2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix G. Alternative Benefits Package Covered ServicesCovered Service Description Prior AuthorizationInpatient hospitalization infreestanding psychiatric hospitalsIntravenous (IV) outpatientservicesThese services include necessary evaluations and psychological testing fortreating severe emotional or substance abuse problems. They also includeregularly scheduled structured counseling and therapy sessions. Theseservices are only for individuals under 21 years of age. Inpatient drugrehabilitation services are not covered. Acute inpatient services for “detox”are covered.Hospital outpatient care includes the use of intravenous (IV) infusions,catheter changes, first aid for IV associated injuries, laboratory and radiologyservices, and diagnostic and therapeutic radiation, including radioactiveisotopes. A partial hospitalization in a general hospital psychiatric unit isconsidered an outpatient service.YesNoSome medications mayrequire priorauthorizationLaboratory servicesThese are medically necessary lab services ordered by doctors or otherlicensed providers. They are performed by ordering providers or are doneunder their supervision in an office lab. They also can be performed by aclinical lab.This includes laboratory genetic testing to specific molecular lab tests suchas BRCA1 and BRCA2 and similar tests used to determine appropriatetreatment. Does not include random genetic screening.NoMedication Assisted Treatment(MAT) for opioid dependenceThis service is treatment for addiction that includes the use of medicationalong with counseling and other support.Midwife services See Page F-8. NoYes, for medicationsonly. Not for officevisitsNutritional counselingOccupational therapyDietary evaluation of counseling as medical management of a documenteddisease, including obesity.These promote fine motor skills, coordination, and integration of the senses.They help the member use adaptive equipment or other technology.Limitation: Short-term therapy only for a two-month period from the initialdate of treatment.YesNoOutpatient hospital-basedpsychiatric services and partialhospitalizationThese services are medically necessary for the diagnosis and/or treatment ofa mental illness, as indicated by the member’s condition. Services andstabilization must be for the purpose of diagnostic study or be expected toimprove the member’s condition.No, outpatient servicesprovided in hospitalsettingOutpatient health careprofessional servicesPharmacy services See Page 8-2.These cover outpatient assessments, evaluations, testing, and therapy.Certain over-the-counter drugs are covered, such as prenatal drug items(examples –vitamins, folic acid; iron), low dose aspirin as preventative forcardiac conditions; contraception drugs and devices, and items for treatingdiabetes.Yes, for partialhospitalization andpsychological testing.No, for evaluations andtesting. Sometherapies may requireprior authorization.Yes, for selectmedicationsG-32014 Practitioner and Provider Manual - Ver. 3