Peach State Provider Office Manual - Peach State Health Plan ...

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Common Brand Name(s) Product Description Covered Brand Product Limitations/RestrictionsFluticasone-Salmeterol Aer Powder BA 500-50MCG/DOSE ADVAIR DISKU Max Qty=60/claim; Min DS=30Aminophylline Tab 100 MGAminophylline Tab 200 MGAMINOPHYLLINDyphylline Tab 400 MGLUFYLLINTheophylline Elixir 80 MG/15MLELIXOPHYLLINTheophylline Cap SR 12HR 125 MG THEOCAPTheophylline Cap SR 24HR 100 MG THEO-24Theophylline Cap SR 24HR 200 MG THEO-24Theophylline Cap SR 24HR 300 MG THEO-24Theophylline Cap SR 24HR 400 MG THEO-24Theophylline Tab SR 12HR 100 MG(Generic: THEO-DUR)Theophylline Tab SR 12HR 200 MG(Generic: QUIBRON-T SR, THEO-DUR)Theophylline Tab SR 12HR 300 MGTheophylline Tab SR 12HR 450 MG(Generic: UNIPHYL)Theophylline Tab SR 24HR 400 MG(Generic: UNIPHYL)Theophylline Tab SR 24HR 600 MGBeclomethasone Dipropionate Inhal Aero Soln40 MCG/ACT QVAR Package Limit=2/monthBeclomethasone Dipropionate Inhal Aero Soln80 MCG/ACT QVAR Package Limit=2/monthLimited to Ages 6 and Under, Max(Generic: PULMICORT) Budesonide Inhalation Susp 0.25 MG/2MLQty=120/claim(Generic: PULMICORT) Budesonide Inhalation Susp 0.5 MG/2MLLimited to Ages 6 and Under, MaxQty=120/claimLimited to Ages 6 and Under; MaxBudesonide Inhalation Susp 1 MG/2ML PULMICORTQty=60/30 daysBudesonide Inhal Aero Powd 90 MCG/ACT(Breath Activated) PULMICORT Min DS=25; Package Limit=1/claimBudesonide Inhal Aero Powd 180 MCG/ACT(Breath Activated) PULMICORT Min DS=25; Package Limit=1/claimFluticasone Propionate Aer Pow BA 50MCG/BLISTERFLOVENT DISKFluticasone Propionate Aer Pow BA 100MCG/BLISTER FLOVENT DISK Daily Dosage=2Fluticasone Propionate Aer Pow BA 250MCG/BLISTER FLOVENT DISK Daily Dosage=2Fluticasone Propionate HFA Inhal Aerosol 44MCG/ACT FLOVENT HFA Min DS=25; Package Limit=1/claimFluticasone Propionate HFA Inhal Aerosol110 MCG/ACT FLOVENT HFA Min DS=25; Package Limit=1/claimFluticasone Propionate HFA Inhal Aerosol220 MCG/ACT FLOVENT HFA Min DS=25; Package Limit=1/claimMontelukast Sodium Tab 10 MG (Base Equiv) SINGULAIR Daily Dosage=1Montelukast Sodium Chew Tab 4 MG (BaseEquiv) SINGULAIR Daily Dosage=1Montelukast Sodium Chew Tab 5 MG (BaseEquiv) SINGULAIR Daily Dosage=1Montelukast Sodium Oral Granules Packet 4MG (Base Equiv) SINGULAIR Daily Dosage=1LAXATIVESTheophylline-Guaifenesin Cap 300-180 MGQUIBRON-300Magnesium Hydroxide Susp 400 MG/5ML CVS MILK OF Max Qty=992/31 daysMagnesium Citrate SolnMAGNESIUM CI(Generic: FLEET)*Sodium Phosphates - Enema***(Generic: DULCOLAX) Bisacodyl Tab Delayed Release 5 MG CVS BISACODY Daily Dosage=134 of 70
Common Brand Name(s) Product Description Covered Brand Product Limitations/Restrictions(Generic: DULCOLAX) Bisacodyl Suppos 10 MG Max Qty=12/claimSenna Tab 187 MGSenna Powder(Generic: SENOKOT) Sennosides Tab 8.6 MG SENNA TAB 8.(Generic: METAMUCIL) Psyllium Cap 0.52 GMPsyllium Powder 28%NATURAL VEGPsyllium Powder 28.3%Psyllium Powder 30%Psyllium Powder 30.9%Psyllium Powder 33%(Generic: METAMUCIL) Psyllium Powder 48.57% WAL-MUCILPsyllium Powder 50%Psyllium Powder 58.6%Psyllium Powder 68%(Generic: EVAC, KONSYL) Psyllium Powder 100%Docusate Sodium Cap 50 MGCOLACE(Generic: COLACE) Docusate Sodium Cap 100 MG PREM VALUE D Daily Dosage=3Docusate Sodium Cap 250 MGDaily Dosage=3Docusate Sodium Tab 100 MG(Generic: COLACE) Docusate Sodium Liquid 150 MG/15ML CVS SENNA PL(Generic: COLACE)Docusate Sodium Syrup 60 MG/15MLGlycerin Suppos 1.5 GMMax Qty=12/claimGlycerin Suppos 3 GM GLYCERIN 3 M Max Qty=24/claimLactulose Solution 10 GM/15ML(Generic: MIRALAX) Polyethylene Glycol 3350 Oral Powder Daily Dosage=36Sorbitol Oral Solution 70%SORBITOLPhenolphthalein-DSS Tab 65-100 MG(Generic: SENOKOT S)Sennosides-Docusate Sodium Tab 8.6-50 MGCVS SENNA PL, SENNA S8.06, STOOL SOFTEN Daily Dosage=4Bisacodyl-Sod Biphos/Sod Phos Prep Kit FLEET PREP(Generic: NULYTELY)PEG 3350-KCl-Sod Bicarb-NaCl For Soln420 GM Package Limit=1/claimBisacodyl Tab & PEG 3350-KCl-Sod Bicarb-NaCl For Soln KitHALFLYTELYPEG 3350-KCl-Na Bicarb-NaCl-Na SulfateSoln 6 GM/100MLOCL(Generic: GOLYTELY)PEG 3350-KCl-Na Bicarb-NaCl-Na SulfateFor Soln 236 GMPackage Limit=1/claim(Generic: COLYTE,COLYTE/FLAVR)PEG 3350-KCl-Na Bicarb-NaCl-Na SulfateFor Soln 240 GMPackage Limit=1/claimANTIDIARRHEALS(Generic: LOMOTIL)(Generic: LOMOTIL)(Generic: KAOPECTATE)(Generic: PEPTO-BISMOL)(Generic: PEPTO-BISMOL)ANTACIDSDiphenoxylate w/ Atropine Tab 2.5-0.025 MGDiphenoxylate w/ Atropine Liq 2.5-0.025MG/5MLDIPHEN/ATROPLoperamide HCl Cap 2 MGLoperamide HCl Liq 1 MG/5MLAttapulgite Liq 750 MG/15MLAttapulgite Susp 750 MG/15MLBismuth Subsalicylate Chew Tab 262 MGBismuth Subsalicylate Susp 527 MG/30MLAluminum Hydroxide Gel Susp 320 MG/5MLAluminum Hydroxide Gel Susp 600 MG/5ML Max Qty=496/31 daysSodium Bicarbonate Tab 325 MG Max Qty=100/31 daysSodium Bicarbonate Tab 650 MG Max Qty=100/31 days35 of 70
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CHRONIC AND COMPLEX CONDITIONS.....
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Description of GeorgiaFamiliesGeorg
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have any questions about Peach Stat
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Provider ResponsibilitiesPRIMARY CA
