Prior Auth Required. Practitioner/Provider agrees to accept our normal reimbursement for similar services and services are provided in New Mexico. Any care related to the Cancer Clinical Trial that is Investigational requires Prior Authorization. Other medical services that are not Investigational may require Prior Authorization as described in the Prior Authorization Section. Excl sion Cer ified Hospice Care This benefit has one or more exclusions as specified in the Exclusions section. u Benefits for Inp tient and in-home Hospice services are Covered if you are terminally ill. Prior Auth Required Services must be provided by an approved Hospice program during a Hospice benefit period and will not be Covered to the extent that they duplicate other Covered Services available to you. Benefits that are provided for by a Hospice or other facility require approval by your Practitioner/Provider and our Prior Authorization. The Hospice benefit period is defined as follows: Beginning on the date your Practitioner/Provider certifies that you are terminally ill with a life expectancy of six months or less. Ending six months after it began, u period below, or upon your death. less you require an extension of the Hospice benefit If you require an extension of the Hospice benefit period, the Hospice must provide a new treatment plan and your Practitioner/Provider must re-authorize your medical condition to us. We will not Authorize more than one additional Hospice benefit period. You must be a Covered Member throughout your Hospice benefit period. The following services are Covered: Inpatient Hospice care Practitioner/Provider visits by Certified Hospice Practitioner/Providers Home Health Care Services by approved home health care personnel Physical therapy Medical supplies Prescription Drugs and Medication for the pain and discomfort specifically related to the terminal illness Medical transportation Respite care (care that provides a relief for the care-giver) for a period not to exceed five continuous days for every 60 days of Hospice care. No more than two respite care stays will be available during a Hospice benefit period.
Prior Auth Required o To obtain Alcoholism/Substance Abuse services, Members may contact our Behavioral Health Department at 505) 923-5470 or toll-free at 0-000-000-0000. The Behavioral Health Practitioner/Provider will be responsible for any additional Prior Authorizations. o For Out-of-network Services, Members need to contact our Behavioral Health Department in order to obtain Prior Authorization, when required. Please refer to the Prior Authorization Section. o In all cases, treatmen must be Medically Necessary in order to be Covered. o Acute Medical Detoxification Benefits are Covered under Inpatient and Outpatient Hospital Services found in the Benefits Section of this Agreement. Inpatient Hospital Services must be Prior Authorized. Exclusion Nutritional Support and Supplements This benefit has one or more exclusions as specified in the Exclusions section. Nutritional Supplements for prenatal care when prescribed by a Practitioner/Provider are Covered for regnant women. Nutritional supplements that require a prescription to be dispensed are Covered when q Prior Auth Re uired prescribed by an In-network Practitioner/Provider and when Medically Necessary to replace a specific documented deficiency. Prior Authorization is required. Nutritional supplements administered by injection at the Practitioner’s/Provider’s office are Covered when Medically Necessary. Enteral formulas or products, as Nutritional support, are Covered only when prescribed by an In-network Practitioner/Provider and administered by enteral tube feedings. Total Parenteral Nutrition (TPN) is the administration of nutrients through intravenous catheters via central or peripheral veins and is Covered when ordered by an In-network Practitioner/Provider. Special Medical Foods as listed as Covered benefits in the Genetic Inborn Errors of Metabolism (IEM) Benefit of this Section. Prior Authorization is required. Outpatient Medical Services This benefit has one or more exclusions as specified in the Exclusions section. c
Prior Auth Required o Colonoscopy o Virtual Colonoscopy - Requires Prior Authorization o Double contrast barium enema Refer to Smoking Cessation Program - Refer to Smoking Cessation Counseling/Program in this Section. Screening to determine the need for vision and hearing correction Periodic glaucoma eye test Preventive screening services including screening for depression, diabetes, cholesterol, obesity, various cancers, HIV and s xually transmitted infections, as well as counseling for drug and Tobacco use, healthy eating and other common health concerns. Health education and consultation from In-network Practitioners/Providers to discuss lifestyle behaviors that promote health and well-being including, but not limited to, the consequence of Tobacco use, and/or smoking control, nutrition and diet recommenda ions, and exercise plans. For Members 19 years of age or older, health education also includes information related to lower back protection, immunization practices, breast self-examination, testicular self-examination, use of seat belts in motor vehicles and other preventive health care practices. Routine Immunizations Routine Immunization incl des Cover ge for Adult and Child Immunizations (shots or vaccines), in accordance with the recommendations of: The American Academy of Pediatrics The Advisory Committee on Immunization Practices The U.S. Preventive Services Task Force o Immunizations for routine use in children, adolescents, and adults that have, in effect, a recommendation from the Advisory Committee on Immunizations Practices of the Centers for Disease Control and Prevention (Advisory Committee) with respect to the individual involved. o HPV Vaccine coverage for the Human Papillomavirus as approved by the United States Food and Drug Administration (FDA) and in accordance with all applicable federal and state requirements and the guidelines established by the Advisory Committee on Immunization Practices (ACIP). Childhood Preventive Health Services Childhood Preventive Health Services includes Coverage for Well-Child Care in accordance with the recommendations of the American Academy of Pediatrics. With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA). Key preventive care includes: o Health appraisal exams, laboratory and radiological tests, and early detection procedures for the purpose of a...
