centene audiology guidelines
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Centene audiology guidelines cigna hmo doctors

Centene audiology guidelines

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Immune Globulins PDF. Inclisiran Leqvio PDF. Ipilimumab Yervoy PDF. However, the prescribed medication, device or service may be subject to prior authorization to determine whether it is covered. Bunionectomies are covered only when the bunion is present with:. Bunionectomies are not covered if the sole indications are pain and difficulty finding appropriate shoes.

Routine foot care is defined as services performed in the absence of localized illness, injury or symptoms involving the foot. Routine foot care is considered medically necessary in very limited circumstances. These services include:. Routine foot care is considered medically necessary when the member has a systemic disease of sufficient severity that performance of foot care procedures by a nonprofessional would be hazardous.

Conditions that might necessitate medically necessary foot care include metabolic, neurological, and peripheral vascular systemic diseases. Examples include, but are not limited to:. Treatment of a fungal mycotic infection is considered medically necessary foot care and is covered when the member has all of the following:.

Flu shots are available to all members. Copayments may only be collected for flu shots when given in conjunction with an office visit. PCPs must be available to administer immunizations during routine office hours.

At each visit, the PCP should inquire whether the patient has received immunizations from another provider. The PCP should also educate members regarding their responsibility to inform the PCP if they receive immunizations elsewhere such as from an LHD or nonparticipating provider.

Observation services do not apply when a member with a known diagnosis enters a hospital for a scheduled procedure or treatment that is expected to keep the member in the hospital for less than 24 hours. This is considered an outpatient procedure, regardless of the hour in which the member presented to the hospital, whether a bed was utilized or whether services were rendered after midnight.

Extended stays after outpatient surgery must be billed as recovery room extensions. Observation services must be ordered in writing by a physician or other individual authorized to admit patients to the hospital or to order outpatient diagnostic tests or treatments. There is no maximum time limit for observation services as long as medical necessity exists.

Factors taken into consideration when ordering observation services include:. The medical record must document the basis for the observation services and at a minimum must include:. The Health Plan covers medically necessary services provided in contracting skilled nursing facilities SNFs for members who need defined nursing care 24 hours a day, but who do not require acute hospital care under the daily direction of a physician.

Prior authorization is required for SNF services prior to admission, except in those cases for which retro-eligibility precludes the ability to obtain prior authorization. In these cases, the case is subject to medical review. Medically necessary SNF services are covered for a period not to exceed 90 days per contract year October 1 to September The following criteria apply:.

The SNF must coordinate with the member or their representative on alternate methods of payment for continuation of services beyond the day coverage with the Health Plan until the member is enrolled in the ALTCS program or until the beginning of the new contract year.

The Health Plan provides benefits for standard polysomnography inpatient and outpatient sleep studies in the following settings:. Suspected sleep-related breathing disorders, such as obstructive sleep apnea OSA , when one of the following two criteria are met:. The preferred method is a split night study in which the sleep study is performed during the first half of the night and positive air pressure system, such as continuous positive airway pressure CPAP or biphasic intermittent positive airway pressure BiPAP , titration is performed during the second half of the night.

In cases where testing and titration cannot be completed in one session, the Health Plan may authorize a second night subject to medical necessity criteria. Polysomnography is not covered for the following symptoms or conditions existing alone in the absence of other features suggestive of OSA:.

There are no geographic restrictions for Telehealth; services delivered via Telehealth are covered by the Health Plan in rural and urban regions. The Health Plan promotes the use of Telehealth to support an adequate provider network. Transmission of recorded health history e. Asynchronous care allows practitioners to assess, evaluate, consult, or treat conditions using secure digital transmission services, data storage services and software solutions.

Healthcare services delivered via asynchronous store and forward , remote patient monitoring, deledentistry, or telemedicine interactive audio and video. Location of the AHCCCS member at the time the service is being furnished via telehealth or where the asynchronous service originates. The acquisition and transmission of all necessary subjective and objective diagnostic data through interactive audio, video, or data communications by an AHCCCS registered dental provider to a dentist at a distant site for triage, dental treatment planning, and referral.

