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

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Common Brand Name(s) Product Description Covered Brand Product Limitations/RestrictionsCalcium Carbonate (Antacid) Chew Tab 500(Generic: TUMS, TUMS LASTING) MG(Generic: MAG-OX 400) Magnesium Oxide Tab 400 MG(Generic: MAALOX SUS)Aluminum & Magnesium Hydroxides Susp 225-200 MG/5ML Max Qty=744/31 days(Generic: MYLANTA)Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML Max Qty=744/31 daysULCER DRUGS(Generic: LEVSIN)Hyoscyamine Sulfate Tab 0.125 MG(Generic: SYMAX DUOTAB) Hyoscyamine Sulfate Tab CR 0.375 MG(Generic: LEVSIN/SL)Hyoscyamine Sulfate Tab SL 0.125 MG(Generic: LEVSIN)(Generic: LEVSIN)(Generic: LEVSINEX)(Generic: ANASPAZ)Hyoscyamine Sulfate Elixir 0.125 MG/5MLHyoscyamine Sulfate Inj 0.5 MG/MLHyoscyamine Sulfate Soln 0.031 MG/MLHyoscyamine Sulfate Soln 0.125 MG/MLHyoscyamine Sulfate PowderHyoscyamine Sulfate Oral Aerosol Soln 0.125MG/MLHyoscyamine Sulfate Cap SR 12HR 0.375 MGHyoscyamine Sulfate Orally Disintegrating Tab0.125 MGHyoscyamine Sulfate Tab Disp 0.25 MGLEVSINCOLYTROLIB-STAT(Generic: LEVBID) Hyoscyamine Sulfate Tab SR 12HR 0.375 MG Daily Dosage=4(Generic: BENTYL)Dicyclomine HCl Cap 10 MG(Generic: BENTYL)Dicyclomine HCl Tab 20 MG(Generic: BENTYL) Dicyclomine HCl Oral Soln 10 MG/5ML Max Qty=496/31 days(Generic: DONNATAL)Belladonna Alkaloids-Phenobarbital Tab 16.2MG(Generic: DONNATAL)Belladonna Alkaloids-Phenobarbital Elixir 16MG/5ML(Generic: TAGAMET, TAGAMETHB)Cimetidine Tab 200 MGCimetidine Tab 300 MGCimetidine Tab 400 MGCimetidine Tab 800 MGCimetidine HCl Soln 300 MG/5ML(Generic: TALADINE, ZANTAC) Ranitidine HCl Cap 150 MG Daily Dosage=2(Generic: TALADINE, ZANTAC) Ranitidine HCl Cap 300 MG Daily Dosage=1(Generic: ZANTAC 75) Ranitidine HCl Tab 75 MG Daily Dosage=2(Generic: ZANTAC, ZANTAC 150) Ranitidine HCl Tab 150 MG(Generic: ZANTAC)Ranitidine HCl Tab 300 MG(Generic: ZANTAC)(Generic: PEPCID AC)(Generic: PEPCID)(Generic: PEPCID)(Generic: CYTOTEC)(Generic: CYTOTEC)Ranitidine HCl Syrup 75 MG/5MLFamotidine Tab 10 MGFamotidine Tab 20 MGFamotidine Tab 40 MGNizatidine Tab 75 MGMisoprostol Tab 100 MCGMisoprostol Tab 200 MCGAXID ARPA, Limited to Ages 6 and Under; DailyDosage=20(Generic: PREVACID) Lansoprazole Cap Delayed Release 15 MG PREVACID 24H OTC OTC: Daily Dosage=4Lansoprazole Tab Delayed Release OrallyLimited to Ages 6 and Under, Daily(Generic: PREVACID)Disintegrating 15 MGPREVACIDDosage=136 of 70
Common Brand Name(s) Product Description Covered Brand Product Limitations/Restrictions(Generic: PREVACID)Lansoprazole Tab Delayed Release OrallyDisintegrating 30 MGPREVACIDLimited to Ages 6 and Under, DailyDosage=1(Generic: PRILOSEC) Omeprazole Cap Delayed Release 20 MG Daily Dosage=4(Generic: PRILOSEC) Omeprazole Cap Delayed Release 40 MG Daily Dosage=2Omeprazole Magnesium Delayed Release Tab20 MG (Base Equiv) PRILOSEC OTC Daily Dosage=4(Generic: CARAFATE)Sucralfate Tab 1 GMANTIEMETICS(Generic: ANTIVERT)Meclizine HCl Tab 12.5 MG(Generic: ANTIVERT)Meclizine HCl Tab 25 MG(Generic: ZOFRAN ODT) Ondansetron Orally Disintegrating Tab 4 MG Max DS=90/365 days; Daily Dosage=2(Generic: ZOFRAN ODT) Ondansetron Orally Disintegrating Tab 8 MG Max DS=90/365 days; Daily Dosage=2(Generic: ZOFRAN) Ondansetron HCl Tab 4 MG Max DS=90/365 days; Daily Dosage=2(Generic: ZOFRAN) Ondansetron HCl Tab 8 MG Max DS=90/365 days; Daily Dosage=2Ondansetron HCl Tab 24 MG Max Qty=1/14 days(Generic: ZOFRAN)Ondansetron HCl Inj 2 MG/ML(Generic: ZOFRAN) Ondansetron HCl Oral Soln 4 MG/5ML Max Qty=50/31 daysDIGESTIVE AIDSPancrelipase (Lip-Prot-Amyl) DR Cap 4200-10000-17500 Unit PANCREAZEPancrelipase (Lip-Prot-Amyl) DR Cap 5000-17000-27000 Unit PANCRELIPASE, ZENPEPPancrelipase (Lip-Prot-Amyl) DR Cap 6000-19000-30000 Unit CREONPancrelipase (Lip-Prot-Amyl) DR Cap 10000-34000-55000 Unit ZENPEPPancrelipase (Lip-Prot-Amyl) DR Cap 10500-25000-43750 Unit PANCREAZEPancrelipase (Lip-Prot-Amyl) DR Cap 12000-38000-60000 Unit CREONPancrelipase (Lip-Prot-Amyl) DR Cap 15000-51000-82000 Unit ZENPEPPancrelipase (Lip-Prot-Amyl) DR Cap 16800-40000-70000 Unit PANCREAZEPancrelipase (Lip-Prot-Amyl) DR Cap 20000-68000-109000 Unit ZENPEPPancrelipase (Lip-Prot-Amyl) DR Cap 21000-37000-61000 Unit PANCREAZEPancrelipase (Lip-Prot-Amyl) DR Cap 24000-76000-120000 Unit CREONAmylase-Lipase-Protease Cap 20000-4000-25000 UAmylase-Lipase-Protease Cap 30000-8000-30000 U KU-ZYME-HPAmylase-Lipase-Protease Cap 15000-1200-15000 UENZYCAP, KU-ZYME,LAPASEAmylase-Lipase-Protease Cap 30000-2400-30000 U DYGASE, KUTRASEAmylase-Lipase-Protease Tab 12500-1000-12500 U ENZYMAXPANCRELIPASE,Amylase-Lipase-Protease Tab 30000-8000- PANOKASE, PLARETASE,30000 UTRI-PASE 8, VIOKASE 8Amylase-Lipase-Protease Tab 60000-16000- PANOKASE-16, TRI-PASE60000 U16, VIOKASE 16Amylase-Lipase-Protease Powd 70000-16800-70000 U VIOKASE37 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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• 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 161: Common Brand Name(s) Product Descri
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