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

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Common Brand Name(s) Product Description Covered Brand Product Limitations/Restrictions(Generic: BUFFERIN)(Generic: TYLENOL)(Generic: TYLENOL)(Generic: TYLENOL INF)(Generic: TYLENOL CHLD)Aspirin Suppos 60 MG Max Qty=12/31 daysAspirin Suppos 120 MG Max Qty=12/31 daysAspirin Suppos 200 MG Max Qty=12/31 daysAspirin Suppos 300 MG Max Qty=12/31 daysAspirin Suppos 600 MG Max Qty=12/31 daysDiflunisal Tab 500 MGDIFLUNISALSalsalate Tab 500 MGSalsalate Tab 750 MGAspirin Buffered (Ca Carb-Mg Carb-Mg Ox)Tab 324 MGTRI-BUFF ASAAspirin Buffered (Ca Carb-Mg Carb-Mg Ox)Tab 325 MGAspirin Buffered (Mg Carbonate-Al Aminoace)Tab 325 MGAspirin Buffered Tab 325 MGAcetaminophen Tab 325 MGAcetaminophen Tab 500 MGAcetaminophen Chew Tab 80 MGAcetaminophen Chew Tab 160 MGAcetaminophen Susp 80 MG/0.8MLAcetaminophen Susp 160 MG/5MLAcetaminophen Suppos 120 MG Max Qty=12/31 daysAcetaminophen Suppos 325 MG Max Qty=12/31 daysAcetaminophen Suppos 650 MG Max Qty=12/31 daysButalbital-Acetaminophen Cap 50-650 MGPHRENILIN(Generic: PHRENILIN)Butalbital-Acetaminophen Tab 50-325 MG(Generic: SEDAPAP) Butalbital-Acetaminophen Tab 50-650 MG TENCON Max Qty=124/31 days(Generic: ESGIC)Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG Max Qty=124/31 days(Generic: ESGIC, FIORICET)Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG Max Qty=124/31 days(Generic: ESGIC-PLUS)Butalbital-Acetaminophen-Caffeine Tab 50-500-40 MG Max Qty=124/31 days(Generic: FIORINAL) Butalbital-Aspirin-Caffeine Cap 50-325-40 MG Max Qty=124/31 daysButalbital-Aspirin-Caffeine Tab 50-325-40 MGDaily Dosage=4ANALGESICS - OPIOIDCodeine Sulfate Tab 15 MGCodeine Sulfate Tab 30 MGCodeine Sulfate Tab 60 MG(Generic: DURAGESIC) Fentanyl TD Patch 72HR 12.5 MCG/HR FENTANYL DI PA, Daily Dosage=.33(Generic: DURAGESIC) Fentanyl TD Patch 72HR 25 MCG/HR FENTANYL D PA, Daily Dosage=.33(Generic: DURAGESIC) Fentanyl TD Patch 72HR 50 MCG/HR FENTANYL DI PA, Daily Dosage=.33(Generic: DURAGESIC) Fentanyl TD Patch 72HR 75 MCG/HR FENTANYL DIS PA, Daily Dosage=.33(Generic: DURAGESIC) Fentanyl TD Patch 72HR 100 MCG/HR FENTANYL DIS PA, Daily Dosage=.33(Generic: DILAUDID) Hydromorphone HCl Tab 2 MG Daily Dosage=8(Generic: DILAUDID) Hydromorphone HCl Tab 4 MG Daily Dosage=8(Generic: DILAUDID) Hydromorphone HCl Tab 8 MG Daily Dosage=4(Generic: DILAUDID) Hydromorphone HCl Suppos 3 MG Max Qty=62/31 days(Generic: DEMEROL)Meperidine HCl Tab 50 MG(Generic: DEMEROL)Meperidine HCl Tab 100 MG(Generic: DEMEROL)Meperidine HCl Oral Soln 50 MG/5ML(Generic: DOLOPHINE) Methadone HCl Tab 5 MG Daily Dosage=6(Generic: DOLOPHINE) Methadone HCl Tab 10 MG Daily Dosage=6Morphine Sulfate Tab 15 MG Daily Dosage=6Morphine Sulfate Tab 30 MG Daily Dosage=648 of 70
Common Brand Name(s) Product Description Covered Brand Product Limitations/RestrictionsMorphine Sulfate Oral Soln 10 MG/5ML MORPHINE SUL Max Qty=500/31 daysMorphine Sulfate Oral Soln 20 MG/5ML Max Qty=500/31 days(Generic: ROXANOL) Morphine Sulfate Oral Soln 20 MG/ML MORPHINE SUL Max Qty=240/claim(Generic: RMS) Morphine Sulfate Suppos 5 MG Max Qty=24/31 days(Generic: RMS) Morphine Sulfate Suppos 10 MG Max Qty=24/31 days(Generic: RMS) Morphine Sulfate Suppos 20 MG Max Qty=24/31 days(Generic: RMS) Morphine Sulfate Suppos 30 MG Max Qty=24/31 days(Generic: MS CONTIN) Morphine Sulfate Tab SR 12HR 15 MG ORAMORPH SR Daily Dosage=3(Generic: MS CONTIN,ORAMORPH SR) Morphine