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Inside This Issue…January 22, 2002               FEP Benefit Changes for 2002 ...............................................
Blue Shield Report S-01-02                   January 22, 2002                                    Page 2                   ...
Blue Shield Report S-01-02                    January 22, 2002                                   Page 3              New B...
Blue Shield Report S-01-02                      January 22, 2002                                  Page 4                  ...
Blue Shield Report S-01-02                  January 22, 2002                                 Page 5                       ...
Blue Shield Report S-01-02                   January 22, 2002                                   Page 6Q: Do all mental hea...
Blue Shield Report S-01-02                    January 22, 2002                                    Page 7Q: What happens if...
Federal Employee Program 2002 Benefit Chart  MEDICAL SERVICES AND SUPPLIES PROVIDED BY PHYSICIANS AND OTHER HEALTH        ...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002THERAPY SERVICES ......................................................................
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002                                 Medical Services                                   ...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002                                                        MEMBER RESPONSIBILITY    Pre...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002                                                         MEMBER RESPONSIBILITY    Pr...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002                                                         MEMBER RESPONSIBILITY    Pr...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002                                                        MEMBER RESPONSIBILITY    Pre...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002                                                        MEMBER RESPONSIBILITY    Pre...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002                                 Surgical Services    Preferred/Contracting Benefits...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002                            Lab and X-ray Services    Preferred/Contracting Benefits...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002                                 Therapy Services    Preferred/Contracting Benefits ...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002   Home Medical Equipment and Medical Supplies    Preferred/Contracting Benefits    ...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002    Preferred/Contracting Benefits                         MEMBER RESPONSIBILITY    ...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002                                  Dental Services   Preferred/Contracting Benefits  ...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002     Mental Health and Substance Abuse ServicesMHSA Treatment Plan Requirements unde...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002    Preferred/Contracting Benefits                          MEMBER RESPONSIBILITY   ...
FEDERAL EMPLOYEE PROGRAM BENEFITS 2002    Preferred/Contracting Benefits                    MEMBER RESPONSIBILITY         ...
HMS/ValueOptions                                             MANAGED MENTAL HEALTH CARE NETWORK                           ...
Health Management Strategies International, Inc.                                                   MANAGED MENTAL HEALTH C...
5. Treatment Plan Formulation. Based on the patients chief complaint and initial symptom presentation, indicate   the focu...
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  1. 1. Inside This Issue…January 22, 2002 FEP Benefit Changes for 2002 ............................................................. Pg. 1S-01-02 Discontinued Products for 2002............................................................ Pg. 1 Provider Networks for 2002.................................................................. Pg. 2 New Benefit Coverage as of January 1, 2002....................................... Pg. 3Questions:Contact your Professional New to Standard Option in 2002 .......................................................... Pg. 3Relations Representative, or Highlights of Standard and Basic Options............................................ Pg. 4the Professional Relations Questions and Answers About FEP 2002 Benefits............................... Pg. 5Hotline in Topeka at New and Revised Remark Codes.......................................................... Pg. 7785-291-7060 or FEP Benefits Chart ......................................................................... Attached1-800-432-3587. OUR WEB ADDRESS:http://www.bcbsks.com FEP Benefit Changes for 2002 The Blue Shield Report is published by your Professional Relations Department. The Federal Employee Program (FEP) benefits has changed effective Communication January, 2002. This change is an accommodation to FEP member requests Coordinator for the best coverage possible at an affordable premium. Larry Callahan FEP members expressed concern that High Option premiums have become too expensive. Plans were requested to engineer a health plan that is lower in cost than the 2001 Standard Option. The resulting benefits for 2002 have taken into account FEP member feedback and High Option will not be offered in 2002. Members will have the choice of Standard Option or Basic Option, which became effective January, 2002. The following pages outline the 2002 FEP benefits. For more information, you can access the FEP website at www.fepblue.org or call 1-800-432-0379. Discontinued Products for 2002 • High Option is no longer available; it has been merged into the Standard Option. • The Point of Service (POS) pilot program has been discontinued. Sent to: CAP and Oral Surgeons
