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: FLEXERIL) Cyclobenzaprine HCl Tab 5 MG Max Qty=93/31 days(Generic: FLEXERIL) Cyclobenzaprine HCl Tab 10 MG Daily Dosage=3(Generic: SKELAXIN) Metaxalone Tab 800 MG SKELAXIN PA(Generic: ROBAXIN)Methocarbamol Tab 500 MG(Generic: ROBAXIN-750) Methocarbamol Tab 750 MG(Generic: ZANAFLEX)(Generic: ZANAFLEX)(Generic: DANTRIUM)(Generic: DANTRIUM)(Generic: DANTRIUM)ANTIMYASTHENIC AGENTS(Generic: MESTINON)VITAMINS(Generic: SLO-NIACIN)(Generic: SLO-NIACIN)(Generic: DRISDOL)MULTIVITAMINSOrphenadrine Citrate Tab SR 12HR 100 MGTizanidine HCl Tab 2 MGTizanidine HCl Tab 4 MGDantrolene Sodium Cap 25 MGDantrolene Sodium Cap 50 MGDantrolene Sodium Cap 100 MGPyridostigmine Bromide Tab 60 MGPyridostigmine Bromide Tab CR 180 MGMESTINONThiamine HCl Tab 50 MG Max Qty=100/31 daysThiamine HCl Tab 100 MG Max Qty=100/31 daysThiamine HCl Tab 250 MG Max Qty=100/31 daysThiamine HCl Tab 500 MG Max Qty=100/31 daysThiamine Mononitrate Tab 100 MG VITAMIN B-1 Max Qty=100/31 daysRiboflavin Tab 25 MG Max Qty=100/31 daysRiboflavin Tab 50 MG Max Qty=100/31 daysRiboflavin Tab 100 MG Max Qty=100/31 daysNiacin Cap CR 250 MGNiacin Cap CR 500 MGNiacin Tab 500 MGNiacin Tab CR 250 MGNiacin Tab CR 500 MGNiacin Tab CR 750 MGNiacin Tab CR 1000 MGNIACIN TRPyridoxine HCl Tab 25 MGPyridoxine HCl Tab 50 MGPyridoxine HCl Tab 100 MGAscorbic Acid Tab 250 MG Max Qty=100/31 days21ST CENT NA, KROGERAscorbic Acid Tab 500 MGVITAM Max Qty=100/31 daysAscorbic Acid Tab 1000 MG VITAMIN C TA Max Qty=100/31 daysAscorbic Acid Tab 1500 MG Max Qty=100/31 daysErgocalciferol Cap 50000 IUVitamin E Cap 100 IU Max Qty=62/31 daysVitamin E Cap 200 IU Max Qty=62/31 daysVitamin E Cap 400 IU Max Qty=62/31 daysVitamin E Chew Tab 400 IU Max Qty=62/31 daysPhytonadione Tab 5 MGMEPHYTON*B-Complex Vitamin Cap** Max Qty=31/31 days*B-Complex Vitamin Tab**Max Qty=31/31 days*B-Complex w/ C Cap** Max Qty=31/31 days(Generic: NEPHROCAPS) *B-Complex w/ C & Folic Acid Cap 1 MG*** Daily Dosage=1(Generic: NEPHRO-VITE) *B-Complex w/ C & Folic Acid Tab 1 MG*** Daily Dosage=1*B-Complex w/ C-Min-Fe & Folic Acid Tab106-1 MG*** Daily Dosage=1(Generic: CARDENZ, LYSIPLEX,ONE-A-DAY, THERAGRAN) *Multiple Vitamin Tab** Max Qty=31/31 days(Generic: GERITOL EXT,STRESSTABS) *Multiple Vitamins w/ Iron Tab** STRESS FORMU Max Qty=31/31 days54 of 70
Common Brand Name(s) Product Description Covered Brand Product Limitations/Restrictions(Generic: CAROMEGA,CENTRUM, COMPLERE,FEMTABS, FOSFREE...)