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HMK Evidence of Coverage - DPHHS HMK Evidence of Coverage Effective November 1, 2017 2 BEHAVIORAL HEALTH The blending of substance (alcohol, drugs, inhalants, and tobacco) abuse and

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Text of HMK Evidence of Coverage - DPHHS HMK Evidence of Coverage Effective November 1, 2017 2 BEHAVIORAL...

  • Revised November 1, 2017

    Healthy Montana

    Kids

    Evidence of Coverage

    Effective November 1, 2017

  • HMK Evidence of Coverage Effective November 1, 2017 i

    Contents

    ARTICLE ONE – DEFINITIONS ................................................................................................................... 1 ACCIDENT ............................................................................................................................................... 1 ADMISSION CERTIFICATION FOR EMERGENCY CARE AND MATERNITY CARE ........................... 1 ALLOWABLE FEE .................................................................................................................................... 1 ADVANCE MEMBER NOTIFICATION (AMN).......................................................................................... 1 AMBULANCE ........................................................................................................................................... 2 BEHAVIORAL HEALTH............................................................................................................................ 2 BENEFITS OR COVERED BENEFITS .................................................................................................... 2 BENEFIT MANAGEMENT ........................................................................................................................ 2 BENEFIT PERIOD .................................................................................................................................... 2 BLUE CROSS AND BLUE SHIELD OF MONTANA (BCBSMT) .............................................................. 2 CARDIAC REHABILITATION THERAPY ................................................................................................. 2 CARE MANAGEMENT ............................................................................................................................. 2 CHEMICAL DEPENDENCY ..................................................................................................................... 2 CHEMICAL DEPENDENCY OR SUBSTANCE USE DISORDER TREATMENT CENTER .................... 2 CHILD/CHILDREN .................................................................................................................................... 2 CLAIM ADMINISTRATORS...................................................................................................................... 2 COMPLAINT ............................................................................................................................................. 3 COMMUNITY BASED PSYCHIATRIC REHABILITATION AND SUPPORT (CBPRS) ........................... 3 CONDUENT ............................................................................................................................................. 3 CONTINUED STAY REVIEW ................................................................................................................... 3 COPAYMENT ........................................................................................................................................... 3 COVERED MEDICAL EXPENSE ............................................................................................................. 3 DENTAL .................................................................................................................................................... 3 DEPARTMENT ......................................................................................................................................... 3 DISENROLLMENT ................................................................................................................................... 3 DURABLE MEDICAL EQUIPMENT (DME) AND SUPPLIES .................................................................. 3 EFFECTIVE DATE ................................................................................................................................... 3 EMERGENCY CARE ................................................................................................................................ 4 EMERGENCY MEDICAL CONDITION .................................................................................................... 4 EVIDENCE OF COVERAGE (EOC) ......................................................................................................... 4 EXCLUSION ............................................................................................................................................. 4 EXTENDED BEHAVIORAL HEALTH BENEFITS .................................................................................... 4 FAMILY ..................................................................................................................................................... 4 HABILITATIVE CARE ............................................................................................................................... 4 HEALTHY MONTANA KIDS (HMK) COVERAGE GROUP ..................................................................... 4 HEALTHY MONTANA KIDS (HMK) NETWORK ...................................................................................... 4 HOSPITAL ................................................................................................................................................ 5 IDENTIFICATION (ID) CARD ................................................................................................................... 5 ILLNESS ................................................................................................................................................... 5 INSTITUTE FOR MENTAL DISEASE (IMD) ............................................................................................ 5 INCLUSIVE SERVICES/PROCEDURES ................................................................................................. 5 INPATIENT OR HOSPITAL INPATIENT .................................................................................................. 5 INPATIENT BENEFITS (FOR SUBSTANCE USE DISORDER OR MENTAL ILLNESS) ....................... 5 INTERPRETER SERVICES ..................................................................................................................... 5 INVESTIGATIONAL/EXPERIMENTAL/UNPROVEN SERVICE OR CLINICAL TRIAL ........................... 6 MAXIMUM FAMILY LIABILITY ................................................................................................................. 6 MEDICAL POLICY .................................................................................................................................... 6 MEDICALLY NECESSARY ...................................................................................................................... 6 MEMBER OR ENROLLED CHILD OR HEALTHY MONTANA KIDS (HMK) MEMBER .......................... 7 MENTAL HEALTH TREATMENT CENTER ............................................................................................. 7 MENTAL ILLNESS ................................................................................................................................... 7 MONTH ..................................................................................................................................................... 7 MULTIDISCIPLINARY TEAM ................................................................................................................... 7 NON-COVERED OR NON-PARTICIPATING PROVIDER ...................................................................... 7 NURSE FIRST .......................................................................................................................................... 8 OBSERVATION BED/ROOM ................................................................................................................... 8

  • HMK Evidence of Coverage Effective November 1, 2017 ii

    OCCUPATIONAL THERAPY ................................................................................................................... 8 OUTPATIENT ........................................................................................................................................... 8 OUTPATIENT BENEFITS FOR SUBSTANCE USE DISORDER OR MENTAL ILLNESS ...................... 8 PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS ......................................................................... 9 PARTICIPATING PROVIDER .................................................................................................................. 9 PHARMACY ............................................................................................................................................. 9 PHYSICAL THERAPY .............................................................................................................................. 9 PHYSICIAN .............................................................................................................................................. 9 PLAN ADMINISTRATOR.......................................................................................................................... 9 PREADMISSION CERTIFICATION ......................................................................................................... 9 PRIOR AUTHORIZATION ........................................................................................................................ 9 PROFESSIONAL CALL ............................................................................................................................ 9 PSYCHIATRIC RESIDENTIAL TREATMENT CENTER (PRTF) ........................................................... 10 RECOVERY CARE BED/ROOM ..............................