  2. 2. Blue Shield Report S-01-02 January 22, 2002 Page 2 PROVIDER NETWORKS FOR 2002STANDARD OPTIONUnder Standard Option, FEP has expanded their definition of preferred providers to include thefollowing as of January 1, 2002: • Ambulance • Nurse Anesthetist (CRNA) • Audiologist • Nurse Practitioner (ARNP) • Certified Diabetic Counselors • Occupational Therapist • Durable Medical Equipment Supplier • Physical Therapist • Home Infusion • Speech Therapist • Independent LaboratoriesWhen members use preferred providers, they receive the highest level of benefits from FEP and haveless out of pocket expense for themselves. FEP continues to consider physician assistant servicesbilled under the physician assistant’s number to be considered non-preferred. Therefore, whenservices are provided and billed under the physician assistant’s provider number as the performingprovider for a Standard Option member, the benefit payment is reduced to 75 percent of the charge, ormaximum allowable payment (MAP), whichever is less, with 25 percent coinsurance and anyapplicable deductible or copayment being the patients responsibility.Our guidelines from Policy Memo Number 1, page 9, section 11, paragraph B, allows you to bill underthe employing physician’s number when a physician assistant services were provided adjunct to(incident to) the services of the employing physician, thus resulting in payment at the FEP preferredbenefit level. Blue Cross and Blue Shield of Kansas (BCBSKS) follows the Medicare Part Bdefinition of “incident to” for consistency.The guidelines under section 11 paragraph B, also addresses when services are not adjunct to (incidentto) the physician services. When this occurs you must bill Blue Shield using an individual physicianassistant’s number. Under FEP, this will trigger member benefits to pay at the reduced level aspreviously described.PLEASE NOTE: Under Standard Option, there continues to be no FEP member chiropractic benefits.BASIC OPTIONFor Basic Option 2002, FEP considers preferred providers as those providers who contract withBCBSKS, including physician’s assistants. Thus, physician assistant services, either billed undertheir own provider number or services adjunct to (incident to) the physician’s services, result in thesame level of FEP benefits to the member. Under Basic Option, FEP members only receive benefitswhen they use preferred providers. There is no benefit payment if a member uses a non-preferredprovider and the financial responsibility for those services lies entirely with the patient.However under the Basic Option, FEP has a special set of chiropractic benefits, which are detailed onpage three of the FEP 2002 Benefits Chart. Sent to: CAP and Oral Surgeons
  3. 3. Blue Shield Report S-01-02 January 22, 2002 Page 3 New Benefit Coverage as of January 1, 2002: • Services performed in contracting facilities by non-contracting radiologists, anesthesiologists, CRNAs, pathologists, and emergency room physicians will be covered at the highest level of benefit.• Benefits are provided for routine screening for chlamydial infection.• Benefits are provided for organ/tissue transplants to include autologous stem cell support for amyloidosis.• Benefits provided for organ/tissue transplants in clinical trials to include nonmyeloablative allogeneic stem cell transplants for chronic myelogenous leukemia, acute lymphocytic or non- lymphocytic (i.e., myelogenous) leukemia, advanced Hodgkin’s lymphoma, advanced non- Hodgkin’s lymphoma, advanced forms of myelodysplastic syndromes, multiple myeloma, chronic lymphocytic leukemia, early stage (indolent or non-advanced) small cell lymphocytic lymphoma, and renal cell carcinoma.• Smoking cessation services are now treated similar to other medical or mental health/substance abuse services and are not limited to $100 of coverage per lifetime. Cessation drugs are not limited to one course of treatment per year, but additional courses require prior approval and participation in a smoking cessation program.• Benefits are provided for dental accidental injury, but only when treatment is started promptly and completed within 12 months of the accident.New to Standard Option in 2002 • Ambulance services provided in connection with, and within 72 hours after, an accidental injury are covered in full. • Mail Service Prescription Drug Program copayments have changed to $10 for generic drugs and $35 copayment for brand-name drugs. Sent to: CAP and Oral Surgeons
  4. 4. Blue Shield Report S-01-02 January 22, 2002 Page 4 Highlights of Basic and Standard Options Basic Option • No Deductible • Must use contracting providers to receive any benefits • $20 copay for primary care physician (PCP) types (family practice, general practice, internal medicine, pediatrician, OB/GYN, and ancillary services ordered by PCP type) • $30 copay for specialist services • $100 per day copay for inpatient admission, up to a $500 maximum copay • Pre-certification admission required • Benefits for chiropractic services • Prior approval required for all mental health & substance abuse care except emergencies Standard Option • $250 per person /$500 per family deductible • $5,000 maximum copayment • $15 copay for professional services, with no deductible • $100 copay per inpatient admission • Pre-certification admission required • 10% coinsurance on selected services (see benefit chart) Sent to: CAP and Oral Surgeons
