Ancillary provider specialties include:
Home based services:
The following benefit quotes can't be obtained online. Please contact Customer Service at 877-342-5258, option 2 for:
Our billing guidelines are described in the Claims and Payment section of the Provider Reference Manual. Please note the following additional information:
Premera contracts with a variety of providers that deliver home-based services.
The types of services covered under the home health benefit can include skilled nursing, home health aide services, rehabilitative therapy, social services, respiratory therapy and nutritional services. These agencies must be credentialed by us and bill services through the home health agency. Covered employees of a home health agency include:
When requesting coverage for visits from Care Management, include the member's treatment plan and goals with the faxed request. Please notify our Care Management department of any changes in treatment plan.
For home infusion services, each member must have a written physician's plan of care, which includes the medication prescription and statement of medical necessity.
The medication prescription must include the:
The physician is required to approve changes for infusion therapy. The statement of medical necessity renewal is required with each initial therapy request.
Changes in therapy require renewal only if they are long-term drugs and/or therapies (e.g., IGG, prolastin).
Bill drugs using the appropriate HCPC code, including NDC number. Units of billed services must be equal the dosage referenced in the HCPC code description.
Home medical equipment is:
Coverage of home medical equipment is subject to medical necessity. We do not cover equipment that:
Please note the following guidelines:
When necessary, we cover repair and servicing charges for patient-owned equipment due to normal use. Repair charges are not covered if they are greater than the cost of replacing the equipment. Refer to the replacement guidelines below.
All claims for home medical equipment repairs or servicing are subject to review by Premera. If not covered by the manufacturer's warranty, Premera covers the rental fee for necessary loaner equipment while member-owned equipment is being repaired or serviced.
For replacement of home medical equipment, the referring physician must submit a new prescription, and the supplier must indicate the condition of the present equipment on the prescription. Claims for replacement are subject to our review.
Each supply provided should be itemized using appropriate HCPC codes and modifiers.
Generally, the benefits for external prosthetic devices (including fitting expenses), with the exception of intraocular lens, are provided when such devices are used to replace all or part of an absent body limb, or to replace all or part of the function of a permanently inoperative or malfunctioning body organ.
In general, foot orthotics (shoe inserts) and therapeutic shoes (orthopedic) are covered when prescribed for the condition of diabetes or for corrective purposes.
Premera contracts with providers who are licensed as outpatient hospice agencies. Outpatient hospice care is designed to be used by patients who meet the following conditions:
Covered services for hospice care require that this care be:
Because the patient's care may change, the plan should be reviewed every 60 days and revised as needed.
Respite care is unique to hospice care. It is designed to relieve anyone who lives with and cares for a terminally ill person.
Total hours of covered service for respite care may vary. It is important to verify coverage for all available hospice services at the time you receive the referral.
We contract directly with providers who are licensed to provide chiropractic services.
New technologies or treatments may not be covered. A pre-service review can be requested to confirm coverage and medical necessity. See the Integrated Health Management – Reviews section of our manual for more information.
Premera contracts directly with providers who are licensed to provide massage therapy services.
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