2.04.26 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and
Irritable Bowel SyndromeMEDICAL POLICY – 2.04.26 Fecal Analysis in
the Diagnosis of Intestinal Dysbiosis and Irritable Bowel Syndrome
BCBSA Ref. Policy: 2.04.26 Effective Date: July 1, 2021 Last
Revised: June 8, 2021 Replaces: N/A
RELATED MEDICAL POLICIES: None
Select a hyperlink below to be directed to that section.
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED
INFORMATION | EVIDENCE REVIEW | REFERENCES | HISTORY
∞ Clicking this icon returns you to the hyperlinks menu
above.
Introduction
Intestinal dysbiosis is a condition that occurs when the
microorganisms in the digestive tract are out of balance. This
condition is believed to cause diseases of the digestive tract,
including poor nutrient absorption, overgrowth of certain bacteria,
and irritable bowel syndrome (IBS). Symptoms of these digestive
problems are similar and may include: abdominal pain, excess gas,
bloating, and changes in bowel movements (constipation or diarrhea,
or both). One method of diagnosing digestive disorders is by
testing a fecal sample. Using fecal analysis to diagnose intestinal
dysbiosis, IBS, malabsorption, or small intestinal overgrowth of
bacteria is unproven (investigational). More studies are needed to
see if this testing improves health outcomes.
Note: The Introduction section is for your general knowledge and is
not to be taken as policy coverage criteria. The rest of the policy
uses specific words and concepts familiar to medical professionals.
It is intended for providers. A provider can be a person, such as a
doctor, nurse, psychologist, or dentist. A provider also can be a
place where medical care is given, like a hospital, clinic, or lab.
This policy informs them about when a service may be covered.
Policy Coverage Criteria
Page | 2 of 10 ∞
Test Investigational Examples: (this list may not be all inclusive)
• GI effects®
Comprehensive Stool Profile (Genova)
Fecal analysis of the following components is considered
investigational as a diagnostic test for the evaluation of
intestinal dysbiosis, irritable bowel syndrome, malabsorption, or
small intestinal overgrowth of bacteria: • Cholesterol •
Chymotrypsin • Fecal secretory immunoglobulin A • Identification
and quantitation of fecal yeast (including Candida
albicans, Candida tropicalis, Rhodotorula, and Geotrichum) •
Iso-butyrate, iso-valerate, and n-valerate • Levels of
Lactobacilli, bifidobacteria, and Escherichiacoli and
other “potential pathogens,” including Aeromonas, Bacillus cereus,
Campylobacter, Citrobacter, Klebsiella, Proteus, Pseudomonas,
Salmonella, Shigella, Staphylococcus aureus, and Vibrio
• Long-chain fatty acids • Meat and vegetable fibers • N-butyrate •
pH • Short-chain fatty acid distribution (adequate amount and
proportions of the different short-chain fatty acids reflect the
basic status of intestinal metabolism)
• Total short-chain fatty acids • Triglycerides • β
-glucuronidase
Coding
The following CPT codes may be used to identify individual
components of fecal analysis
Code Description CPT
82271 Blood, occult, by peroxidase activity (eg, guaiac),
qualitative; other sources
82272 Blood, occult, by peroxidase activity (eg, guaiac),
qualitative, feces, 1-3 simultaneous determinations, performed for
other than colorectal neoplasm screening
82274 Blood, occult, by fecal hemoglobin determination by
immunoassay, qualitative, feces, 1-3 simultaneous
determinations
82542 Column chromatography, includes mass spectrometry, if
performed (eg, HPLC, LC, LC/MS, LC/MS-MS, GC, GC/MS-MS, GC/MS,
HPLC/MS), non-drug analyte(s) not elsewhere specified, qualitative
or quantitative, each specimen
82656 Elastase, pancreatic (EL-1), fecal, qualitative or
semi-quantitative
82710 Fat or lipids, feces; quantitative
82715 Fat differential, feces, quantitative
82725 Fatty acids, nonesterified
82784 Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM,
each
83520 Immunoassay for analyte other than infectious agent antibody
or infectious agent antigen; quantitative, not otherwise
specified
83630 Lactoferrin, fecal; qualitative
83993 Calprotectin, fecal
87045 Culture, bacterial; stool, aerobic, with isolation and
preliminary examination (eg, KIA, LIA), Salmonella and Shigella
species
87046 Culture, bacterial; stool, aerobic, additional pathogens,
isolation and presumptive identification of isolates, each
plate
87075 Culture, bacterial; any source, except blood, anaerobic with
isolation and presumptive identification of isolates