  5. 5. Blue Shield Report S-01-02 January 22, 2002 Page 5 About FEP 2002 BenefitsQ: What happens if a member came into my office in 2001 and showed the new card with a 2002 effective date? A: The 2001 benefits remained in effect for the member through December 31, 2001. The new 2002 benefits became effective January 1, 2002.Q: What happens to a High Option or Point-of-Service member who does not make a change to their enrollment during open season? Does this mean that the patient will be uninsured? A: The member will be automatically enrolled under the Standard Option coverage for 2002.Q: Is there a different card for Basic Option? A: Yes, Basic Option has a different card and different codes. The new codes are: Self and family is 112 and self only is 111.Q: Will members have to change providers? A: Members obtaining treatment with Competitive Allowance Program (CAP) providers contracting with BCBSKS do not need to change providers.Q: Who are covered providers for Basic Option? A: All contracting providers currently eligible under Standard Option are considered covered in Basic Option. Chiropractors are also considered covered for limited services.Q: Which contracting physicians are considered primary care providers and eligible for the $20 office visit copay? A: Internal medicine, family practice, general practice, pediatricians, and obstetricians/gynecologists are all considered primary care providers.Q: Are non-contracting providers ever paid? What are the payment exceptions and how are providers paid. A: There are some exceptions in which non-contracting providers are covered, such as certain non- contracting hospital-based providers (i.e. radiologists, anesthesiologists, CRNAs, pathologists, assistant surgeons, and emergency room physicians) are paid at 100 percent of BCBSKS allowance when services are rendered in a contracting facility, or a non-contracting emergency room. Members may be financially responsible for the difference between BCBSKS allowance and the provider’s charges.Q: Currently, precertification is required for all inpatient stays, except maternity and when Medicare is the primary payer. Will this be required under Basic Option? A: Yes. Sent to: CAP and Oral Surgeons
  6. 6. Blue Shield Report S-01-02 January 22, 2002 Page 6Q: Do all mental health and substance abuse (MHSA) services require prior approval for Basic Option members? A: In Basic Option, the mental health and substance abuse benefit is a more managed benefit than Standard Option. Prior approval is required, except in emergencies. Members must call HMS/Value Options before receiving any MHSA care. An MHSA professional will triage the call and provide a list of appropriate contracting providers from which the member may select and an initial number of visits may be approved. Thereafter, the provider will coordinate with HMS/Value Options to ensure that proper authorizations are received. If a contracting MHSA provider is not available, HMS/Value Options will assist the member in obtaining appropriate services that will be covered at the in-network level.Q: What are the treatment plan requirements for Basic Option MHSA services under Basic Option? A: When necessary, HMS/Value Options will request a treatment plan from the contracting provider. A written treatment plan is necessary to determine that the care is appropriate and medically necessary. The member must call the MHSA number before receiving care. During the initial telephone call, the member will be triaged to determine the best type of provider and what type of care would most likely produce the best results. The member will be given several names of providers from which to choose and an initial number of visits. Once the member selects a provider, HMS/Value Options will work with that provider to ensure that the member receives all the covered services necessary to increase the chance of obtaining a positive outcome. In most cases, the provider will send HMS/Value Options the necessary information and additional visits will be approved. In difficult or complicated cases, HMS/Value Options may request a formal treatment plan from the provider to evaluate the course of treatment being applied. Unlike Standard Option, a treatment plan will not have to be submitted by a certain visit.Q: Will prior approval be required for certain prescription drugs? A: Yes, prior approval for certain prescription drugs will be necessary for Basic Option as it does today under Standard Option.Q: What services require prior approval? A: The same services that require prior approval under Standard Option require prior approval under Basic Option, with the addition of all mental health and substance abuse services. These services are: • cardiac rehabilitation • home hospice • organ transplants • certain prescription drugs • mental health and substance abuse (intensive outpatient and partial hospitalization are only covered under Standard Option) Sent to: CAP and Oral Surgeons
  7. 7. Blue Shield Report S-01-02 January 22, 2002 Page 7Q: What happens if my patient is receiving home health care as of December 31, 2001? A: Standard Option and Basic Option do not provide benefits for home health care, other than home nursing care.Q: I am a chiropractor. Are benefits available for chiropractic care? A: For Basic Option, benefits are available for covered services provided by network chiropractors. Covered services include the initial office visit, spinal manipulations and the initial set of X-rays. There is a $20 copayment for each visit. Benefits are limited to 20 manipulations per year. Standard Option does not have any chiropractic benefits.Q: How are benefits coordinated with Medicare? A: For members with Medicare Parts A and B as the primary payer, copayments and coinsurance are waived when contracting providers are used. Prescription drug cost sharing is not waived. Members with Medicare who do not use contracting providers will be responsible for their coinsurance and deductibles.Q: What happens if prior authorization is not obtained for MHSA? A: The contracting provider must write-off any care not authorized. New and Revised Remark CodesYou may discover some new remark codes printed on your remittance advice for FEP claims. Belowis a list of the new codes, along with some established codes that have undergone an adjustment to thenomenclature.N4 Non-covered chiropractic services – Basic OptionNA Accidental injury – dental services incurred more than 12 months after the accident dateNB Prior approval not obtained for mental health and substance abuse services – Basic OptionNT Dental sealants not covered for patients over age 16OH Out of network provider rendering services to Basic Option memberPE Dental sealants limited to one per molar – Basic OptionT7 Maximum benefit provided for chiropractic servicesUJ Maximum benefits provided for intra-oral x-rays Sent to: CAP and Oral Surgeons
