AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

RESIDENTIAL TREATMENT FACILITY – MENTAL DISORDERS
This is an institution that meets all of the following requirements:
• On-site licensed Behavioral Health Provider 24 hours per day/seven days a week
• Provides a comprehensive patient assessment (preferably before admission, but at least upon
admission)
• Is admitted by a Physician
• Has access to necessary medical services 24 hours per day/seven days a week
• Provides living arrangements that foster community living and peer interaction that are consistent with
developmental needs
• Offers group therapy session with at least an RN or Masters-Level Health Professional
• Has the ability to involve family/support systems in therapy (required for children and adolescents;
encouraged for adults)
• Provides access to at least weekly sessions with a Psychiatrist or psychologist for individual
psychotherapy
• Has peer oriented activities
• Services are managed by a licensed Behavior Health Provider who, while not needing to be individually
contracted, needs to (1) meet the Aetna credentialing criteria as an individual practitioner, and (2)
function under the direction/supervision of a licensed psychiatrist (medial Director)
• Has individualized active treatment plan directed toward the alleviation of the impairment that caused the
admission
• Provides a level of skilled intervention consistent with patient risk
• Meets any and all applicable licensing standards established by the jurisdiction in which it is located
• Is not a Wilderness Treatment Program or any such related or similar program, school and/or education
service
SURGERY
A cutting operation, suturing of a wound, treatment of a fracture, relocation of dislocation, radiotherapy (if
used in lieu of a cutting operation) diagnostic and therapeutic endoscopic procedures, laser surgery, and
injections classified a Surgery under the CPT.
URGENT CARE PROVIDER
This is a freestanding medical facility which provides unscheduled medical services to treat an Urgent
Condition if the person’s Physician is not reasonable available, routinely provides ongoing unscheduled
medical services for more than eight consecutive hours and makes charges. They are licensed and certified
as required by any state or federal law or regulation. They keep a medical record on each patient. Urgent
Care Provider provides an ongoing quality assurance program, which includes reviews by Physicians other
than those who own or direct the facility. Its run by a staff of Physicians, at least on Physician must be on call
at all times and has a full-time administrator who is licensed Physician. Similar to a Physician’s office, but only
one that has contracted with Aetna to provide urgent care; and is with Aetna’s consent, included in the
directory as Preferred Urgent Care Provider. It is not the emergency room or Outpatient department of a
hospital.
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