. Services rendered during an office visit, such as medical exams, management of therapy, injections, surgery and anesthesia, may be subject to additional charges beyond office visit Out-of-Pocket Costs. When available in the Member’s area, the Plan provides coverage that will include online visit services. Covered Services include a medical consultation. The Plan does not cover communications used for: reporting normal lab or other test results, office appointment requests, billing, insurance coverage or payment questions, requests for referrals to Providers outside the online care panel, benefit precertification, physician to physician consultation. Please refer to the “Telemedicine” provisions for additional or different services available and applicable requirements.
Office Visits. For prescription drug coverage, see Section 3.27 - Prescription Drugs and Diabetic Equipment/Supplies. See the Summary of Pharmacy Benefits for benefit limits and the amount that you pay.
Office Visits. This plan allows the designation of a Primary Care Provider (PCP). You can receive the lower copayment amount on primary care office visit copays by selecting a provider as your PCP and telling us the name of the PCP any time prior to an office visit. You have the right to designate any PCP in the network. Each member can select a different PCP. Children can select a pediatrician. Your PCP must be one of the following provider types: Family practice physician General practice physician Geriatric practice provider Gynecologist Internist Naturopath Nurse practitioner Obstetrician Pediatrician Physician Assistant You do not need a referral from your PCP or any other person authorizing access to specialty care. This includes but is not limited to gynecologists and obstetricians. However, there may be services provided by the specialist that require prior authorization. Please see Prior Authorization for details. We encourage you to select a PCP at the time you enroll in this plan. If you have difficulty locating an available PCP, contact us and we will help you in selecting one. If you do not choose a PCP, we may assign as your PCP a provider you have previously seen. You may change this PCP selection by contacting us. If your PCP is part of a group practice, you can see any provider type listed above in that practice, and receive the PCP office visit copay. You can change your PCP selection at any time by contacting us, but the change will be effective the first of the next month. If you need to see your PCP and your PCP is not available, you may see a PCP within the same clinic and you will only be responsible for the lower cost share. If your PCP is a sole practitioner, you may see a PCP that your provider has asked to cover in their absence. You will only be responsible for the lower copay. Please call Customer Service for more information about selecting a PCP and to provide us with your selection. Urgent care, telehealth, preventive and specialty visits are not included. All other covered services provided by your selected PCP during the primary care office visit are subject to standard cost shares. For example, if you select a PCP and see that PCP for a cut that needs stitches, you will pay the lower copayment amount for the office visit and will pay your plan’s deductible and/or coinsurance for the stitching procedure. If you do not select a PCP, your office visit copay will be the higher copayment amount. See the Summary of Your Co...
Office Visits. The following covered preventive office visits are not subject the calendar year deductible: • Adult preventive office visit rendered by your primary care physician; and • Pediatric preventive care office visits See the Summary of Benefits for benefit limits and level of coverage. Our allowance for an office visit includes medical supplies provided as part of the office visit. See the Summary of Benefits for benefit limits and level of coverage for each service listed in this section.