  8. 8. Federal Employee Program 2002 Benefit Chart MEDICAL SERVICES AND SUPPLIES PROVIDED BY PHYSICIANS AND OTHER HEALTH CARE PROFESSIONALS.NOTE: The calendar year deductible applies to almost all Standard Option benefits on the chart. It isindicated when the deductible does not apply to a specific service. There is no deductible under BasicOption.MEDICAL SERVICES .................................................................................................. Pg. 3 • Allergy Care....................................................................................................................... Pg. 3 • Alternative Treatments..................................................................................................... Pg. 3 • Chiropractic....................................................................................................................... Pg. 3 • Diagnostic and Treatment Services ................................................................................. Pg. 4 • Educational Classes and Programs ................................................................................. Pg. 4 • Family Planning ................................................................................................................ Pg. 5 • Foot Care ........................................................................................................................... Pg. 5 • Hearing Services................................................................................................................ Pg. 5 • Home Health Services ....................................................................................................... Pg. 6 • Inpatient Professional Services ........................................................................................ Pg. 6 • Maternity Care.................................................................................................................. Pg. 6 • Preventative Care, Adult.................................................................................................. Pg. 7 • Preventative Care, Children ............................................................................................ Pg. 7 • Vision Services................................................................................................................... Pg. 8SURGICAL SERVICES ................................................................................................ Pg. 9 • Reconstructive Surgery .................................................................................................... Pg. 9 • Surgical and Anesthesia Services..................................................................................... Pg. 9LAB AND X-RAY SERVICES ............................................................................. Pg. 10 X- • Lab, X-ray, and Other Diagnostic Tests ....................................................................... Pg. 10January 22, 2002 Pg. 1 BCBSKS
  9. 9. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002THERAPY SERVICES ............................................................................................... Pg. 11 • Occupational and Speech Therapies ............................................................................. Pg. 11 • Physical Therapy............................................................................................................. Pg. 11 • Treatment Therapies ...................................................................................................... Pg. 11HOME MEDICAL EQUIPMENT AND MEDICAL SUPPLIES ........ Pg. 12 • Home Medical Equipment.............................................................................................. Pg. 12 • Medical Supplies ............................................................................................................. Pg. 13 • Orthopedic and Prosthetic Devices ............................................................................... pg. 13DENTAL SERVICES .................................................................................................... Pg. 14MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES....... Pg. 15 • Mental Health and Substance Abuse ............................................................................ pg. 16 • Inpatient Professional Visits .......................................................................................... Pg. 16 • Inpatient Services Provided and Billed by a Hospital or Other Covered Facility.... Pg. 16 • Outpatient Services Provided and Billed by a Hospital or Other Covered Facility . Pg. 16 • Professional Services....................................................................................................... Pg. 17 • Professional Charges for Outpatient Diagnostic Tests................................................ Pg. 17 • Other Services ................................................................................................................. Pg. 17 • Not Covered ..................................................................................................................... Pg. 17 • HMS/Value Options Outpatient Diagnostic Treatment Report for Medication Management.......................................................................................... Pg. 18 • HMS/Value Options Outpatient Diagnostic Treatment Report ................................. Pg. 19January 22, 2002 Pg. 2 BCBSKS
