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. Clinical Preventive Health Services 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. Before you are admitted as an Inpatient to a Hospital, Skilled Nursing Facility or other facility or before you receive certain Covered Health Care Services and supplies, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services Section. 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. 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. When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before pro...
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 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
Refer to. “LCMs shall be normally closed:
Refer to. Gateway must communicate and interface with a minimum of two thermostats:
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. 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. C -855-261-7737. Hearing impaired users may call the TTY 711 or toll-free at 1-800-659- 8331. You may also visit our website at xxx.xxx.xxx. Acute Medical Detoxification All Hospital admissions, Inpatient non-emergent Autism Spectrum Disorder Bariatric Services and Surgery for the treatment of obesity Bone Growth Stimulator Certified Hospice Care Computed Axial Tomography (CAT) scans in an outpatient setting Cancer Clinical Trials (Investigational/Experimental) 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 Caridia Outpatient Telemetry and real time continuous attended cardiac monitoring systems Newborn Delivery and Hospital Obstertrical 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 o Ankle Subtalar Arthoereisis o Blepharoplasty/Brow Ptosis Surgery o Breast implant removal and/or replacement and Capsulectomy o Breast Reconstruction following Mastectomy o Breast Reduction for gynecomastia o Breast Reduction Mammoplasty for symptomatic breast hypertrophy o Cholecystectomy by Laparoscopy o Endoscopy Nasal/Sinus balloon dilation o Hysterectomy o Lumbar/Cervical Spine Surgery o Meniscus Implant and Allograft/Meniscus Transplant o Panniculectomy o Rhinoplasty o Septoplasty o Tonsillectomy o Total Ankle Replacement o Total Hip Replacement o Total Knee Replacement Skilled Nursing Facility care Sleep Disorder Studies in an outpatient setting Special Inpatient services for example, private room and board and/or special duty nursing Special Medical Foods Substance Abuse services, Inpatient, Partial Hospitalization and select ...
Refer to. Article 22.3 for information re: the impact of a leave of absence on seniority.