87102 Culture, fungi (mold or yeast) isolation, with presumptive
identification of isolates; other source (except blood)
87177 Ova and parasites, direct smears, concentration and
identification
87209 Smear, primary source with interpretation; complex special
stain (eg, trichrome, iron hemotoxylin) for ova and parasites
Page | 4 of 10 ∞
immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA],
fluorescence immunoassay [FIA], immunochemiluminometric assay
[IMCA]) qualitative or semiquantitative; Clostridium difficile
toxin(s)
87427 Infectious agent antigen detection by immunoassay technique,
(eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay
[ELISA], fluorescence immunoassay [FIA], immunochemiluminometric
assay [IMCA]) qualitative or semiquantitative; Shiga-like
toxin
87328 Infectious agent antigen detection by immunoassay technique,
(eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay
[ELISA], fluorescence immunoassay [FIA], immunochemiluminometric
assay [IMCA]) qualitative or semiquantitative;
cryptosporidium
87329 Infectious agent antigen detection by immunoassay technique,
(eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay
[ELISA], fluorescence immunoassay [FIA], immunochemiluminometric
assay [IMCA]) qualitative or semiquantitative; giardia
87336 Infectious agent antigen detection by immunoassay technique,
(eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay
[ELISA], fluorescence immunoassay [FIA], immunochemiluminometric
assay [IMCA]) qualitative or semiquantitative; Entamoeba
histolytica dispar group
87338 Infectious agent antigen detection by immunoassay technique,
(eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay
[ELISA], fluorescence immunoassay [FIA], immunochemiluminometric
assay [IMCA]) qualitative or semiquantitative; Helicobacter pylori,
stool
87449 Infectious agent antigen detection by immunoassay technique,
(eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay
[ELISA], fluorescence immunoassay [FIA], immunochemiluminometric
assay [IMCA]) qualitative or semiquantitative; not otherwise
specified, each organism
87505 Infectious agent detection by nucleic acid (DNA or RNA);
gastrointestinal pathogen (eg, Clostridium difficile, E. coli,
Salmonella, Shigella, norovirus, Giardia), includes multiplex
reverse transcription, when performed, and multiplex amplified
probe technique, multiple types or subtypes, 3-5 targets
87798 Infectious agent detection by nucleic acid (DNA or RNA), not
otherwise specified; amplified probe technique, each organism
89160 Meat fibers, feces
HCPCS Note: CPT codes, descriptions and materials are copyrighted
by the American Medical Association (AMA). HCPCS
codes, descriptions and materials are copyrighted by Centers for
Medicare Services (CMS).
Page | 5 of 10 ∞
Related Information
Benefit Application
Due to the nonspecific nature of the CPT codes used to identify
different components of fecal analysis, identification of these
claims may require identification of those laboratories that
specialize in the analysis for the evaluation of intestinal
dysbiosis. Because there are a limited number of laboratories that
provide this type of fecal analysis, these services may be provided
by out-of-network providers. Also, a review of these services may
be approached through a retrospective review looking for specific
patterns of testing.
Evidence Review
Description
Intestinal dysbiosis may be defined as a state of disordered
microbial ecology that is believed to cause disease. Laboratory
analysis of fecal samples is proposed as a method of identifying
individuals with intestinal dysbiosis and other gastrointestinal
disorders.
Irritable bowel syndrome (IBS) is a functional gastrointestinal
(GI) disorder that affects 10% to 20% of the general population in
the U.S. and worldwide. Symptoms include abdominal pain and/or
bloating associated with disordered bowel habit (constipation,
diarrhea, or both). Pathophysiology is poorly understood but may be
related to chronic low-grade mucosal inflammation and disturbances
in GI flora. Recommended treatments include dietary restriction and
pharmacologic symptom control. As living microorganisms that
promote health when administered to a host in therapeutic doses,
probiotics are being investigated as a treatment for IBS. Several
systematic reviews of randomized controlled trials have found
evidence to support efficacy but results from recent randomized
controlled trials have been mixed. This discrepancy may be due in
part to the differential effects of different probiotic strains and
doses.