  10. 10. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 Medical Services MEMBER RESPONSIBILITY Preferred/Contracting Benefits Standard Option Basic OptionAllergy Care 10% coinsurance $20 visit copayment • Testing and treatment, including for primary care materials (such as allergy serum) provider • Allergy injections $30 visit copayment for specialty provider Note: Services billed by an independent lab or radiologist requires a separate $20 copayment.Alternative Treatments 10% coinsurance $20 copayment perAcupuncture – when performed and billed by a visit for primary carephysician or physical therapist, for: provider • pain relief, and • as a modality of physical therapy $30 copayment per visit for specialty providerChiropractic Member responsible $20 copayment per • Initial office visit for full charges visit, up to 20 • Spinal manipulations (Only CPT 98940, manipulations per 98941, and 98942 covered) calendar year. • Initial set of x-raysJanuary 22, 2002 Pg. 3 BCBSKS
  11. 11. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 MEMBER RESPONSIBILITY Preferred/Contracting Benefits Standard Option Basic OptionDiagnostic and treatment services • Outpatient consultations $15 office visit $20 office visit • Outpatient second surgical opinions copayment. copayment per visit. • Office visits No deductible. primary care provider • Home visits types (FP, GP, PED, • Initial examination of newborn needing IM, OB/GYN) definitive treatment when covered under a family enrollment $30 specialist office • Pharmacotherapy visit copayment per • Neurological testing visitEducational classes and programs • Smoking cessation $15 copayment for the $20 visit copayment office visit charge. No for primary care deductible $30 visit copayment 10% coinsurance for for specialty provider all other services (deductible applies) • Diabetic education when billed by a 10% coinsurance $20 visit copayment covered provider for primary care providerNote: Covered providers are diabetic educatorswho bill independently only as part of a $30 visit copaymentcertified diabetic education program. for specialty providerJanuary 22, 2002 Pg. 4 BCBSKS
  12. 12. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 MEMBER RESPONSIBILITY Preferred/Contracting Benefits Standard Option Basic OptionFamily Planning 10% coinsurance $20 visit copaymentA broad range of voluntary family planning for primary careservices limited to: provider • Depo-Provera • Diaphragms $30 visit copayment • IUDs for specialty provider • Norplant • Oral contraceptives Note: Services billed • Voluntary sterilization by an independent lab or radiologist requires a separate $20 copayment.Foot Care $15 visit copayment $20 visit copaymentRoutine foot care when under active treatment No deductible for primary carefor a metabolic or peripheral vascular disease, providersuch as diabetes $30 visit copayment for specialty providerHearing Services (testing, treatment andsupplies)Hearing tests related to illness or injury 10% coinsurance $20 visit copayment for primary care provider $30 visit copayment for specialty providerJanuary 22, 2002 Pg. 5 BCBSKS
  13. 13. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 MEMBER RESPONSIBILITY Preferred/Contracting Benefits Standard Option Basic OptionHome Health Services (limited to homenursing care only)Home nursing care for two (2) hours per day, 10% coinsurance $20 visit copaymentup to 25 visits per calendar year, when: per visit. Any • A registered nurse (RN) or licensed provider. practical nurse (LPN) providers the service and, • Service is ordered by a physician.Inpatient professional services • During a hospital stay • Services ordered by attending 10% coinsurance Member pays nothing physicians • Consultations when ordered by attending provider • Concurrent care (medically necessary) • Physical Therapy by other than the attending provider • Initial exam of newborn needing definitive treatment when covered under a family enrollment • Neurological testing • Second surgical opinionMaternity CareComplete maternity (obstetrical) care including Member pays nothing. $100 deliveryrelated conditions resulting in childbirth or No deductible. copayment. Membermiscarriage when provided or ordered and pays nothing forbilled by physician. prenatal and postpartum care.January 22, 2002 Pg. 6 BCBSKS
  14. 14. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 MEMBER RESPONSIBILITY Preferred/Contracting Benefits Standard Option Basic OptionPreventative care, adult $15 visit copayment $20 visit copaymentHome and office visits for routine (screening) for the exam. for primary Carephysical exams. No deductible providerUnder Standard Option, benefits are limited to $30 visit copaymentthe following when performed as routine Note: One routine for specialistphysical exam: physical examination • History and risk assessment every three calendar Note: Services billed • Chest x-ray years for members by an independent lab • EKG under age 65. or radiologist requires • Urinalysis Members over age 65, a separate $20 • Basic or comprehensive metabolic panel one routine exam per copayment. test year. • CBC • Cholesterol tests • Chlamydial infection testUnder Basic Option, benefits are provided forall of the services listed above and otherappropriate screening tests and services.Note: These benefits do not apply to persons Note: Screeningunder age 22. services billed separately from theCancer Screening routine physical • Colorectal cancer screening, including examination, may be -fecal occult blood test assessed an additional -sigmoidoscopy copayment for each • Prostate cancer screening (PSA) test office visit billed. • Cervical cancer screening • Breast cancer screening (routine mammogram)Preventative care, children Member pays nothing $20 visit copayment • All healthy newborn visits including No deductible for primary Care routine screenings (inpatient or provider outpatient) • The following services are $30 visit copayment recommended by the American for specialty provider Academy of Pediatrics up the age of 22 -Routine physical exam Note: Services billed -Routine hearing tests by an independent lab -Laboratory tests or radiologist requires -Immunizations a separate $20 -Related office visits copayment.January 22, 2002 Pg. 7 BCBSKS
