Physician Covered Services for HUSKY Health A, B, C, and D Members Last Update: 6/20/14
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Physician 1 Covered Services for HUSKY Health A, B, C, and D Members *Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per the CT Department of Social Services (DSS). Last Update: 6/20/14 MMTPE0001---0312
HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D
Allergy 100% Covered 100% Covered 100% Covered
Cardiac Rehab 100% Covered 100% Covered 100% Covered
Contraceptives 100% Covered Covered 100% Covered
Oral Contraceptives:
• Pharmacy co-pays apply
• No co-pay if provided in physician office
or clinic setting
Family Planning 100% covered 100% covered for office visit. 100% covered
Services can be performed by PCP or Services can be performed by PCP or Services can be performed by PCP or
specialist specialist. specialist
Sterilization requires submission of a Exclusions – not covered: Sterilization requires submission of a
completed W612 Consent to Sterilization • Fertility drugs are not covered completed W612 Consent to Sterilization
form. Sterilization is covered only for • Sterilization is not a covered benefit form. Sterilization is covered only for
members 21 or older. members 21 or older.
Exclusions – not covered: Exclusions – not covered:
• Sterilizations for patients who are under • Sterilizations for patients who are
age twenty-one (21), mentally under age twenty-one (21), mentally
incompetent, or institutionalized incompetent, or institutionalized
• Hysterectomies performed solely for the • Hysterectomies performed solely for the
purpose of rendering an individual purpose of rendering an individual
permanently incapable of reproducing permanently incapable of reproducing
• Services for infertility treatment including- • Services for infertility treatment including-
reversal sterilization, tuboplasty, artificial reversal sterilization, tuboplasty, artificial
insemination, in vitro fertilization, fertility insemination, in vitro fertilization, fertility
drugs drugs
1
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D
Genetic Testing Prior authorization required Prior authorization required Prior authorization required
Refer to DSS Laboratory Fee Schedule for Refer to DSS Laboratory Fee Schedule for Refer to DSS Laboratory Fee Schedule for
specific codes requiring PA. specific codes requiring PA. specific codes requiring PA.
Prior authorization will not be required for Prior authorization will not be required for Prior authorization will not be required for
cystic fibrosis testing (CPT Codes 81220- cystic fibrosis testing (CPT Codes 81220- cystic fibrosis testing (CPT Codes 81220-
81224) if billed with one of the diagnosis 81224) if billed with one of the diagnosis 81224) if billed with one of the diagnosis
codes listed in Table 11 of the DSS fee codes listed in Table 11 of the DSS fee codes listed in Table 11 of the DSS fee
schedule instructions located at schedule instructions located at schedule instructions located at
www.ctdssmap.com → Provider → Provider www.ctdssmap.com → Provider → Provider www.ctdssmap.com → Provider → Provider
Fee Schedule Download. Fee Schedule Download. Fee Schedule Download.
Prior authorization will not be required for Prior authorization will not be required for Prior authorization will not be required for
spinal muscular atrophy (SMA) testing (CPT spinal muscular atrophy (SMA) testing (CPT spinal muscular atrophy (SMA) testing (CPT
code 81329) if billed with one of the code 81329) if billed with one of the code 81329) if billed with one of the
diagnosis codes listed in Table 11A of the diagnosis codes listed in Table 11A of the diagnosis codes listed in Table 11A of the
DSS fee schedule instructions located at DSS fee schedule instructions located at DSS fee schedule instructions located at
www.ctdssmap.com → Provider → Provider www.ctdssmap.com → Provider → Provider www.ctdssmap.com → Provider → Provider
Fee Schedule Download Fee Schedule Download Fee Schedule Download
Inpatient MD 100% covered 100% covered 100% covered
(professional) No co-pays
Labs 100% covered 100% covered 100% covered
Maternity 100% covered for prenatal and postpartum 100% covered for prenatal and postpartum 100% covered for prenatal and postpartum
visits visits visits
2
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D
Maternal Depression Covered up to one year after delivery. Covered up to one year after delivery. N/A
Screenings Multiple screenings can be performed when Multiple screenings can be performed when
there is a documented risk of depression. there is a documented risk of depression.
Requires validated screening tool. May be Requires validated screening tool. May be
performed by pediatric providers on mother performed by pediatric providers on mother
to assess risk to infant. Based on risk, a to assess risk to infant. Based on risk, a
pediatric provider can perform multiple pediatric provider can perform multiple
screenings on mother until the infant turns screenings on mother until the infant turns
one. one.