Page | 6 of 10 ∞
Fecal Markers of Dysbiosis
Laboratory analysis of both stool and urine has been investigated
as markers of dysbiosis. Commercial laboratories may offer testing
for comprehensive panels or individual components of various
aspects of digestion, absorption, microbiology, and metabolic
markers. Representative components of fecal dysbiosis testing are
summarized in Table 1.
Table 1. Components of the Fecal Dysbiosis Marker Analysis
Markers Analytes Digestion • Triglycerides
• Identification and quantitation of fecal yeast (including Candida
albicans, Candida tropicalis, Rhodotorula, and Geotrichum)
(optional viral and/or parasitology components)
Metabolic • N-butyrate (considered key energy source for colonic
epithelial cells)
• β-glucuronidase
• pH
Page | 7 of 10 ∞
Markers Analytes Short-chain fatty acid distribution (adequate
amount and proportions of the different short-chain fatty acids
reflect the basic status of intestinal metabolism)
Immunology • Fecal secretory immunoglobulin A (as a measure of
luminal immunologic function)
• Calprotectina
a Fecal calprotectin as a stand-alone test is not addressed in this
policy.
Fecal Testing for Intestinal Dysbiosis
The gastrointestinal tract is colonized by a large number and a
variety of microorganisms including bacteria, fungi, and archaea.
The concept of intestinal dysbiosis rests on the assumption that
abnormal patterns of intestinal flora, such as overgrowth of some
commonly found microorganisms, have an impact on human health.
Symptoms and conditions attributed to intestinal dysbiosis in
addition to gastrointestinal disorders include chronic disorders
(eg, irritable bowel syndrome [IBS], inflammatory or autoimmune
disorders, food allergy, atopic eczema, unexplained fatigue,
arthritis, ankylosing spondylitis), malnutrition, or
neuropsychiatric symptoms or neurodevelopmental conditions (eg,
autism), and breast and colon cancer.
The gastrointestinal tract symptoms attributed to intestinal
dysbiosis (ie, bloating, flatulence, diarrhea, constipation)
overlap in part with either IBS or small intestinal bacterial
overgrowth syndrome. The diagnosis of IBS is typically made
clinically, based on a set of criteria referred to as the Rome
criteria. The small intestine normally contains a limited number of
bacteria, at least as compared with the large intestine. Small
intestine bacterial overgrowth may occur due to altered motility
(including blind loops), decreased acidity, exposure to
antibiotics, or surgical resection of the small bowel. Symptoms
include malabsorption, diarrhea, fatigue, and lethargy. The
laboratory criterion standard for diagnosis consists of the culture
of a jejunal fluid sample, but this requires invasive testing.
Hydrogen breath tests, commonly used to evaluate lactose
intolerance, have been adapted for use in diagnosing small
intestinal bacterial overgrowth.
The GI Effects Comprehensive Stool Profile (Genova Diagnostics) is
a multianalyte stool assay.2 The test uses polymerase chain
reaction (PCR) to quantify 26 commensal gut bacteria and standard
biochemical and culture methods to measure levels of other stool
components (eg, lipids, fecal occult blood) and potential pathogens
(ova and parasites, opportunistic bacteria, yeast). The test is
purported to optimize management of gut health and to differentiate
IBS from inflammatory bowel disease (IBD).
Page | 8 of 10 ∞
Summary of Evidence
For individuals who have gastrointestinal conditions such as
suspected intestinal dysbiosis, irritable bowel syndrome,
malabsorption, or small intestinal bacterial overgrowth who receive
fecal analysis testing, the evidence includes several cohort and
case-control studies comparing fecal microbiota in patients who had
a known disease with healthy controls. Relevant outcomes are test
validity, symptoms, and functional outcomes. The available
retrospective cohort studies on fecal analysis have suggested that
some components of the fecal microbiome and inflammatory markers
may differ across patients with irritable bowel syndrome subtypes.