  15. 15. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 MEMBER RESPONSIBILITY Preferred/Contracting Benefits Standard Option Basic OptionVision Services (testing, treatment andsupplies) 10% coinsurance 30% coinsurance • One pair of eyeglasses, replacement lenses, or contact lenses to correct an impairment directly caused by a single $20 visit copayment instance of accidental ocular injury or for primary care intraocular surgery. provider • Eye examinations related to a specific medical condition (routine eye exams $30 visit copayment are NOT covered) for specialty provider • Nonsurgical treatment for amblyopia and strabismus, for children from birth through age 12January 22, 2002 Pg. 8 BCBSKS
  16. 16. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 Surgical Services Preferred/Contracting Benefits MEMBER RESPONSIBILITY Standard Option Basic OptionReconstructive Surgery 10% coinsurance $100 copayment per • Surgery to correct a functional defect performing physician • Surgery to correct a congenital anomaly – a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes. • Treatment to restore the mouth to a pre- cancer state • All stages of breast reconstruction surgery following a mastectomy, such as: - surgery to produce a symmetrical appearance on the other breast - treatment of any physical complications, such as lymphedemasSurgical and Anesthesia services 10% coinsurance $100 copayment perA comprehensive range of services provided or performing physicianordered and billed by a physician. Note: Services of a co- surgeon, member pays a second $100 copayment. No additional copayment applies to services of an assistant surgeon.January 22, 2002 Pg. 9 BCBSKS
  17. 17. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 Lab and X-ray Services Preferred/Contracting Benefits MEMBER RESPONSIBILITY Standard Option Basic OptionLab, X-ray, and other diagnostic testsDiagnostic tests provided, or ordered and billed 10% coinsurance $20 visit copayment forby a physician, such as: primary care provider • Blood tests • CT scans/MRIs $30 visit copayment for • EKGs and EEGs specialist provider • Laboratory tests • Pathology services Note: Services billed by • Ultrasounds an independent lab or • x-rays radiologist requires a separate $20 copayment. • Laboratory and pathology services billed by an independent labJanuary 22, 2002 Pg. 10 BCBSKS
  18. 18. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 Therapy Services Preferred/Contracting Benefits MEMBER RESPONSIBILITY Standard Option Basic OptionOccupational and Speech Therapies 10% coinsurance $20 visit copayment forOccupational and speech therapy when Note: Benefits primary care providerperformed by an occupational therapist, speech limited to 25 visits pertherapist, or physical therapist. person, per calendar $30 visit copayment for year for occupational specialty provider therapy or speech therapy or a Note: Benefits are limited combination of both. to 50 visits per person per calendar year for physical, Note: Visits paid while occupational, or speech meeting the calendar therapy, or a combination year deductible count of all three. toward the 25 per person limit.Physical Therapy 10% coinsurance $20 visit copayment forWhen performed by a physical therapist or primary care providerphysician: • Physical therapy $30 visit copayment for • Acupuncture as a physical therapy specialty provider modalityTreatment Therapies 10% coinsurance $20 visit copayment forOutpatient treatment therapy primary care provider • Renal dialysis – hemodialysis and peritoneal dialysis $30 visit copayment for • Intravenous (IV) infusion therapy – specialty provider home IV or infusion therapyNote: Home nursing visits associated with Note: Member pays 30%home IV/infusion therapy are covered as shown of the plan allowance forunder the Home health services. drugs and supplies related • Pharmacotherapy to outpatient treatment • Outpatient cardiac rehab. Prior approval therapies. required.Inpatient treatment therapy 10% coinsurance Member pays nothing • Chemotherapy and radiation therapy • Renal dialysis – hemodialysis and peritoneal dialysis • PharmacotherapyJanuary 22, 2002 Pg. 11 BCBSKS
  19. 19. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 Home Medical Equipment and Medical Supplies Preferred/Contracting Benefits MEMBER RESPONSIBILITY Standard Option Basic OptionHome Medical Equipment (HME) 10% coinsurance 30% coinsuranceHome medical equipment is equipment andsupplies that: • Are prescribed by the attending physician; • Are medically necessary; • Are primarily and customarily used only for a medical purpose; • Are generally useful only to a person with an illness or injury; • Are designed for prolonged use; and • Serve a specific therapeutic purpose in the treatment of an illness or injury.Coverage is available for rental or purchase atthe option of FEP, includes repair andadjustments of home medical equipment.Covered under this benefit is: • Home dialysis equipment • Oxygen equipment • Hospital beds • Wheelchairs • Crutches • Walkers • Other items determined by FEP to be HMEJanuary 22, 2002 Pg. 12 BCBSKS