Sulfate Tab SR 12HR 30 MG ORAMORPH SR Daily Dosage=3(Generic: MS CONTIN) Morphine Sulfate Tab SR 12HR 60 MG ORAMORPH SR Daily Dosage=3(Generic: MS CONTIN,ORAMORPH SR) Morphine Sulfate Tab SR 12HR 100 MG ORAMORPH SR Daily Dosage=3(Generic: MS CONTIN) Morphine Sulfate Tab SR 12HR 200 MG Daily Dosage=3(Generic: OXYIR) Oxycodone HCl Cap 5 MG OXYCODONE Daily Dosage=6(Generic: ROXICODONE) Oxycodone HCl Tab 5 MG Max Qty=186/31 days(Generic: ROXICODONE) Oxycodone HCl Tab 15 MG Daily Dosage=6(Generic: ROXICODONE) Oxycodone HCl Tab 30 MG Daily Dosage=4Oxycodone HCl Tab SR 12HR 10 MG OXYCONTIN PA Required; Daily Dosage=2Oxycodone HCl Tab SR 12HR 15 MG OXYCONTIN PA Required; Daily Dosage=2Oxycodone HCl Tab SR 12HR 20 MG OXYCONTIN PA Required; Daily Dosage=2Oxycodone HCl Tab SR 12HR 30 MG OXYCONTIN PA Required; Daily Dosage=2Oxycodone HCl Tab SR 12HR 40 MG OXYCONTIN PA Required; Daily Dosage=2Oxycodone HCl Tab SR 12HR 60 MG OXYCONTIN PA Required; Daily Dosage=2Oxycodone HCl Tab SR 12HR 80 MG OXYCONTIN PA Required; Daily Dosage=2(Generic: ROXICODONE) Oxycodone HCl Conc 20 MG/ML OXYCODONE Max Qty=120/claim(Generic: ULTRAM) Tramadol HCl Tab 50 MG Daily Dosage=4(Generic: TYLOX)Oxycodone w/ Acetaminophen Cap 5-500MG Max Qty=186/31 days(Generic: PERCOCET)Oxycodone w/ Acetaminophen Tab 5-325MG Max Qty=186/31 daysOxycodone w/ Acetaminophen Tab 5-500MG ROXICET Max Qty=124/31 days(Generic: PERCOCET)Oxycodone w/ Acetaminophen Tab 7.5-325MG Max Qty=186/31 days(Generic: PERCOCET)Oxycodone w/ Acetaminophen Tab 7.5-500MG Max Qty=186/31 days(Generic: PERCOCET)Oxycodone w/ Acetaminophen Tab 10-325MG Max Qty=186/31 days(Generic: PERCOCET)Oxycodone w/ Acetaminophen Tab 10-650MG Max Qty=186/31 daysOxycodone w/ Acetaminophen Soln 5-325MG/5ML ROXICET Max Qty=500/31 days(Generic: PERCODAN) Oxycodone w/ Aspirin Tab Full Strength Max Qty=186/31 daysAcetaminophen w/ Codeine Tab 300-15 MG Max Qty=186/31 days(Generic: TYLENOL/COD) Acetaminophen w/ Codeine Tab 300-30 MG Max Qty=186/31 days(Generic: TYLENOL/COD) Acetaminophen w/ Codeine Tab 300-60 MG Max Qty=186/31 daysAcetaminophen w/ Codeine Soln 120-12MG/5MLAspirin w/ Codeine Tab 325-30 MGAspirin w/ Codeine Tab 325-60 MG(Generic: FIORICET/COD)Butalbital-Acetaminophen-Caff w/ COD Cap50-325-40-30 MG Max Qty=124/31 days(Generic: FIORINAL/COD)Butalbital-Aspirin-Caff w/ Codeine Cap 50-325-40-30 MG Max Qty=124/31 days(Generic: NORCO)Hydrocodone-Acetaminophen Tab 10-325MGDaily Dosage=6(Generic: LORTAB, LORTAB 5,VICODIN) Hydrocodone-Acetaminophen Tab 5-500 MG Daily Dosage=849 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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Member ServicesPeach State is commi
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• Income• Health Status• Arre
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• To keep all your appointments.
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• An Administrative Law Hearing d
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The staff often answers questions a
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PharmacyThe Peach State preferred d
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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
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Page 133 and 134: SPECIALTY MEDICATIONPRIOR AUTHORIZA
Page 135 and 136: Common Brand Name(s) Product Descri
Page 173: Common Brand Name(s) Product Descri
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