No studies were identified on the diagnostic accuracy of fecal
analysis vs another diagnostic approach or that compared health
outcomes in patients managed with and without fecal analysis tests.
No studies were identified that directly informed the use of fecal
analysis in the evaluation of intestinal dysbiosis, malabsorption,
or small intestinal bacterial overgrowth. The evidence is
insufficient to determine that the technology results in an
improvement in the net health outcomes.
No studies were identified that assessed the accuracy of the GI
Effects fecal panel for diagnosing IBS or for documenting "gut
health," a concept that may be difficult to define given large
interindividual variability in gut flora. Evidence for the clinical
validity and utility of the GI Effects Comprehensive Stool Profile
is lacking. Because probiotics are not currently a standard
treatment of IBS, the impact of test results on disease management
is uncertain; ie, a chain of evidence for clinical utility of the
test cannot be established.
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in November 2020 did not identify
any ongoing or unpublished trials that would likely influence this
review.
Practice Guidelines and Position Statements
Page | 9 of 10 ∞
Regulatory Status
Clinical laboratories may develop and validate tests in-house and
market them as a laboratory service; laboratory-developed tests
must meet the general regulatory standards of the Clinical
Laboratory Improvement Amendments. Laboratories that offer
laboratory-developed tests must be licensed by the Clinical
Laboratory Improvement Amendments for high-complexity testing. To
date, the U.S. Food and Drug Administration has chosen not to
require any regulatory review of comprehensive testing for fecal
dysbiosis.
References
1. Emmanuel A, Landis D, Peucker M, et al. Faecal biomarker
patterns in patients with symptoms of irritable bowel syndrome.
Frontline Gastroenterol. Oct 2016; 7(4): 275-282. PMID
27761231
2. Genova Diagnostics. 2015; www.gdx.net. Accessed June 16,
2021.
3. Goepp J, Fowler E, McBride T, et al. Frequency of abnormal fecal
biomarkers in irritable bowel syndrome. Glob Adv Health Med. May
2014; 3(3): 9-15. PMID 24891989
4. Andoh A, Kuzuoka H, Tsujikawa T, et al. Multicenter analysis of
fecal microbiota profiles in Japanese patients with Crohn's
disease. J Gastroenterol. Dec 2012; 47(12): 1298-307. PMID
22576027
5. Sobhani I, Tap J, Roudot-Thoraval F, et al. Microbial dysbiosis
in colorectal cancer (CRC) patients. PLoS One. Jan 27 2011; 6(1):
e16393. PMID 21297998
6. Joossens M, Huys G, Cnockaert M, et al. Dysbiosis of the faecal
microbiota in patients with Crohn's disease and their unaffected
relatives. Gut. May 2011; 60(5): 631-7. PMID 21209126
7. Langhorst J, Elsenbruch S, Koelzer J, et al. Noninvasive markers
in the assessment of intestinal inflammation in inflammatory bowel
diseases: performance of fecal lactoferrin, calprotectin, and
PMN-elastase, CRP, and clinical indices. Am J Gastroenterol. Jan
2008; 103(1): 162-9. PMID 17916108
Page | 10 of 10 ∞
Date Comments 07/01/21 New policy, approved June 8, 2021. Fecal
analysis in the diagnosis of intestinal dysbiosis and
irritable
bowel syndrome is considered investigational.
Disclaimer: This medical policy is a guide in evaluating the
medical necessity of a particular service or treatment. The Company
adopts policies after careful review of published peer-reviewed
scientific literature, national guidelines and local standards of
practice. Since medical technology is constantly changing, the
Company reserves the right to review and update policies as
appropriate. Member contracts differ in their benefits. Always
consult the member benefit booklet or contact a member service
representative to determine coverage for a specific medical service
or supply. CPT codes, descriptions and materials are copyrighted by
the American Medical Association (AMA). ©2021 Premera All Rights
Reserved.
Scope: Medical policies are systematically developed guidelines
that serve as a resource for Company staff when determining
coverage for specific medical procedures, drugs or devices.
Coverage for medical services is subject to the limits and
conditions of the member benefit plan. Members and their providers
should consult the member benefit booklet or contact a customer
service representative to determine whether there are any benefit
limitations applicable to this service or supply. This medical
policy does not apply to Medicare Advantage.