Prior Auth Required o Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require Prior Authorization. o In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guid lines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will be available to the mother for the first few days following early discharge. o Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Refer to Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. o High-risk Ambulance services are Covered in accordance with the Ambulance Services Benefits Section. o The services of a Midwife or Certified Nurse Midwife are Covered, for the following: ♦ The midwife’s services must be provided strictly according to their legal scope of practice and in accordance with all applicable state licensing regulations which may include a supervisory component. ♦ The services must be provided in preparation for delivery of a newborn. or in connection with the ♦ For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. ♦ The combined fees of the midwife and any attending or supervising Practitioners/Providers, for all services provided before, during and after the birth, may not exceed the allowable fee(s) that would have been payable to the Practitioner/Provider had he/she been services. • Newborn Care the sole Practitioner/Provider of those Tim...
Prior Auth Required. Durable Medical Equipment is equipment that is Medically Necessary for treatment of an illness or Accidental Injury or to prevent further deterioration. This equipment is designed for repeated use, and includes items such as oxygen equipment, functional wheelchairs, and crutches. All Durable Medical Equipment requires Prior
Prior Auth Required o Medically Necessary nutritional supplements as determined and prescribed by the attending Practitioner/Provider. Prescription nutritional supplements require Prior
Prior Auth Required. Some mental health services require Prior Authorization. The In-network Behavioral Health Practitioners/Providers will be responsible for obtaining Prior Authorization, when required. For Out-of-network Services, Members need to contact our Behavioral Health Department to obtain Prior Authorization, when required. Please refer to the Prior Authorization Section for services that require Prior Authorization. For assistance or for questions related to mental health services, you may call our Behavioral Health Department directly at Refer to (000) 000-0000 or toll-free at 0-000-000-0000. o Partial H spitalization can be substituted for the Inpatient mental health services when our Behavioral Health Department approves the Prior Authorization request. Partial Hospitalization is a non-residential, Hospital-based day program that includes various daily and weekly therapies. o Acute medical detoxification benefits are Covered under Inpatient and Outpatient Medical services found in the Benefits
Prior Auth Required. Hyperbaric Oxygen Therapy is a covered benefit only if the therapy is proposed for a condition recognized as one of the accepted indications as defined by the Hyperbaric Oxygen Therapy Committee of The Undersea and Hyperbaric Medical Society (UHMS). Hyperbaric Oxygen Therapy is Excluded for any other condition. Hyperbaric Oxygen Therapy requires Prior Authorization and services must be provided by your In-network Practitioner/Provider in order to be Covered. Infertility Treatment Infertility Treatment Diagnosis and medically indicated treatments for physical conditions causing infertility. Mental Health Services and Alcoholism and Substance Abuse Services Exclusion This benefit has one or more exclusions as specified in the Exclusions section. Mental Health Services
Prior Auth Required. Is a covered benefit only if the therapy is proposed for a condition recognized as one of the accepted indications as defined by the Hyperbaric Oxygen Therapy Committee of The Undersea and Hyperbaric Medical Society (UHMS). Hyperbaric Oxygen Therapy is Excluded for any other condition. Hyperbaric Oxygen Therapy requires Prior Authorization when provided by an In-network Practitioner/Provider in order to be Covered. Infertility Treatment Infertility Trea ment Diagnosis and medically indicated treatments for physical conditions causing infertility. Mental Health Services and Alcoholism and Substance Abuse Services Exclusion This benefit has one or more exclusions as specified in the Exclusions section. Mental Health Services Some mental health services require Prior Authorization. The In-network Behavioral Prior Auth Required Health Practitioners/Providers will be responsible for obtaining Prior Authorization, when required. For Out-of-network Services, Members need to contact our Behavioral Health Refer to Department to obtain Prior Authorization, when required. Please refer to the Prior Authorization Section for services that require Prior Authorization. For assistance or for questions related to mental health services, you may call our Behavioral Health Department directly at (000) 000-0000 or toll-free at 0-000-000-0000. o Partial Hospitalization can be substituted for the Inpatient mental health services when our Behavioral Health Department approves the Prior Authorization request. Partial Hospitalization is a non-residential, Hospital-based day program that includes various daily and weekly therapies. o Acute medical detoxification benefits are Covered under Inpatient and Outpatient Medical services Authorization. found in the Benefits
Prior Auth Required o Partial H spitalization can be substituted for the Inpatient mental health services when our Behavioral Health Department approves the Prior Authorization request. Partial Hospitalization is a non-residential, Hospital-based day program that includes various daily and weekly therapies. o Acute medical detoxification benefits are Covered under Inpatient and Outpatient Medical services found in the Benefits