Personal health and medical data collection from a member in one location via electronic communication technologies, which is transmitted to a provider in a different location for use in providing improved chronic disease management, care, and related support. Such monitoring may be either synchronous real-time or asynchronous store and forward. There are no geographic restrictions for Telehealth; services delivered via Telehealth are covered by the health plan in rural and urban regions.

TheHealth Plan promotes the use of Telehealth to support an adequate provider network. Asynchronous store and forward does not require real-time interaction with the member. Reimbursement for this type of consultation is limited to:. Teledentistry includes the provision of preventative and other approved therapeutic services by the AHCCCS registered Affiliated Practice Dental Hygienist, who provides dental hygiene services under an affiliated practice relationship with a dentist.

Teledentistry does not replace the dental examination by the dentist, limited periodic and comprehensive examinations cannot be billed through the use of Teledentistry alone.

Telehealth codes have been temporarialy expanded to include telephonic codes. The following organ and tissue transplant services are covered for members ages 21 and older if prior authorized and coordinated with The Health Plan:.

Any other transplants not specifically listed under Covered Transplants for Members Ages 21 and Older. The following transplant and transplant-related services are not covered when the transplant procedure itself is not covered:.

For members who require medically necessary dental services as a prerequisite to AHCCCS covered organ or tissue transplantation, covered dental services are limited to the elimination of oral infections and the treatment of oral disease, which include dental cleanings, treatment of periodontal disease, medically necessary extractions, and the provision of simple restorations. Benefits are provided for these services only after a transplant evaluation determines that the member is an appropriate candidate for organ or tissue transplantation.

Only solid organ and hematopoietic stem cell transplants that are AHCCCS covered services when medically necessary, cost effective, nonexperimental, and not primarily for purposes of research, are covered under The Health Plan product.

Live donor kidney transplants are covered for pediatric and adult members. Live donor transplants may be considered on a case-by-case basis for solid organs, other than kidney, when medically appropriate and cost effective. Following is additional information on coverage for other transplants and devices under the Health Plan product:.

The Health Plan covers emergency ground and air ambulance transportation services within certain limitations. Covered transportation services include:. A provider who responds to an emergency call and provides medically necessary treatment at the scene, but does not transport the member is eligible for reimbursement limited to the approved base rate and medical supplies used. The Health Plan covers medically necessary non-emergency ground and air transportation to and from a required medical service.

All genetic testing requires prior authorization. Prior authorization requests must include documentation regarding how the genetic testing is consistent with the genetic testing coverage limitations. Genetic testing is only covered when the results of such testing are necessary to differentiate between treatment option specific diagnoses or syndromes. Genetic testing is not covered to determine the likelihood of associated medical conditions occurring in the future.

Routine, non-genetic testing for other medical conditions such as renal disease and hepatic disease that may be associated with an underlying genetic condition is covered when medically necessary.

Genetic testing is not covered as a substitute for ongoing monitoring or testing of potential complications or sequelae of a suspected genetic anomaly. Genetic testing is not covered to determine whether a member carries a hereditary predisposition to cancer or other diseases. Genetic testing is also not covered for members diagnosed with cancer to determine whether their particular cancer is due to a hereditary genetic mutation known to increase the risks of developing that cancer.

The Health Plan provides benefits for medically necessary radiology and medical imaging services for all eligible members when ordered by a primary care physician PCP or other practitioner for diagnosis, prevention, treatment, or assessment of medical conditions. Radiology services must be provided by a participating radiology provider. Members may be responsible for copayments that correspond to the type of facility where services are rendered. Complete the entire radiology order form when requesting radiology services, including all insurance information.

Participating providers with applicable radiology equipment can provide diagnostic radiology services in their office.

Specific Physical Health Provider Requirements. Providers must notify the Health Plan at least 45 days in advance of their inability to accept additional Medicaid members.