  20. 20. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 Preferred/Contracting Benefits MEMBER RESPONSIBILITY Standard Option Basic OptionMedical SuppliesMedical foods for children with inborn errors of 10% coinsurance 30% coinsuranceamino acid metabolism • Medical foods and nutritional supplements when administered by catheter or nasogastric tubes • Ostomy and catheter supplies • Oxygen and catheter supplies • Oxygen, regardless of provider • Blood and blood plasma except when donated or replaced, and blood plasma expandersOrthopedic and prosthetic devicesOrthopedic braces and prosthetic appliances 10% coinsurance 30% coinsurancesuch as: • Artificial limbs and eyes • Functional foot orthotics when prescribed by a physician • Rigid devices attached to the foot or a brace, or placed in a shoe • Replacement, repair, and adjustment of covered devices • Following a mastectomy, breast prostheses and surgical bras, including necessary replacements.January 22, 2002 Pg. 13 BCBSKS
  21. 21. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 Dental Services Preferred/Contracting Benefits MEMBER RESPONSIBILITY Standard Option Basic OptionDental Care: Scheduled allowances $20 copayment for 2 for diagnostic and exams, x-rays, cleaningsNote: The FEP PPO Dental Network is preventive services, per year, and sealants for applicable for both Standard and Basic fillings, extractions; children up to age 16 Options. regular benefits for dental services $20 copayment for dentalNote: See the 2002 FEP dental benefits required due to services due to accidental newsletter for a complete listing of the accidental injury and injury dental service codes applicable to these covered under oral and separate benefit programs. maxillofacial surgery Medical benefits are applicable for covered oral and maxillofacial surgery.January 22, 2002 Pg. 14 BCBSKS
  22. 22. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 Mental Health and Substance Abuse ServicesMHSA Treatment Plan Requirements under Standard Option:The provider must submit a written treatment plan to HMS/Value Options prior to the member’s ninthoutpatient visit. HMS/Value Options will approve or deny additional services based on theinformation on the treatment plan. If a treatment plan is not submitted and/or approved, the serviceswill be denied as provider write-off. If the member changes providers after their ninth visit, atreatment plan will be necessary from the new provider of care. Treatment plan forms are available onthe www.bcbsks.com Website, under provider services and in the “Forms” area. Samples of the formsare located at the end of this document.The medical criteria used to evaluate the treatment plans may be found on the HMS/Value Optionsweb site, www.ValueOptions.com.Approval of MHSA Services under Basic Option:The member is responsible for contacting HMS/Value Options for triage, approval of care, and toreceive the number of approved visits prior to seeking care. Several names and phone numbers ofcontracting providers will be provided for the member to schedule care with the provider of theirchoice. Benefits are allowed only when the member seeks care from a contracting provider.Otherwise services are not covered.Under Basic Option, a treatment plan must be submitted from the initial visit. This can be averbal report, but in certain situations, a written treatment plan may be required. Highlight of the MHSA Benefits for Standard and Basic OptionsStandard Option • Maximum of 25 visits per year for office visits combined in-network and out of network. • Unlimited visits with an approved treatment plan. • In-network benefits are payable when the care is clinically appropriate for the patient’s condition and when received as part of an approved treatment plan. • Applicable deductibles and copaymentsBasic Option • Must use in-network providers • Members must call HMS/Value Options for triage and care approval • No calendar year deductiblePrecertification for all inpatient hospital and intensive outpatient treatment plan stays is required forboth Standard Option and Basic Option. A $500 penalty will be applied if precertification is notobtained.January 22, 2002 Pg. 15 BCBSKS
  23. 23. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 Preferred/Contracting Benefits MEMBER RESPONSIBILITY Standard Option Basic OptionMental Health and Substance Abuse Deductible and co- Applicable copayment(s)(MHSA) insurance applies.All diagnostic and treatment services containedwithin the approved treatment plan. The Note: A treatment plan Note: HMS/Value Optionstreatment plan may include services, drugs, and is required before the may contact the providersupplies. 9th visit. and request a treatment plan.Inpatient professional visits (MHSA) 10% coinsurance Member pays nothing. Note: Must obtain prior approval for service.Inpatient services provided and billed $100 copayment per $100 copayment per dayby a hospital or other covered facility admission. up to $500 per admission.(MHSA) No deductibleRoom and board, such as semiprivate orintensive accommodations, general nursingcare, meals and special diets, and other hospitalservices and diagnostic testsNote: Precertification is required for allinpatient stays. Failure to obtainprecertification will result in a $500 penalty.Outpatient services provided and 10% coinsurance $30 copayment per daybilled by a hospital or other covered per facilityfacility (MHSA) • Diagnostic tests • Services in the following approved treatment programs: - partial hospitalization - facility-based intensive outpatient treatmentJanuary 22, 2002 Pg. 16 BCBSKS
  24. 24. FEDERAL EMPLOYEE PROGRAM BENEFITS 2002 Preferred/Contracting Benefits MEMBER RESPONSIBILITY Standard Option Basic OptionProfessional services (MHSA): $15 copayment for the $20 copayment • Individual or group therapies visit, up to two hours • Office or home visits (no deductible) $30 copayment for • In a hospital outpatient department services billed by an (except for ER) outpatient facility. Note: All care must be pre-certified by HMS/Value OptionsProfessional charges for outpatientdiagnostic tests (MHSA) 10% coinsurance $20 copayment per visitOther Services (MHSA): 10% coinsurance $20 copayment per visit • Pharmacotherapy (medication deductible applies with primary care provider management) or other health care Note: Other services professional • Psychological testing are not subject to the two-hour limit. $30 copayment per visit with specialist Note: $30 copayment for outpatient services billed by a facility.Not covered (MHSA): HMS/ValueOptions Not Involved in the following: Member responsible Member responsible for all charges for all charges • Services not approved • Educational or training services • Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present. • Psychotherapy for smoking cessationJanuary 22, 2002 Pg. 17 BCBSKS