Discrimination is Against the Law
Premera Blue Cross complies with applicable Federal civil rights
laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. Premera does not exclude
people or treat them differently because of race, color, national
origin, age, disability or sex.
Premera: • Provides free aids and services to people with
disabilities to communicate
effectively with us, such as: • Qualified sign language
interpreters • Written information in other formats (large print,
audio, accessible
electronic formats, other formats) • Provides free language
services to people whose primary language is not
English, such as: • Qualified interpreters • Information written in
other languages
If you need these services, contact the Civil Rights
Coordinator.
If you believe that Premera has failed to provide these services or
discriminated in another way on the basis of race, color, national
origin, age, disability, or sex, you can file a grievance with:
Civil Rights Coordinator - Complaints and Appeals PO Box 91102,
Seattle, WA 98111 Toll free 855-332-4535, Fax 425-918-5592, TTY
800-842-5357 Email
[email protected]
You can file a grievance in person or by mail, fax, or email. If
you need help filing a grievance, the Civil Rights Coordinator is
available to help you.
You can also file a civil rights complaint with the U.S. Department
of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint
Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at: U.S. Department of Health and Human Services 200 Independence
Avenue SW, Room 509F, HHH Building Washington, D.C. 20201,
1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
Getting Help in Other Languages
This Notice has Important Information. This notice may have
important information about your application or coverage through
Premera Blue Cross. There may be key dates in this notice. You may
need to take action by certain deadlines to keep your health
coverage or help with costs. You have the right to get this
information and help in your language at no cost. Call 800-722-1471
(TTY: 800-842-5357).
(Amharic): Premera Blue Cross 800-722-1471 (TTY:
800-842-5357)
( :( .
.
. 800-722-1471 (TTY: 800-842-5357)
.Premera Blue Cross
.
Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba.
Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin
tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu
danda’a. Guyyaawwan murteessaa ta’an beeksisa kana keessatti
ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa
keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu
danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin
odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu.
Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii
bilbilaa.
Français (French): Cet avis a d'importantes informations. Cet avis
peut avoir d'importantes informations sur votre demande ou la
couverture par l'intermédiaire de Premera Blue Cross. Le présent
avis peut contenir des dates clés. Vous devrez peut-être prendre
des mesures par certains délais pour maintenir votre couverture de
santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette
information et de l’aide dans votre langue à aucun coût. Appelez le
800-722-1471 (TTY: 800-842-5357).
Kreyòl ayisyen (Creole): Avi sila a gen Enfòmasyon Enpòtan ladann.
Avi sila a kapab genyen enfòmasyon enpòtan konsènan aplikasyon w
lan oswa konsènan kouvèti asirans lan atravè Premera Blue Cross.
Kapab genyen dat ki enpòtan nan avi sila a. Ou ka gen pou pran kèk
aksyon avan sèten dat limit pou ka kenbe kouvèti asirans sante w la
oswa pou yo ka ede w avèk depans yo. Se dwa w pou resevwa
enfòmasyon sa a ak asistans nan lang ou pale a, san ou pa gen pou
peye pou sa. Rele nan 800-722-1471 (TTY: 800-842-5357).
Deutsche (German): Diese Benachrichtigung enthält wichtige
Informationen. Diese Benachrichtigung enthält unter Umständen
wichtige Informationen bezüglich Ihres Antrags auf
Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie
nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie
könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren
Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten.
Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer
Sprache zu erhalten. Rufen Sie an unter 800-722-1471 (TTY:
800-842-5357).
Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem
ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov ntsiab lus tseem
ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam
los ntawm Premera Blue Cross. Tej zaum muaj cov hnub tseem ceeb uas
sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam
uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau
hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho
mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom
lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub
dawb rau koj. Hu rau 800-722-1471 (TTY: 800-842-5357).
Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti Napateg nga
Impormasion. Daytoy a pakdaar mabalin nga adda ket naglaon iti
napateg nga impormasion maipanggep iti apliksayonyo wenno coverage
babaen iti Premera Blue Cross. Daytoy ket mabalin dagiti importante
a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga
aramidenyo nga addang sakbay dagiti partikular a naituding nga
aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong
kadagiti gastos. Adda karbenganyo a mangala iti daytoy nga
impormasion ken tulong iti bukodyo a pagsasao nga awan ti
bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY:
800-842-5357).
