2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix G. Alternative Benefits Package Covered ServicesCovered Service Description Prior AuthorizationTobacco/smoking cessation pharmacotherapy is prescriptiondrugs/medications prescribed by your provider for a 30-day supply up to themaximum dose recommended by the manufacturer. These medications can bepurchased at a pharmacy. Coverage is limited to two 90-day courses oftreatment per calendar year.Specialized behavioral healthservices for adultsSpeech and language therapyTelehealth servicesThese include Intensive Outpatient (IOP), Assertive Community Treatment(ACT) and Psychosocial Rehabilitation (PSR).This is a covered benefit for members under the age of 21. The servicesmust be provided by speech and language pathologists, physical therapists,and occupational therapists. Services must be prescribed or ordered by themember’s PCP or other doctor.Limitation: Short-term therapy only for a two-month period from the initialdate of treatment.An interactive telehealth communication system that must include bothinteractive audio and video. It must be delivered on a real-time basis at theoriginal site and distant sites. Providers may use telehealth when it isavailable for the following services:ConsultationsEvaluation and management servicesIndividual psychotherapyPharmacologic managementPsychiatric diagnostic interview examsEnd-stage renal disease-related servicesIndividual medical nutrition servicesNoNoNoTransplant servicesThese include hospital, doctor, laboratory, outpatient surgical, and othercovered services needed to perform a transplant.YesLimitation: 2 per lifetime.Transportation services (medical)Vision servicesPresbyterian covers expenses for transportation and other related expenseswhich are determined as necessary to secure Medicaid-covered medicalexaminations and treatment for eligible recipients in or out of their homecommunity. Travel expenses include the cost of transportation by publictransportation, taxicab, handivan, and ground or air ambulance. Relatedtravel expenses include the cost of meals and lodging made necessary byreceipt of medical care away from the recipient’s home community. Whenmedically necessary, Medicaid covers similar expenses for an attendant whoaccompanies the recipient to the medical examination or treatment.The diagnoses and treatment of eye diseases and the correction of visionproblems.Certain types of glasses are not covered. See the Non-covered Benefits list.Exclusion: Refractions are not covered.Limitation: Eyeglasses and contact lenses are only covered for aphakiafollowing the removal of the lens.NoSome services requireprior authorizationG-52014 Practitioner and Provider Manual - Ver. 3