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Medical Benefits3. Services provided by a licensed Acupuncturist, including office visits for diagnosis, evaluation andtreatment planning for musculoskeletal conditions, pain management, treatment of asthma,treatment of substance abuse, treatment of nausea related to pregnancy or chemotherapy.Services are excluded for emergency care, preventive care, treatment of cardiacconditions, acute abdominal symptoms, fractures or dislocations (suspected or actual),any hemorrhagic disorder, or acute respiratory distress that has not been previouslydiagnosed as asthma and routine foot care.ORGAN/TISSUE TRANSPLANTSA Transplant is defined as a procedure or series of procedures by which an organ or tissue is eitherremoved:1. From the body of one person (the donor) and implanted in the body of another person (therecipient) who is a Participant); or2. From and replaced in the same person’s body (a self-donor who is a Participant).The term transplant does not include services related to the transfusion of blood or blood derivatives(except hematopoietic stem cells) or replacement of a cornea.Covered services for transplants are limited to services that:1. Are pre-authorized and determined to be Medically Necessary and medically appropriateaccording to national standards of care;2. Are provided at a Center of Excellence facility;3. Involve one or more of the following organs or tissues:A. Heart,B. lung,C. Liver,D. Kidney,E. Pancreas,F. Small bowel,G. Autologous hematopoietic stem cell/bone marrow, orH. Allogeneic hematopoietic stem cell/bone marrow; and4. Are directly related to the transplant procedure, including services that occur before, during andafter the transplant procedure.Covered services for transplant recipients include medical services, hospital services, medical supplies,medications and prescription drugs while hospitalized, diagnostic modalities, prostheses, and high dosagechemotherapy for stem cell/bone marrow transplants.Western Montana Providence Health & Services - SPD 28Group #2000204 - January 1, 2011
Medical BenefitsServices for donors are covered when the donor is not eligible for coverage of donation services underany other health benefit plan or government funding program. If both the donor and the recipient arecovered under this Plan, Expenses Incurred by each person will be treated separately for each person.Covered services for donors include:1. Initial evaluation of the donor and related program administration costs;2. Preserving the organ or tissue to the transplant site;3. Transporting the organ or tissue to the transplant site;4. Acquisition charges for cadaver or live donor;5. Services required to remove the organ or tissue from the donor; and6. Treatment of medical complications directly resulting from the surgery performed to obtain theorgan or tissue for a period of time not to exceed 30 consecutive days following that surgery.Benefits for outpatient medications and anti-rejection (immunosuppressive) drugs are covered under thePharmacy Benefit.To qualify for coverage all transplant related services, procedures, treatment protocols, and facilities mustbe pre-authorized, including the initial consultation, evaluation, transplant facilities, donor evaluation,donor services, HLR typing, pre-transplant care, self-donation services, transplant services and follow-uptreatment.BARIATRIC SURGERY BENEFITServices must be performed at St. Patrick Hospital and Health Sciences Center or in a Medicareapproved Bariatric Center of Excellence.“Morbid Obesity/Clinically Severe Obesity” means maintaining a Body Mass Index (BMI) of 35 or more fora period of at least 12 consecutive months, combined with at least one of the following conditions whichmust be documented by a physician as life-threatening:1. Severe sleep apnea;2. Pickwickian syndrome;3. Congestive heart failure;4. Cardiomyopathy;5. Insulin dependent or oral medication dependent diabetes;6. Severe Musculoskeletal dysfunction;7. Gastric Esophageal Reflux Disorder;8. Pulmonary edema; or9. Hypertension.Western Montana Providence Health & Services - SPD 29Group #2000204 - January 1, 2011
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Page 9 and 10: SCHEDULE OF MEDICAL BENEFITS - PROV
Page 11 and 12: Schedule of Medical Benefits - Prov
Page 13 and 14: SCHEDULE OF MEDICAL BENEFITS - PROV
Page 16 and 17: Schedule of Medical Benefits - Prov
Page 18 and 19: Pharmacy BenefitWhen Primary Covera
Page 20 and 21: Pharmacy BenefitPRIMARY COVERAGE UN
Page 22 and 23: MEDICAL BENEFIT DETERMINATION REQUI
Page 24 and 25: Medical Benefit Determination Requi
Page 26 and 27: Medical Benefits5. Charges made by
Page 28 and 29: Medical Benefits15. Charges for dru
Page 30 and 31: Medical BenefitsGENETIC AND INFERTI
Page 32 and 33: Medical BenefitsPREVENTIVE CARE“P
Page 36 and 37: Medical BenefitsBody Mass Index (BM
Page 38 and 39: Pre-Authorization6. A letter of med
Page 40 and 41: Hospital Admission CertificationCON
Page 42 and 43: Medical Benefit Exclusions10. Charg
Page 44 and 45: GENERAL PLAN EXCLUSIONS AND LIMITAT
Page 46 and 47: General Plan Exclusions and Limitat
Page 48 and 49: Coordination of Benefits“Plan”
Page 50 and 51: Coordination of Benefits3. For Cove
Page 52 and 53: Procedures for Claiming Benefits1.
Page 54 and 55: Procedures for Claiming Benefits2.
Page 56 and 57: Eligibility ProvisionsD. The ABR is
Page 58 and 59: EFFECTIVE DATE OF COVERAGEAll cover
Page 60 and 61: Effective Date of CoverageD. Placem
Page 62 and 63: QUALIFIED MEDICAL CHILD SUPPORT ORD
Page 64 and 65: FAMILY AND MEDICAL LEAVE ACT OF 199
Page 66 and 67: Family and Medical Leave ActENFORCE
Page 68 and 69: Termination of Coverage7. The date
Page 70 and 71: CONTINUATION COVERAGE AFTER TERMINA
Page 72 and 73: Continued Coverage After Terminatio
Page 74: Continued Coverage After Terminatio
Page 77 and 78: COVERAGE FOR A MILITARY RESERVISTTo
Page 80 and 81: Recovery/Reimbursement/SubrogationT
Page 82 and 83: PLAN ADMINISTRATIONPURPOSEThe purpo
Page 84 and 85:
CREDITABLE COVERAGE PROCEDURESCERTI
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General ProvisionsWORKERS' COMPENSA
Page 88 and 89:
General DefinitionsBENEFIT PERCENTA
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General DefinitionsCUSTODIAL CARE
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General Definitions“Reliable Evid
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General DefinitionsLATE ENROLLMENT
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General Definitions9. Are approved
Page 98 and 99:
General DefinitionsPREVENTIVE CARE
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General DefinitionsTOTAL DISABILITY
Page 102 and 103:
ERISA Statement of RightsIf you hav
Page 104 and 105:
HIPAA Privacy and Security Standard
Page 106:
Plan Summary9. IDENTIFICATION NUMBE
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