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: ZYLOPRIM)Allopurinol Tab 300 MGColchicine Tab 0.6 MGProbenecid Tab 500 MGCOLCRYSColchicine w/ Probenecid Tab 0.5-500 MGANTICONVULSANTS(Generic: KLONOPIN)Clonazepam Tab 0.5 MGLimited to Ages 21 and Older, DailyDosage=3(Generic: KLONOPIN)Clonazepam Tab 1 MGLimited to Ages 21 and Older, DailyDosage=3(Generic: KLONOPIN)Clonazepam Tab 2 MGLimited to Ages 21 and Older, DailyDosage=3Diazepam Rectal Gel Delivery System 2.5 MG DIASTAT PEDLimited to Ages 21 and Under, MaxQty=1/claimLimited to Ages 21 and Under, MaxDiazepam Rectal Gel Delivery System 10 MG DIASTAT ACDLQty=1/claimDiazepam Rectal Gel Delivery System 20 MG DIASTAT ACDLLimited to Ages 21 and Under, MaxQty=1/claimFelbamate Tab 400 MGFELBATOLFelbamate Tab 600 MGFELBATOLFelbamate Susp 600 MG/5MLFELBATOLTiagabine HCl Tab 2 MGGABITRILTiagabine HCl Tab 4 MGGABITRILTiagabine HCl Tab 12 MGGABITRILTiagabine HCl Tab 16 MGGABITRILPhenytoin Chew Tab 50 MGDILANTIN(Generic: DILANTIN-125) Phenytoin Susp 125 MG/5MLPhenytoin Sodium Extended Cap 30 MG DILANTIN(Generic: DILANTIN)Phenytoin Sodium Extended Cap 100 MG(Generic: ZARONTIN)Ethosuximide Cap 250 MG(Generic: ZARONTIN)Ethosuximide Soln 250 MG/5ML(Generic: DEPAKOTE)Divalproex Sodium Tab Delayed Release 125MG Daily Dosage=2(Generic: DEPAKOTE)Divalproex Sodium Tab Delayed Release 250MG DEPAKOTE Daily Dosage=3(Generic: DEPAKOTE)Divalproex Sodium Tab Delayed Release 500MG Daily Dosage=7(Generic: DEPAKOTE SPR) Divalproex Sodium Cap Sprinkle 125 MG Daily Dosage=8(Generic: DEPAKOTE ER) Divalproex Sodium Tab SR 24 HR 250 MG Max Qty=93/31 days(Generic: DEPAKOTE ER) Divalproex Sodium Tab SR 24 HR 500 MG DEPAKOTE ER Daily Dosage=7(Generic: DEPAKENE)Valproate Sodium Syrup 250 MG/5ML(Generic: DEPAKENE)Valproic Acid Cap 250 MG(Generic: TEGRETOL)Carbamazepine Tab 200 MG(Generic: TEGRETOL)Carbamazepine Chew Tab 100 MG(Generic: TEGRETOL)Carbamazepine Susp 100 MG/5MLCarbamazepine Tab SR 12HR 100 MG TEGRETOL XR(Generic: TEGRETOL XR) Carbamazepine Tab SR 12HR 200 MG TEGRETOL XR(Generic: TEGRETOL XR) Carbamazepine Tab SR 12HR 400 MG TEGRETOL XR(Generic: NEURONTIN) Gabapentin Cap 100 MG NEURONTIN Daily Dosage=4(Generic: NEURONTIN) Gabapentin Cap 300 MG Daily Dosage=4(Generic: NEURONTIN) Gabapentin Cap 400 MG Daily Dosage=4Gabapentin Tab 100 MG GABARONE Daily Dosage=4Gabapentin Tab 300 MG GABARONE Daily Dosage=4Gabapentin Tab 400 MG GABARONE Daily Dosage=4(Generic: NEURONTIN) Gabapentin Tab 600 MG Daily Dosage=4(Generic: NEURONTIN) Gabapentin Tab 800 MG Daily Dosage=4Gabapentin Oral Soln 250 MG/5ML NEURONTIN(Generic: LAMICTAL)Lamotrigine Tab 25 MG52 of 70