Italiano ( ): Questo avviso contiene informazioni importanti.
Questo avviso può contenere informazioni importanti sulla tua
domanda o copertura attraverso Premera Blue Cross. Potrebbero
esserci date chiave in questo avviso. Potrebbe essere necessario un
tuo intervento entro una scadenza determinata per consentirti di
mantenere la tua copertura o sovvenzione. Hai il diritto di
ottenere queste informazioni e assistenza nella tua lingua
gratuitamente. Chiama 800-722-1471 (TTY: 800-842-5357).
Italian
037338 (07-2016)
800-722-1471 (TTY: 800-842-5357)
(Korean): . Premera Blue Cross . . . . 800-722-1471 (TTY:
800-842-5357) .
(Lao): . Premera Blue Cross. .
. . 800-722-1471 (TTY: 800-842-5357).
Premera Blue Cross
Khmer
.
.
,
,
800-722-1471 (TTY: 800-842-5357).
(Punjabi):
(Farsi): .
.
Premera Blue Cross .
. .
Polskie (Polish): To ogoszenie moe zawiera wane informacje. To
ogoszenie moe zawiera wane informacje odnonie Pastwa wniosku lub
zakresu wiadcze poprzez Premera Blue Cross. Prosimy zwrócic uwag na
kluczowe daty, które mog by zawarte w tym ogoszeniu aby nie
przekroczy terminów w przypadku utrzymania polisy ubezpieczeniowej
lub pomocy zwizanej z kosztami. Macie Pastwo prawo do bezpatnej
informacji we wasnym jzyku. Zadzwocie pod 800-722-1471 (TTY:
800-842-5357).
Português (Portuguese): Este aviso contém informações importantes.
Este aviso poderá conter informações importantes a respeito de sua
aplicação ou cobertura por meio do Premera Blue Cross. Poderão
existir datas importantes neste aviso. Talvez seja necessário que
você tome providências dentro de determinados prazos para manter
sua cobertura de saúde ou ajuda de custos. Você tem o direito de
obter e sta informação e ajuda em seu idioma e sem custos. Ligue
para 800-722-1471 (TTY: 800-842-5357).
Român (Romanian): Prezenta notificare conine informaii importante.
Aceast notificare poate conine informaii importante privind cererea
sau acoperirea asigurrii dumneavoastre de sntate prin Premera Blue
Cross. Pot exista date cheie în aceast notificare. Este posibil s
fie nevoie s acionai pân la anumite termene limit pentru a v menine
acoperirea asigurrii de sntate sau asistena privitoare la costuri.
Avei dreptul de a obine gratuit aceste informaii i ajutor în limba
dumneavoastr. Sunai la 800-722-1471 (TTY: 800-842-5357).
P (Russian): . Premera Blue Cross. . , , . . 800-722-1471 (TTY:
800-842-5357).
Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni
fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei
fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga
o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai.
Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i
lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e
faia ao le’i aulia le aso ua ta’ua i lenei fa’asilasilaga ina ia e
iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo’o e
iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei
fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i ai
aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY:
800-842-5357).
Español ( ): Este Aviso contiene información importante. Es posible
que este aviso contenga información importante acerca de su
solicitud o cobertura a través de Premera Blue Cross. Es posible
que haya fechas clave en este
tiene derecho a recibir esta información y ayuda en su idioma sin
costo
aviso. Es posible que deba tomar alguna medida antes de
determinadas fechas para mantener su cobertura médica o ayuda con
los costos. Usted
alguno. Llame al 800-722-1471 (TTY: 800-842-5357).
Spanish
Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang
impormasyon. Ang paunawa na ito ay maaaring naglalaman ng
mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa
pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang
petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng
hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong
pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka
na makakuha ng ganitong impormasyon at tulong sa iyong wika ng
walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357).
(Thai):
(Ukrainian): . Premera Blue Cross. , . , , . . 800-722-1471 (TTY:
800-842-5357).