(Generic: TRI-VI-SOL)(Generic: POLY-VI-SOL)(Generic: POLY-VI-SOL)(Generic: POLY-VI-FLOR)(Generic: NESTABS RX)*Multiple Vitamins w/ Minerals Tab**ADV DIABETIC,ANTIOXIDANT, B-50FORMULA, BACMIN,BASIC AM... Max Qty=31/31 days*Pediatric Vitamins ADC Drops 1500IU-400IU-35 MG/ML*** Max Qty=50/claim*Pediatric Multiple Vitamin w/ C Soln 35MG/ML** Max Qty=50/claim*Pediatric Multiple Vitamin w/ C & FA ChewTab** Daily Dosage=1*Pediatric Multiple Vitamins w/ Iron Drops 10MG/ML** Max Qty=50/claim*Pediatric Vitamins ACD w/ Iron Drops 10MG/ML*** TRI-VI-SOL Max Qty=50/claim*Pediatric Vitamins ACD w/ Fluoride ChewTab 1 MG***Limited to Ages 21 and Under, Retail only*Pediatric Vitamins ACD w/ Fluoride SolnLimited to Ages 21 and Under, Max0.25 MG/ML*** TRIPHLUORIVIQty=50/claim*Pediatric Vitamins ACD w/ Fluoride Soln 0.5Limited to Ages 21 and Under, MaxMG/ML***Qty=50/claim*Pediatric Multiple Vitamins w/ FluorideChew Tab 0.25 MG****Pediatric Multiple Vitamins w/ FluorideLimited to Ages 21 and Under, DailyChew Tab 0.5 MG***Dosage=1*Pediatric Multiple Vitamins w/ FluorideChew Tab 1 MG****Pediatric Multiple Vitamins w/ Fluoride SolnLimited to Ages 21 and Under, Max0.25 MG/ML*** PHLUORIVITQty=50/claim*Pediatric Multiple Vitamins w/ Fluoride SolnLimited to Ages 21 and Under, Max0.5 MG/ML***Qty=50/claim*Pediatric Multiple Vitamins w/ Fl-Fe ChewTab 0.5-12 MG***Pediatric Multiple Vitamins w/ Fl-Fe ChewTab 1-12 MG***Pediatric Multiple Vitamins w/ Fl-Fe DropsLimited to Ages 21 and Under, Max0.25-10 MG/ML**Qty=50/claim*Pediatric Multiple Vitamins w/ Fl-Fe DropsLimited to Ages 21 and Under, Max0.5-10 MG/ML** POLY-VIT/FEQty=50/claim*Pediatric Vitamins ACD Fluoride & Fe Drops0.25-10 MG/ML***Limited to Ages 50 and Under, Limited to*Prenatal Vitamin Fast Dissolving Tab** CALNAFemale, Retail only*Prenatal Multivitamins & Minerals w/ Iron &FA Cap 0.1MG***TYLER PRENAT*Prenatal Multivitamins & Minerals w/ Iron &FA Cap 1 MG***MYNATAL, VITA-NATAL*Prenatal Multivitamins & Minerals w/ Iron &FA Tab 0.1MG***KPN*Prenatal Multivitamins & Minerals w/ Fe &FA Tab 0.25 MG***NUTRICIONP D NATAL/FA, P-DNATAL, PRE-NATAL,*Prenatal Multivitamins & Minerals w/ Iron & PRENATAL,FA Tab 0.8MG***PRENATAL/FE*Prenatal Multivitamins & Minerals w/ Iron &FA Tab 1 MG****Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 PRENATABS RX, RE-NATAMG***29, VOL-TAB RXLimited to Ages 50 and Under, Limited toFemale, Retail onlyLimited to Ages 12 and Older, Limited toAges 50 and Under, Limited to Female, RetailonlyLimited to Ages 50 and Under, Limited toFemale, Retail onlyLimited to Ages 50 and Under, Limited toFemale, Retail onlyLimited to Ages 50 and Under, Limited toFemale, Retail onlyLimited to Ages 50 and Under, Limited toFemale, Retail onlyLimited to Ages 49 and Under; Limited toFemale55 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
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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 179: Common Brand Name(s) Product Descri
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