  25. 25. HMS/ValueOptions MANAGED MENTAL HEALTH CARE NETWORK OUTPATIENT DIAGNOSTIC TREATMENT REPORT FOR MEDICATION MANAGEMENT THIS FORM MUST BE COMPLETED IN ITS ENTIRETY AND RETURNED TO HMS FOR ADDL AUTHORIZATION. FAILURE TO DO SO MAY RESULT IN A DENIAL OF CLAIMS PAYMENT.Subscriber:_____________________________________ ____________________ _____________ Last Name First MI Insured ID # Group #Patient:________________________________________ ____________________ _____________ Last Name First MI DOB Sex1. Diagnosis: Use DSM-IV Codes Only (All 5 axes are mandatory)Axis I: ___________ ____________ Axis III:___________ Axis V: Current:____________ ___________ Axis II:____________ Axis IV:___________ Highest PY:_____________2. Current Functional Assessment Identify all areas where patient currently demonstrates impaired functioning. Indicate the degree of severity by placing a check mark in the applicable box. None Mild Moderate Severe Description of Dysfunction/ Impairments a. Occupation/Education/Work ! ! ! ! Comments b. Marital/Family ! ! ! ! c. Interpersonal/Social ! ! ! ! d. Control of Drives/Impulses ! ! ! ! e. Adult Daily Living Skills ! ! ! ! f. Neurovegetative Functions ! ! ! ! (eating, sleeping, energy level, etc.) g. Psychological Well being ! ! ! !3. Please indicate current medications, with dosage and frequency, used to treat patient.4. # of sessions requested over next year? ___________ 5. Expected Termination Date: __________________6. Yes ____ No _____ Are you providing services in addition to medication mgmt or 20-30 min psychotherapy with medication mgmt? If so, please utilize the standard 2-page outpatient treatment form to request additional sessions of mental health services.7. Yes ____ No _____ Are you coordinating care with the client’s Primary Care Physician? Client Refused ____8. Yes ____ No _____ Is there a need for additional services besides medication mgmt? If so, please describe on the back of this form.By signing below, I certify that the information provided herein is accurate and truthful to the best of myknowledge. In addition, I attest that these services have been provided by me.___________________________________ ____________________Providers Signature Date Mail or Fax to: HMS/ValueOptions_______________________________ 107 SW 6th St., Topeka, KS 66603Full Name (Please Print) Fax #: (785) 233-1209 03/01/01
  26. 26. Health Management Strategies International, Inc. MANAGED MENTAL HEALTH CARE NETWORK OUTPATIENT DIAGNOSTIC TREATMENT REPORT THIS FORM MUST BE COMPLETED IN ITS ENTIRETY AND RETURNED TO HMS FOR ADDL AUTHORIZATION. FAILURE TO DO SO MAY RESULT IN A DENIAL OF CLAIMS PAYMENT.Subscriber:_____________________________________ ____________________ _____________ Last Name First MI Insured ID # Group #Patient:________________________________________ ____________________ _____________ Last Name First MI DOB Sex1. Diagnosis: Use DSM-IV Codes Only (All 5 axes are mandatory)Axis I: ___________ ____________ Axis III:___________ Axis V: Current:____________Axis II:____________ Axis IV:___________ Highest PY:_____________2. Current Functional Assessment Identify all areas where patient currently demonstrates impaired functioning. Indicate the degree of severity by placing a check mark in the applicable box. None Mild Moderate Severe Description of Dysfunction/ Impairments a. Occupation/Education/Work ! ! ! ! Comments b. Marital/Family ! ! ! ! c. Interpersonal/Social ! ! ! ! d. Control of Drives/Impulses ! ! ! ! e. Adult Daily Living Skills ! ! ! ! f. Neurovegetative Functions ! ! ! ! (eating, sleeping, energy level, etc.) g. Psychological Well being ! ! ! !3. Describe patients condition/dysfunction (associated with the diagnoses above) that the patient presented with at the beginning of this episode of treatment, or from the last continued stay review. Onset of Illness (date):4. Previous Treatment (check all that apply) Patients Response to Treatment Interventions! Inpatient/Partial Hospital Dates! Outpatient Psychotherapy Dates:! Medications (names/ dosage)! Other
  27. 27. 5. Treatment Plan Formulation. Based on the patients chief complaint and initial symptom presentation, indicate the focus(es) of treatment. For individual or family tx, please indicate current specific goals of tx including discharge criteria. For med mgmt, please indicate med, dosage, and frequency.6. Progress to date. Please indicate progress client has shown during the treatment process, or from the last continued stay review.# of Sessions Requested: ______________________ Frequency of Tx: _______________________________Date of next appt:______________________ Expected Termination Date: _________________ .7. Is there a need for an additional referral, i.e., psychological evaluation, medication evaluation, etc.?8. Yes ____ No _____ Are you coordinating care with the client’s Primary Care Physician? Client Refused ____By signing below, I certify that the information provided herein is accurate and truthful to the best of my knowledge.In addition, I attest that these services have been provided by me._____________________________________________ ____________________Providers Signature Date________________________________________Full Name (Please Print) Address City State Zip Mail or Fax to: Health Management Strategies, Inc. 107 SW 6th Street, Topeka, KS 66603 Topeka, KS 66603 03/01/01 FAX: (785) 233-1209

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