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

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Common Brand Name(s) Product Description Covered Brand Product Limitations/Restrictions*Spacer/Aerosol-Holding Chambers -Device***AEROCHAMBER,BREATHERITEMax Qty=2/360 days*Spacer/Aerosol-Holding Chamber Supplies -Bags*** INSPIREASE Max Qty=3/180 days*Blood Glucose Calibration - Liquid***ONE-TOUCH, TRUE-TRACK Max Qty=1/90 daysONE-TOUCH, TRUE-*Blood Glucose Calibration - Liquid - High*** TRACK Max Qty=1/90 days*Blood Glucose Calibration - Liquid -Normal***ONE-TOUCH, TRUE-TRACK*Blood Glucose Calibration - Liquid - Low***ONE-TOUCH, TRUE-TRACK Max Qty=1/90 days*Blood Glucose Monitoring Devices****ONE-TOUCH, TRUE-TRACK Max Qty=1/730 days*Blood Glucose Monitoring Kit****ONE-TOUCH, TRUE-TRACKPA; Max Qty=1/730 days*Blood Glucose Monitoring Kit w/Device****ONE-TOUCH, TRUE-TRACK Max Qty=1/730 days*Lancets****ONE-TOUCH, TRUE-TRACK Max Qty=200/30 days*Lancet Devices****ONE-TOUCH, TRUE-TRACKMax Qty=1/180 days*Gauze Pads & Dressings - Pads 2" X 2"****Gauze Pads & Dressings - Pads 3" X 3"***CUREX SPONGECURITY GAUZEPHARMACEUTICAL ADJUVANTSASSORTED CLASSES*Gauze Pads & Dressings - Pads 4" X 4"*** ALLEVYN, BIATAINCondoms Latex Lubricated ATLAS CONDOM Max Qty=36/30 daysDiaphragm Arc-Spring 65 MMORTHO FLEXDiaphragm Arc-Spring 70 MMORTHO FLEXDiaphragm Arc-Spring 75 MMORTHO FLEXDiaphragm Arc-Spring 80 MMORTHO FLEXDiaphragm Coil Spring Kit 50 MM ORTHO COIL Max Qty=1/365 daysDiaphragm Coil Spring Kit 100 MM ORTHO COILDiaphragm Coil Spring Kit 105 MM ORTHO COILDiaphragm Flat Spring Kit 55 MMORTHO FLATDiaphragm Flat Spring Kit 60 MMORTHO FLATDiaphragm Flat Spring Kit 65 MMORTHO FLATDiaphragm Flat Spring Kit 70 MMORTHO FLATDiaphragm Flat Spring Kit 75 MMORTHO FLATDiaphragm Flat Spring Kit 80 MMORTHO FLATDiaphragm Flat Spring Kit 85 MMORTHO FLATDiaphragm Flat Spring Kit 90 MMORTHO FLATDiaphragm Flat Spring Kit 95 MMORTHO FLAT*Alcohol Swabs*** ALCOHOL PREP Max Qty=400/30 daysLanolinLAN-O-SOOTHE,LANOLIN HYDR,LANSINOHPenicillamine Cap 125 MGPenicillamine Cap 250 MGCUPRIMINECUPRIMINE(Generic: SANDIMMUNE)Cyclosporine Cap 25 MGMax Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-276768 of 70
Common Brand Name(s) Product Description Covered Brand Product Limitations/Restrictions(Generic: SANDIMMUNE)(Generic: SANDIMMUNE)(Generic: NEORAL)(Generic: NEORAL)(Generic: NEORAL)(Generic: CELLCEPT)(Generic: CELLCEPT)Cyclosporine Cap 100 MGCyclosporine Oral Soln 100 MG/MLCyclosporine Modified Cap 25 MGCyclosporine Modified Cap 50 MGCyclosporine Modified Cap 100 MGCyclosporine Modified Oral Soln 100 MG/MLMycophenolate Mofetil Cap 250 MGMycophenolate Mofetil Tab 500 MGMax Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Mycophenolate Mofetil For Oral Susp 200MG/MLMycophenolate Sodium Tab DR 180 MG(Mycophenolic Acid Equiv)Mycophenolate Sodium Tab DR 360 MG(Mycophenolic Acid Equiv)Sirolimus Tab 1 MGSirolimus Tab 2 MGSirolimus Oral Soln 1 MG/MLCELLCEPTMYFORTICMYFORTICRAPAMUNERAPAMUNERAPAMUNEMax Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767(Generic: PROGRAF)(Generic: PROGRAF)(Generic: PROGRAF)(Generic: IMURAN)Tacrolimus Cap 0.5 MGTacrolimus Cap 1 MGTacrolimus Cap 5 MGAzathioprine Tab 50 MGMax Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Azathioprine Tab 75 MGAzathioprine Tab 100 MGAZASANAZASANMax Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-2767Max Days Supply=7/claim at Retail / MDmust contact CAREMARK 800-237-276769 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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Page 193: Common Brand Name(s) Product Descri
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