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Medicare Prior Authorization List Effective January 1, 2021

Medicare Prior Authorization List Effective January 1, 2021. Allwell from Superior HealthPlan (HMO and HMO SNP) requires Prior Authorization as a condition of payment for many services. This notice contains information regarding Prior Authorization requirements and is applicable to all Medicare products offered by Allwell. Allwell is committed to delivering cost Effective quality care to members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior Authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria.

Substance Use Disorder Treatment/Rehabilitation Bronchial Thermoplasty : Outpatient procedure for the treatment of ... Skilled Nursing Facility (SNF) Hyperbaric O2 Therapy . Includes HBO therapy administered in a ... J3304 INJECT TRIAMCINOLONE ACETONIDE PF ER MS F 1 MG J3357 USTEKINUMAB FOR SUBQ INJECTION 1 MG J3380 INJECTION VEDOLIZUMAB …

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Superior HealthPlan PHONE: o Physical Health: 1-800-218 ...

www.superiorhealthplan.com

Physical Therapy, Occupational Therapy, Speech Therapy Skilled Nursing Visits Private Duty Nursing Abdominal Hysterectomy Bariatric Surgery Circumcision (One year and older) Cardiac Surgeries ENT Services: Nasal/Sinus Endoscopy, Tonsillectomy & Adenoidectomy, Typanostomy, Myringotomy Musculoskeletal Surgical Procedures

  Speech

CLAIMS APPEAL PAYMENT RECONSIDERATION & DISPUTE …

www.superiorhealthplan.com

Please complete the following form to help expedite the review of your claims appeal. *Is this a. Request for Reconsideration: you disagree with the original claim outcome (payment amount, denial reason, etc.) Please check if this is the first time you are asking for a review of the claim. ... Farmington, Missouri 63640- 3800 . Author: Jill ...

  Form, 0308

Tamiflu® Treatment and Prophylaxis Information per CDC ...

www.superiorhealthplan.com

o Prevention of influenza among residents of institutions, such as long-term care facilities, during influenza outbreaks in the institution. For more information, see IDSA Guidelines website. An emphasis on close monitoring and early initiation of antiviral treatment if fever and/or respiratory symptoms develop is an alternative to

  Treatment, Prevention

Claim Adjustment Reason Codes Crosswalk to EX Codes

www.superiorhealthplan.com

Claim Adjustment Reason Codes Crosswalk to EX Codes: SHP_20161447 2 Revised April 2016 EX Code Reason Code (CARC) RARC DESCRIPTION TYPE EXCB 15 N596 AUTHORIZATION IS CANCELLED -ERROR IN ENTRY DENY EXHc 15 . N517 DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICE(S) BILLED . DENY EXhf . 15 N596 . DENY: NO …

  Code, Reasons, Reason codes

Ambetter from Superior HealthPlan

www.superiorhealthplan.com

• High-Tech Imaging (i.e., CT, MRI, PET) • Infertility • Obstetrical Ultrasound – Two allowed in a nine month period. Any additional ultrasounds will require prior authorization (unless rendered by a Perinatologist). – For urgent/emergent ultrasounds, treat using best clinical judgment and authorizations will be reviewed retrospectively.

  Form, Superior, Imaging, Ultrasound, Healthplan, Ambetter, Obstetrical, Obstetrical ultrasound, Ambetter from superior healthplan

Claim Adjustment Reason Codes Crosswalk

www.superiorhealthplan.com

ex07 7 n517 deny: the procedure code is inconsistent with the patient s sex deny ex09 9 n657 deny: the diagnosis is inconsistent with the patient s age or sex deny ... visit & preven codes are not payable on same dos w o documentation deny ... svc not covered based on age of patient and provider specialty deny

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REQUEST FOR PRIOR AUTHORIZATION - Superior HealthPlan

www.superiorhealthplan.com

Authorization Number. Units Dates Authorized. Genetic Testing Type: Pregnant. Yes No. Urgent Request - By checking this box, I certify that this is an urgent request medically necessary treatment, which must be treated within 24 hours.

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Wellcare By Allwell

www.superiorhealthplan.com

HEDIS/Care gap reviews Financial analysis EHR Utilization Demographic information updates Initiate credentialing of a new practitioner . Confidential and Proprietary Information Membership. Confidential and Proprietary Information ... Supplemental Benefits at a Glance

  Glance, Hide, At a glance

Ambetter from Superior HealthPlan

www.superiorhealthplan.com

• Ambetter from Superior HealthPlan is an HMO Benefit Plan. • Members enrolled in Ambetter must use in- network participating providers, except in the case of emergency services. • If an out-of-network provider is used (except in the case of emergency services), the member will be 100% responsible for all charges.

  Superior, Healthplan, Superior healthplan

TX-PAF-5869 - Medicaid Prior Authorization Fax Form

www.superiorhealthplan.com

MEDICAID PRIOR AUTHORIZATION FORM Complete and Fax to: 800-690-7030 Behavioral Health Requests/Medical Records: Fax. 866-570-7517. Transplant: Fax. 833-589-1245 . Request for additional units. Existing Authorization. Units. Urgent requests - I certify this request is urgent and medically necessary to treat an injury, illness or condition (not ...

  Medicaid, Authorization, Prior, Medicaid prior authorization

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Provider Preauthorization and Precertification Requirements

www.bcbsm.com

All behavioral health and substance use disorder inpatient, partial hospital and intensive outpatient ... • Skilled Nursing Facility, Acute Inpatient Rehabilitation Facility Fax AssessmentForm ... − er’sThe memb contract number, date of birth, the spelling of theirfirst name and ZIPcode 3. Listen to the member’s eligibility information.

  Nursing, Disorders, Substance, Substance use disorders

Ambetter Quick Reference Guide

ambetter.pshpgeorgia.com

Mental Health/Substance Use Disorder Admissions/Concurrent Review – Phone: 1-877-687-1180 Fax: 1-855-279-6174 Call to provide clinical information and obtain authorization for all behavioral health admissions. High Tech Imaging – MRI/CT/PET Phone: 1-877-687-1180 www.radmd.com . Home Health, DME, Home Infusion – Univita:

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AUTHORIZATION TO RELEASE COPIES OF A MEDICAL RECORD

www.med.umich.edu

5. Record set to be released to the party indicated above: Use form 70-10232 for release of alcohol / substance use disorder info. I request the following information be released, which may include: alcohol and drug abuse/treatment; psychological and social work

  Disorders, Substance, Substance use disorders

MENTAL HEALTH AND THE LGBTQ COMMUNITY

suicidepreventionlifeline.org

• The NSDUH found that 15 percent of LGBQ adults had an alcohol or drug use disorder in the past year, compared to eight percent of heterosexual adults (Medley 2016). Stigma drives the higher rates of mental health problems in LGBTQ communities. • A 2014 study found that LGBQ people who live in communities with more stigmatizing

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BENEFIT SUMMARY - Cigna

www.cigna.com

Emergency Room Includes Professional, X-ray and/or Lab services performed at the Emergency Room and billed by the facility as part of the ER visit. Per visit copay is waived if admitted. An additional per scan copay of $65 applies to Advanced Radiological Imaging. $250 copay, and plan pays 100% ^ $250 copay, and plan pays 100% ^

  Room, Emergency, Cigna, Emergency room

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Substance use disorder, Nursing, Use disorder, Cigna, Emergency Room