Common Brand Name(s) Product Description Covered Brand Product Limitations/Restrictions(Generic: LAMICTAL)(Generic: LAMICTAL)(Generic: LAMICTAL)(Generic: LAMICTAL)Lamotrigine Tab 100 MGLamotrigine Tab 150 MGLamotrigine Tab 200 MGLamotrigine Tab Chewable Dispersible 5 MG(Generic: LAMICTAL)Lamotrigine Tab Chewable Dispersible 25 MG(Generic: KEPPRA) Levetiracetam Tab 250 MG Daily Dosage=4(Generic: KEPPRA) Levetiracetam Tab 500 MG Daily Dosage=4(Generic: KEPPRA) Levetiracetam Tab 750 MG Daily Dosage=4(Generic: KEPPRA) Levetiracetam Soln 100 MG/ML Daily Dosage=16(Generic: TRILEPTAL)Oxcarbazepine Tab 150 MG(Generic: TRILEPTAL)Oxcarbazepine Tab 300 MG(Generic: TRILEPTAL)Oxcarbazepine Tab 600 MG(Generic: TRILEPTAL)Oxcarbazepine Susp 300 MG/5ML (60MG/ML)(Generic: MYSOLINE)Primidone Tab 50 MG(Generic: MYSOLINE)Primidone Tab 250 MG(Generic: TOPAMAX) Topiramate Tab 25 MG TOPAMAX Daily Dosage=3(Generic: TOPAMAX) Topiramate Tab 50 MG TOPAMAX Daily Dosage=3(Generic: TOPAMAX) Topiramate Tab 100 MG TOPAMAX Daily Dosage=3(Generic: TOPAMAX) Topiramate Tab 200 MG TOPAMAX Daily Dosage=3(Generic: TOPAMAX SPR) Topiramate Sprinkle Cap 15 MG PA, Max Qty=100/30 days(Generic: TOPAMAX SPR) Topiramate Sprinkle Cap 25 MG PA, Max Qty=100/30 days(Generic: ZONEGRAN) Zonisamide Cap 25 MGZonisamide Cap 50 MG(Generic: ZONEGRAN) Zonisamide Cap 100 MGANTIPARKINSON AGENTSBenztropine Mesylate Tab 0.5 MGBenztropine Mesylate Tab 1 MGBenztropine Mesylate Tab 2 MGTrihexyphenidyl HCl Tab 2 MG(Generic: ARTANE)Trihexyphenidyl HCl Tab 5 MGTrihexyphenidyl HCl Elixir 0.4 MG/ML Max Qty=500/31 daysAmantadine HCl Cap 100 MGAmantadine HCl Syrup 50 MG/5ML(Generic: PARLODEL)Bromocriptine Mesylate Cap 5 MG(Generic: PARLODEL)Bromocriptine Mesylate Tab 2.5 MG(Generic: REQUIP) Ropinirole Hydrochloride Tab 0.25 MG REQUIP Daily Dosage=6(Generic: REQUIP) Ropinirole Hydrochloride Tab 0.5 MG Daily Dosage=3(Generic: REQUIP) Ropinirole Hydrochloride Tab 1 MG REQUIP Daily Dosage=3(Generic: REQUIP) Ropinirole Hydrochloride Tab 2 MG REQUIP Daily Dosage=3(Generic: REQUIP) Ropinirole Hydrochloride Tab 3 MG Daily Dosage=6(Generic: REQUIP) Ropinirole Hydrochloride Tab 4 MG Daily Dosage=6(Generic: REQUIP) Ropinirole Hydrochloride Tab 5 MG Daily Dosage=3(Generic: SINEMET)Carbidopa & Levodopa Tab 10-100 MG(Generic: SINEMET)Carbidopa & Levodopa Tab 25-100 MG(Generic: SINEMET)Carbidopa & Levodopa Tab 25-250 MG(Generic: SINEMET CR)Carbidopa & Levodopa Tab CR 25-100 MG(Generic: SINEMET CR)(Generic: ELDEPRYL)Carbidopa & Levodopa Tab CR 50-200 MGSelegiline HCl Cap 5 MGSelegiline HCl Tab 5 MGCarbidopa Tab 25 MGLODOSYNMUSCULOSKELETAL THERAPY AGENTSBaclofen Tab 10 MGBaclofen Tab 20 MG(Generic: SOMA) Carisoprodol Tab 350 MG Daily Dosage=4(Generic: PARAFON FORT) Chlorzoxazone Tab 500 MG53 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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• Experimental drugs• Nutrition
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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 177: Common Brand Name(s) Product Descri
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