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: DRYSOL) Aluminum Chloride Soln 20%ANTISEPTICS & DISINFECTANTSChlorhexidine Gluconate Liquid 4%ANTIDOTES(Generic: REVIA)DIAGNOSTIC PRODUCTSIpecac SyrupSuccimer Cap 100 MGNaltrexone HCl Tab 50 MGGNP IPECAC, IPECAC, QCIPECAC, RA IPECAC, SMIPECAC...CHEMETCHEMICALSAcetone (Urine) Test StripGlucose Blood Test StripKetone Blood Test StripCHEK-STIX, CHEMSTRIPK, KETOCARE, KETOSTIXONE-TOUCH, TRUE-TRACKNOVA MAX PLS, PRECISNXTRA Max Qty=30/30 daysMEDICAL DEVICESOmeprazole (Bulk) PowderInsulin Syringe (Disp) U-100 1 ML INSULIN SYRG Max Qty=155/30 daysPAInsulin Syringe/Needle U-40 1 ML 26 x 1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 28 x1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 29 x1/2"INS SYRINGE, INSULINSYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 30 x3/8" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 30 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 30 x1/2"INS SYRINGE, INSULINSYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 30 x7/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 27 x1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 28 G x1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 29 x7/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 30 x3/8" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 30 x7/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 30 G x1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 31 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 28 x1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 29 x 1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 28 x 1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 29 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 29 x1/2"INS SYRINGE, INSULINSYRG Max Qty=150/30 days66 of 70
Common Brand Name(s) Product Description Covered Brand Product Limitations/RestrictionsInsulin Syringe/Needle U-100 1/2 ML 30 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 30 x1/2"INS SYRINGE, INSULINSYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 25 x 5/8" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 25 x 1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 26 x 1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 27 x 1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 27 x 5/8" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 28 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 28 x 1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 30 G x 1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 29 x7/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 29 x 1/2"INS SYRINGE, INSULINSYRG, MAGELLAN INS Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 29 x 1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 29 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 30 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 30 x7/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 30 x 1/2"INS SYRINGE, INSULINSYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 31 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 31 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 2 ML 27.5 x5/8" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 2 ML 29 x 1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 29 x7/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 29 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 29 x 1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 30 x 1" INSULIN SYRG Max Qty=150/30 days*Insulin Pen Needle*** ULTILET PEN Max Qty=150/30 daysInsulin Pen Needle 29 G X 12 MM Max Qty=150/30 daysInsulin Pen Needle 30 G X 8 MM Max Qty=150/30 daysInsulin Pen Needle 31 G X 5 MM Max Qty=150/30 daysInsulin Pen Needle 31 G X 6 MM Max Qty=150/30 daysInsulin Pen Needle 31 G X 8 MM Max Qty=150/30 days*Respiratory Therapy Supplies - Misc** ADULT MASK Max Qty=1/360 days*Respiratory Therapy Supplies -Mouthpieces**ALL FLOW67 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
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Gender LimitsSome medications on th
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Cyclosporine, Digoxin, Disopyramide
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SPECIALTY MEDICATIONPRIOR AUTHORIZA
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Common Brand Name(s) Product Descri
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