BlueCaid Coverage Chart - e-Referral - BCBSM.com

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BlueCaid coverage chartBlueCaid benefitOral surgicalservicesPediatric servicesDescription of BlueCaid coverageOral surgical services are limited to emergent and urgent services for the relief of pain orinfection and surgical services. BlueCaid members are covered for these oral surgical services: Emergency surgery of the jaw or maxillofacial area due to trauma, accident, or injury Diagnosis and treatment of cysts and of benign and malignant tumors of the maxilla andmandible and adjacent structures Hospital and medical expenses for extractions that must be performed in a hospital as theresult of an underlying critical medical condition Medically necessary medical or surgical, but not dental, management of internalderangements of the jaw, as determined by a BlueCaid-affiliated physician and authorizedby BlueCaidBlueCaid covers routine preventive health care services rendered by a pediatrician or aninternist/pediatrician without a referral from the primary care physician.BlueCaid covers routine preventive health care services rendered by a pediatrician or aninternist/pediatrician without a referral from the primary care physician.PharmacyPhysical examsPodiatryPrenatal andpostpartumservicesProfessionalservices byphysiciansRadiologySkilled nursingfacilitiesSmokingcessationBlueCaid members have coverage for outpatient medications. Providers should refer to the“BlueCaid Pharmacy Services” section of this chapter for additional information.Physical exams with the member’s primary care physician are covered.For all BlueCaid members: Foot care services with the member’s physician or podiatrist are covered when the membermanifests signs and symptoms from a specific systemic disease of sufficient severity (suchas severe diabetes) that care by a nonprofessional would be hazardous. Treatment for subluxations, results of injury, mycotic infections, plantar warts and nailavulsions is also covered. Routine foot care, removal of corns and calluses and the trimming of nails are not covered.Prenatal and postpartum services are covered.Professional services rendered by primary care physicians are covered. Professional servicesrendered by specialists are covered but require a referral from the primary care physician.Radiology services are covered. Short-term, medically necessary restorative health services are covered for up to 45cumulative days of skilled care within a 12-month rolling period that starts with the initialadmission. Care must be provided in a SNF affiliated with BlueCaid. Long-term custodial care is not covered. After the 45-day limit is reached, the member will be disenrolled from the Medicaid plan.Individuals receiving long-term custodial care will also be disenrolled from BlueCaid. Members who use tobacco in any form may elect to enroll in the Quit the Nic program forsupport and phone counseling. For information, members can call 1-800-811-1764. Coverage is provided for prescription and over-the-counter smoking cessation aids with avalid prescription, subject to quantity limitations. Coverage for smoking cessation products is limited to a three-month supply every 12months.10Updated January 2012
BlueCaid coverage chartBlueCaid benefitSurgeryTelemedicine(telehealth)Termination ofpregnancyTherapy:outpatientphysical,occupational andspeechTransplants:human organ andtissueDescription of BlueCaid coverageOutpatient surgery coverage includes all related surgical services and anesthesia for coveredsurgical procedures.Note: BlueCaid covers services rendered in ambulatory surgical centers in the same way asthey are covered by the MDCH. Providers may access additional details from MDCH bulletinsMSA 10-63 (Dec. 2, 2010) and MSA 10-23 (June 15, 2010).Initial and follow-up consultations completed using telemedicine are covered by BlueCaid aslong as the services are rendered in line with the policies described in the MDCH Bulletin MSA06-22 (April 1, 2006).See: Abortion. Physical, occupational and speech therapy covered services include a maximum of 36 visitsin 90 consecutive days. Requests for visits beyond the initial 36 or the 90 consecutive daysrequire clinical review. Physical, occupational and speech therapy services are covered when medically necessary,when the condition is expected to improve in a relatively predictable time period. Physical, occupational and speech therapy services are available in a hospital outpatientfacility, freestanding facility or home health care. Names and addresses of providers forBlueCaid can be accessed through BlueCaid Provider Inquiry at 1-800-688-3290 between 8a.m. and 5 p.m. Monday through Friday. Physical and occupational therapy services provided in a physician’s office are eligible forcoverage, effective Feb. 1, 2010. Services must be performed by properly credentialedprofessionals under the supervision of the physician and billed with the physician’s NationalProvider Identifier. Physical, occupational and speech therapy for cognitive rehabilitation is excluded. Cornea and kidney transplants are covered. Extrarenal organ transplants (heart, lung, heart-lung, liver, pancreas, bone marrow includingallogenic, autologous and peripheral stem cell harvesting, and small bowel) are covered on apatient-specific basis when determined medically necessary according to current acceptablestandards of care. If a transplant is covered, additional benefits are provided to assure that the transplant will beprovided (including donor search fees). The Medical Services Administration mandates that transportation and lodging be provided, ifnecessary, so that transplant services can be accessed. BlueCaid has the right to direct themember to less costly services. BlueCaid covers small bowel transplants on a case-by-case basis following a review. Other transplants that BlueCaid considers to be investigational are reviewed on a case-by-casebasis. Transplants and evaluations are directed to Blue Distinction Centers for Transplants.11Updated January 2012
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