For the antipsychotic class of medications, prior authorization may be required. This includes the monitoring and adjustments of behavioral health medications. The Health Plan has a valid signed authorization from our members authorizing any physician, health care provider, hospital, insurance or reinsurance company, the Medical Information Bureau, Inc.

MIB , or other insurance information exchange to release information to The Health Plan if requested. Participating providers may obtain a copy of this authorization by contacting The Health Plan. The Health Plan does not reimburse for the cost of retrieval, copying and furnishing of medical records.

In the event of provider termination, cooperating with The Health Plan and other participating providers to provide or arrange for continuity of care to members undergoing an active course of treatment, subject to the requirements and limitations of Arizona Statute.

Operating and providing contracted services in compliance with all applicable local, state, and federal laws, rules, regulations, and institutional and professional standards of care, including federal laws and regulations designed to prevent or ameliorate fraud, waste, and abuse, including, but not limited to, applicable provisions of federal criminal law, the False Claims Act 31 U.

The Health Plan encourages answering services to follow these steps when receiving a call: Inform the member that if they are experiencing a medical emergency, they should hang up and call or proceed to the nearest emergency medical facility. Contact the on-call physician with the facts as stated by the member.

After office hours, the on-call physician must return telephone calls and pages within four hours. If an on-call physician cannot be reached, direct the member to a medical facility where they can receive emergency or urgent care treatment.

This is considered authorization, which is binding and cannot be retracted. If a Health Plan participating physician is unable to cover the practice, the following must occur: The non-participating physician must agree in writing to abide by the terms of the Health Plan contract and all Health Plan policies and procedures.

The Health Plan must give prior approval for the use of a non-participating physician. They include factors like: Education Employment Physical environment Socioeconomic status Social support networks As appropriate and within a scope of practice, providers are required to routinely screen for, and document, the presence of social determinants. Covered services include: Exams or evaluations for hearing aids Exams or evaluations for cochlear implants Evaluations for prescription of speech-generating and non-speech-generating augmentative and alternative communicating devices Therapeutic service s for the use of speech-generating and non-speech-generating devices, including programming and modification, and devices such as hearing aids, cochlear implants, speech-generating and non- speech-generating Audiology services must be provided by an audiologist who is licensed by the Arizona Department of Health Services ADHS and who meets federal requirements specified under 42 CFR Referrals are based on, but not limited to: member request members may also self-refer to a behavioral health provider ; sentinel event, such as a member-defined crisis episode; psychiatric hospitalization; identification of behavioral health diagnosis outside the scope of the PCP or substance abuse disorder issues.

To request this service, PCPs must complete and submit the behavioral health referral form and check one-time, face-to-face request. Breast reconstructive surgery coverage includes: Reconstruction of the affected and the unaffected contralateral breast.

Reconstructive breast surgery of the unaffected contralateral breast following mastectomy is considered medically necessary only when required to achieve relative symmetry with the reconstructed affected breast.

The surgeon must determine medical necessity and request prior authorization for reconstructive breast surgery of the unaffected contralateral breast prior to the time of reconstruction or during the immediate post- operative period Medically necessary implant removal and implant replacement when the original implant was the result of a medically necessary mastectomy.

Implant replacements are not covered when the purpose of the original implant was cosmetic, such as augmentation External prostheses, including a surgical brassiere, for members who choose not to have breast reconstruction, or who choose to delay breast reconstruction until a later time Prior authorization is required for breast reconstruction surgery. Medically necessary outpatient dialysis treatments are covered, including: Supplies Diagnostic testing including routine medically necessary laboratory tests Medications Inpatient dialysis treatments are covered when the hospitalization is for: Acute medical condition requiring dialysis treatments hospitalization related to dialysis Medical condition requiring inpatient hospitalization experienced by a member routinely maintained on an outpatient chronic dialysis program Placement, replacement, or repair of the chronic dialysis route First aid supplies except under a prescription.

Hearing aids for members ages 21 and older. Prescriptive lenses for members ages 21 and older except if medically necessary following cataract removal.