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Planning for Healthy BabiesWaiver P
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Tubal Ligation(Sterilization)• St
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Additional InformationProviders see
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83655 Lead Effective: 11/2010 Submi
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PROVIDER VISIT - WAITING TIMES• S
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Medical Management/Case Management1
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• Notification of all newborn del
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PROVIDER ASSISTANCE WITH PUBLIC HEA
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competency begins with self-awarene
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• Unresolved problems from previo
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• Member’s name, ID number• P
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Peach State may shorten the period
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Provider Services1-866-874-063302/2
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Notification is required to track i
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Members, a member’s representativ
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• HIV / AIDS• Children with Spe
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the member. The Peach State Medical
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Provider Services1-866-874-063302/2
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• A plan physician with privilege
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• In order to reimburse providers
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• Influence a member to choose on
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Covered Services andBenefits for Pe
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If you have any questions about the
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HEALTH CHECKGEORGIA HEALTH CHECK SE
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Health Check (EPSDT) Billing Requir
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Vaccine Codes must be billed with m
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Interperiodic Vision Only and Heari
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BLOOD LEAD SCREENINGPhysicians are
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General BillingInformation and Guid
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Peach State dental claims should be
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IMAGING REQUIREMENTSPeach State use
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PROCEDURES FOR FILING A CLAIM/ENCOU
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medical necessity. Peach State may
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Example: CPT 42820 submitted for a
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Procedure 99213 is submitted within
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Example: CPT 69436 billed with a 50
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BILLING CODESIt is important that p
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-Charge information and units• Se
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UB 04 CLAIM INSTRUCTIONSPeach State
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EMERGENCY DEPARTMENT HOSPITAL CLAIM
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Peach State Health PlanATTN: Peach
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Inquiry, Claims Adjustmentsand Prov
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selected, unless the plan and the p
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As accountable and fiscally respons
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CredentialingCREDENTIALING REQUIREM
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CREDENTIALING OF HEALTH DELIVERY OR
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Quality ImprovementTHE PEACH STATE
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PROVIDER REVIEWThe Peach State Qual
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AUTHORITY AND RESPONSIBILITYThe Pea
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Page 111 and 112: Member ServicesPeach State is commi
Page 113 and 114: • Income• Health Status• Arre
Page 115 and 116: • To keep all your appointments.
Page 117 and 118: • An Administrative Law Hearing d
Page 119 and 120: The staff often answers questions a
Page 121 and 122: PharmacyThe Peach State preferred d
Page 123 and 124: • Experimental drugs• Nutrition
Page 125 and 126: The member or provider, acting with
Page 127 and 128: Pharmacy ProgramPeach State Health
Page 129 and 130: Gender LimitsSome medications on th
Page 131 and 132: Cyclosporine, Digoxin, Disopyramide
Page 133 and 134: SPECIALTY MEDICATIONPRIOR AUTHORIZA
Page 135 and 136: Common Brand Name(s) Product Descri
Page 159: Common Brand Name(s) Product Descri
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