CUSTODIAL NURSING HOME CARE - … · Custodial Nursing Home Care PRIOR AUTHORIZATION REQUIRED ... Observation Care PLAN NOTIFICATION NOT REQUIRED ... Septoplasty/Rhinoplasty)

All Out-of-Network Services

Require Plan Approval

HAP Midwest Health Plan

2018 Authorization Grid

MI Health Link

Red=Not a Benefit

Yellow=Plan Notification Required

Green=No Authorization Required

Chiropratic Services PRIOR AUTHORIZATION REQUIRED

Custodial Nursing Home Care PRIOR AUTHORIZATION REQUIRED

DME Equipment and Supplies PRIOR AUTHORIZATION REQUIRED

Incontinence Supplies: Diapers, briefs, wipes, gloves, pads PRIOR AUTHORIZATION REQUIRED

Infusion (IV, Enteral) Services PRIOR AUTHORIZATION REQUIRED

Outpatient Therapy Evaluation Only: OT, PT & Speech Therapy

PLAN NOTIFICATION NOT REQUIRED

PCP to Refer Member to In-Network Provider

Outpatient Therapy Services (PT, OT, ST) PRIOR AUTHORIZATION REQUIRED

Physician Services (Vision, Podiatry, PCP, Specialty Care)



FACILITY BASED SERVICES

Inpatient Hospital Care PRIOR AUTHORIZATION REQUIRED

Elective Inpatient Admission or Elective Inpatient Surgery PRIOR AUTHORIZATION REQUIRED

CUSTODIAL NURSING HOME CARE

H:\Master Auth Grids\2018 MI Health Link Auth Grid_02232018





MI Health Link

Red=Not a Benefit



Inpatient Rehabilitation Care PRIOR AUTHORIZATION REQUIRED

Skilled Nursing Facility Admission PRIOR AUTHORIZATION REQUIRED

Non-Custodial Nursing Home Care PRIOR AUTHORIZATION REQUIRED

Long Term Acute Care (LTAC) PRIOR AUTHORIZATION REQUIRED

Emergency Room Care PLAN NOTIFICATION NOT REQUIRED

Observation Care


Must meet CMS/MDHHS Observation Criteria

Urgent Care PLAN NOTIFICATION NOT REQUIRED

OUTPATIENT SERVICES

Allergy Testing/Injections



Ambulance-Emergency Services (Air) PRIOR AUTHORIZATION REQUIRED

Ambulance-Emergency Services (Land) PLAN NOTIFICATION NOT REQUIRED

Ambulance-Non Emergency Services PRIOR AUTHORIZATION REQUIRED






MI Health Link

Red=Not a Benefit



Anesthesia for Outpatient Dental Procedures PRIOR AUTHORIZATION REQUIRED

Angiography



Bariatric Surgery

PRIOR AUTHORIZATION REQUIRED

(Must meet medical necssity criteria)

Blepharoplasty (Eye lid surgery)


(Must meet medical necessity criteria)

Bone Density



Breast Reconstruction


(Covered only after mastectomy for treatment of Breast Cancer)

Cardiac Catherization



Cardiac Rehabilitation PRIOR AUTHORIZATION REQUIRED

Cardiac Stress Testing/Imaging



Chiropractic Care PRIOR AUTHORIZATION REQUIRED

Cochlear Implant PRIOR AUTHORIZATION REQUIRED

Cosmetic Procedures (Keloid & Scar Revision, Panniculectomy, Septoplasty/Rhinoplasty)


(Must meet medical necssity criteria)

Dental Care


MANAGED BY DELTA DENTAL

CALL 1-800-482-8915

Diabetes Education (Certified Diabetic Educator) PRIOR AUTHORIZATION REQUIRED






MI Health Link

Red=Not a Benefit



Diagnostic Imaging: CT Scan, MRI



Diagnostic Imaging: PET Scan



Dialysis: Hemodialysis & Peritoneal Dialysis



Eye Exams and Glasses


MANAGED BY HERITAGE OPTICAL

CALL 800-252-2053

Family Planning Services (Including Vasectomy & Tubal Ligation)



Genetic Testing PRIOR AUTHORIZATION REQUIRED

Hearing Aids NOT COVERED

Home Health Care (Skilled Nursing, PT, OT, Speech Therapy) PRIOR AUTHORIZATION REQUIRED

Hospice (Community-Based) PLAN NOTIFICATION REQUIRED

Hospice (Inpatient) PRIOR AUTHORIZATION REQUIRED

Immunizations (CDC/ACIP Recommended)



Infusion & Injection Therapy (Remicaid, IVIG, Xolair, Embrel, Humera)


(Contact Medicare Health Services for Additional Meds)

Lab Services (Genetic Testing requires Prior Authorization)


(Must have a prescription)

Long Term Support Services PRIOR AUTHORIZATION REQUIRED






MI Health Link

Red=Not a Benefit



Maternal Infant Health Program (MIHP)



OB Care (Office Visits, Ultrasound, NSTs)



Outpatient Diagnostic or Screening Procedures (Bronchospcopy,Colonoscopy, EGD, Hysteroscopy,

Ultrasound, Doppler Studies, Echocardiograms, X-rays etc.)



Outpatient Surgery (Knee Arthroscopy, Cataract, ORIF, D&C, etc.)