Penile implants or vacuum devices for members who are ages 21 and older. Coverage for Members Under Age 21 Orthotic devices are a covered benefit for The Health Plan members under age 21 when they are medically necessary and the orthotics cost less than other treatments that are as helpful for the condition.

The orthotic is less expensive than all other treatment options or surgical procedures to treat the same diagnosed condition. Bunionectomies are covered only when the bunion is present with: Overlying skin ulceration; Neuroma secondary to bunion neuroma to be removed at same surgery and documented by pathology report.

These services include: Cutting or removal of corns or calluses Nail trimming including mycotic nails Other hygienic and preventive maintenance care in the realm of self-care such as cleaning and soaking the feet, and the use of skin creams to maintain skin tone of both ambulatory and bedfast patients Routine foot care is considered medically necessary when the member has a systemic disease of sufficient severity that performance of foot care procedures by a nonprofessional would be hazardous.

Treatment of a fungal mycotic infection is considered medically necessary foot care and is covered when the member has all of the following: A systemic condition Clinical evidence of mycosis of the toenail Compelling medical evidence documenting the member either: Has a marked limitation of ambulation due to the mycosis, which requires active treatment of the foot In the case of a nonambulatory member, has a condition that is likely to result in significant medical complications in the absence of such treatment.

The following criteria apply: A participating physician has ordered SNF services. The medical condition of the member is such that if SNF services are not provided, it would result in hospitalization, or the treatment is such that it cannot be rendered safely in a less restrictive setting, such as at home by a home health services provider; The 90 days of coverage is per member, per contract year and does not restart if the member transfers to a different nursing facility.

The Health Plan members residing in a SNF at the beginning of a new contract year begin a new day coverage period. Unused days do not carry over. The 90 days of coverage begins on the day of admission regardless of whether the member is covered by a third- party insurance carrier, including Medicare. The Health Plan provides benefits for standard polysomnography inpatient and outpatient sleep studies in the following settings: A licensed and certified hospital facility; A nonhospital facility that meets one of the following sets of criteria: Is licensed by the Arizona Department of Health Services ADHS and the facility is accredited by the American Academy of Sleep Medicine Has a medical director who is certified by the American Board of Sleep Medicine and has a managing sleep technician who is registered by the Board of Registered Polysomnographic Technologists; For sleep electroencephalogram EEG only, the facility must have a physician who is a board- certified neurologist.

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See Also : Medical , Health Show details. See Also : Medical Show details. They include but are not limited to policies relating to evolving medical technologies .

The purpose of this policy is to define medical necessity criteria for commonly used urodynamic studies. The Centene Corporation is a fortune company offering both Medicaid and other specialty services to government-sponsored health care programs. Correctional healthcare: Centene offers healthcare and staffing to correctional systems via a subsidiary, Centurion, a national provider of healthcare and staffing services to correctional systems and other government agencies.

Centene is the largest Medicaid managed care organization in the U. Centene is also the national leader in managed long-term services and supports, and the number one carrier in the nation on the Health Insurance Marketplace.

After the death of Brinn, the non-profit organization was sold to investors, with the proceeds going to the Betty Brinn Foundation, which subsequently became a major shareholder in Centene.

General criteria: File Size: KB. Clinical Payment Policies Ambetter from Coordinated Care 2 hours ago WebClinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. Clinical Policy: Urodynamic Testing Health Net 2 hours ago Webfollowing an appropriate evaluation and symptom characterization. What is Centene healthcare?

Centene's competitive advantage is driven by capability, capacity, scale, and more than 30 years of experience operating government-sponsored healthcare programs. Centene is the largest Medicaid managed care organization in the U. Centene is also the national leader in managed long-term services and supports, and the number one carrier in the nation on the Health Insurance Marketplace. The health and safety of our members, employees, and communities is our uncompromising priority.

Transforming the health of the community, one person at a time. Featured Stories Honoring Dr. Martin Luther King Jr. Through Service and Advancing an Inclusive Culture. At Centene, healthcare is personal. Every family, individual, and community we serve is unique.