(Does not include Outpatient Dental Surgery - See Dental)



Outpatient Therapy Evaluation Only: OT, PT & Speech Therapy



Outpatient Therapy: Physical Therapy, Occupational Therapy & Speech Therapy PRIOR AUTHORIZATION REQUIRED

Outpatient Treatment (Chemotherapy, Radiation Therapy)



Parenteral and Enteral Nutrition PRIOR AUTHORIZATION REQUIRED

Podiatry



Pulmonary Rehabilitation PRIOR AUTHORIZATION REQUIRED

Reduction Mammoplasty (Females Only)


(Must meet specific criteria)

Sleep Studies



Second Surgical Opinion



Specialty Care



Transportation (Non-emergency)

MANAGED BY HAP MIDWEST CUSTOMER SERVICES WITH 4 BUSINESS

DAYS NOTICE. CALL 1-888-654-0706H:\Master Auth Grids\2018 MI Health Link Auth Grid_02232018





MI Health Link

Red=Not a Benefit



Transplant Services: Organ Transplant, Bone Marrow PRIOR AUTHORIZATION REQUIRED

Travel Vaccines NOT COVERED

Vein Procedures: Sclerotherapy, Stripping/Ligation, etc.


(Must meet specific criteria)

Well Woman Care (Mammogram, Pap Smear, etc.)



DURABLE MEDICAL EQUIPMENT (DME)

Braces (arm, leg, back & neck) PRIOR AUTHORIZATION REQUIRED

Canes (excludes white canes for the blind) PRIOR AUTHORIZATION REQUIRED

Commode chairs PRIOR AUTHORIZATION REQUIRED

Continuous passive motion (CPM) machine PRIOR AUTHORIZATION REQUIRED

Crutches PRIOR AUTHORIZATION REQUIRED

Enteral nutrition equipment (feeding pump) PRIOR AUTHORIZATION REQUIRED

Home oxygen equipment PRIOR AUTHORIZATION REQUIRED

Hospital beds and Mattresses PRIOR AUTHORIZATION REQUIRED

Infusion pumps PRIOR AUTHORIZATION REQUIRED

Implantable Automatic Defibrillators PRIOR AUTHORIZATION REQUIRED






MI Health Link

Red=Not a Benefit



INR (Home Monitoring) PRIOR AUTHORIZATION REQUIRED

Insulin Pumps PRIOR AUTHORIZATION REQUIRED

Life Vest (DME) PRIOR AUTHORIZATION REQUIRED

Nebulizers and nebulizer medications PRIOR AUTHORIZATION REQUIRED

Patient Lifts PRIOR AUTHORIZATION REQUIRED

Pneumatic Compression Devices (Lymphedema Pump) PRIOR AUTHORIZATION REQUIRED

Positive Airway Pressure Devices and supplies: (CPAP, BiPAP) PRIOR AUTHORIZATION REQUIRED

Power Mobility Devices PRIOR AUTHORIZATION REQUIRED

Prosthetics & Orthotics PRIOR AUTHORIZATION REQUIRED

Seat Lift PRIOR AUTHORIZATION REQUIRED

Speech Generating Devices PRIOR AUTHORIZATION REQUIRED

Suction pumps PRIOR AUTHORIZATION REQUIRED

Stimulators: Bone , Electrical, Neuromuscular, Transcutaneous Electrical Nerve Stimulators (TENS) PRIOR AUTHORIZATION REQUIRED

Therapeutic shoes or inserts PRIOR AUTHORIZATION REQUIRED

Traction equipment PRIOR AUTHORIZATION REQUIRED

Walkers PRIOR AUTHORIZATION REQUIREDH:\Master Auth Grids\2018 MI Health Link Auth Grid_02232018





MI Health Link

Red=Not a Benefit



Wheelchairs PRIOR AUTHORIZATION REQUIRED

MEDICAL SUPPLIES

Diabetic Supplies: Glucometers, strips, lancettes, syringes/needles, alcohol wipes.


Supplies covered by Pharmacy Benefit

Diabetic Insulin Pump Supplies PRIOR AUTHORIZATION REQUIRED

Enteral nutrition (feeding) supplies PRIOR AUTHORIZATION REQUIRED

Incontinence supplies: Diapers, briefs, wipes, gloves, pads PRIOR AUTHORIZATION REQUIRED

Nebulizer supplies PRIOR AUTHORIZATION REQUIRED

Ostomy & Tracheostomy supplies PRIOR AUTHORIZATION REQUIRED

Oxygen supplies PRIOR AUTHORIZATION REQUIRED

Urology supplies PRIOR AUTHORIZATION REQUIRED

Wound Care supplies PRIOR AUTHORIZATION REQUIRED

BEHAVIORAL HEALTH SERVICES

Inpatient Psychiatric Admission

PLAN NOTIFICATION NOT REQUIRED MANAGED PER PIHP

CALL DETROIT WAYNE COUNTY MENTAL HEALTH AUTHORITY

(800) 241-4949 OR MACOMB COUNTY COMMUNITY MENTAL HEALTH

(586) 948-0222 (CAN CALL COLLECT)






MI Health Link

Red=Not a Benefit



Outpatient Behavioral Health Services





Behavioral Health Office Visits





Substance Abuse Treatment





Partial Hospitalization






Documents

CUSTODIAL NURSING HOME CARE - … · Custodial Nursing Home Care PRIOR AUTHORIZATION REQUIRED ... Observation Care PLAN NOTIFICATION NOT REQUIRED ... Septoplasty/Rhinoplasty)