For positive screens, mothers should be For positive screens, mothers should be
referred to CTBHP for follow-up care. referred to CTBHP for follow-up care.
Providers may contact: 1.877.552.8247. Providers may contact: 1.877.552.8247.
Uninsured or undocumented mothers who Uninsured or undocumented mothers who
need a depression screen should be directed need a depression screen should be directed
to the INFOLINE by calling 211 for to the INFOLINE by calling 211 for
alternative resources. alternative resources.
Billing requirements: Billing requirements:
• Providers should bill using code 96160 • Providers should bill using code 96160
“Administration of patient-focused health “Administration of patient-focused health
risk assessment instrument (e.g., health risk assessment instrument (e.g., health
hazard appraisal) with scoring and hazard appraisal) with scoring and
documentation, per standardized documentation, per standardized
instrument” or 96161 “Administration of instrument” or 96161 “Administration of
caregiver-focused health risk assessment caregiver-focused health risk assessment
instrument (e.g., depression inventory) for instrument (e.g., depression inventory) for
the benefit of the patient, with scoring and the benefit of the patient, with scoring and
documentation, per standardized • documentation, per standardized
instrument”. instrument”.
3
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D
Maternal Depression • Modifier use is not required to identify a • Modifier use is not required to identify a
Screenings positive or negative screen. positive or negative screen.
(cont.) • Pediatric providers should bill using code • Pediatric providers should bill using code
96161 and the infant’s ID number. 96161 and the infant’s ID number.
Documentation requirements: Documentation requirements:
• Screening tool used • Screening tool used
• Score • Score
• Time spent • Time spent
• Actions taken including referrals • Actions taken including referrals
• Name and credentials of practitioner who • Name and credentials of practitioner who
performed screening performed screening
• Date of service • Date of service
Pediatric medical providers should document Pediatric medical providers should document
in the pediatric patients record in the pediatric patients record
Ref: DSS PB 2016-63 “Maternal Depression Ref: DSS PB 2016-63 “Maternal Depression
Screenings” Screenings”
Nurse Midwife Covered 100% Covered Covered 100%
Preventive - No co-pay
Non-Preventive - $10 co-pay
Nurse Practitioners Covered 100% Covered Covered 100%
Preventive - No co-pay
Non-Preventive - $10 co-pay
4
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Nutritional Counseling 100% covered. 100% covered. 100% covered.
Nutritional counseling services may be Nutritional counseling services may be Nutritional counseling services may be
performed by: performed by: performed by:
• Independently enrolled physicians, • Independently enrolled physicians, • Independently enrolled physicians,
advanced practice registered nurses and advanced practice registered nurses and advanced practice registered nurses and
physician assistants (as part of an physician assistants (as part of an physician assistants (as part of an
evaluation and management service) evaluation and management service) evaluation and management service)
• CMAP enrolled clinics (including FQHCs • CMAP enrolled clinics (including FQHCs • CMAP enrolled clinics (including FQHCs
and hospital outpatient clinics). and hospital outpatient clinics). and hospital outpatient clinics).
Currently registered dieticians are not eligible Currently registered dieticians are not eligible Currently registered dieticians are not eligible
for CMAP enrollment and therefore are not for CMAP enrollment and therefore are not for CMAP enrollment and therefore are not
able to receive reimbursement for services. able to receive reimbursement for services. able to receive reimbursement for services.
When nutritional counseling is performed in a When nutritional counseling is performed in a When nutritional counseling is performed in a
hospital outpatient clinic, reimbursement is hospital outpatient clinic, reimbursement is hospital outpatient clinic, reimbursement is
limited to the clinic under HCPCS Code limited to the clinic under HCPCS Code limited to the clinic under HCPCS Code
G0463 (clinic visit) and no separate payment G0463 (clinic visit) and no separate payment G0463 (clinic visit) and no separate payment
will be made to the individual provider. will be made to the individual provider. will be made to the individual provider
Obesity Treatment for obesity is not a covered benefit Treatment for obesity is not a covered benefit Treatment for obesity is not a covered benefit
unless caused by an illness or is aggravating unless caused by an illness or is aggravating unless caused by an illness or is aggravating
an illness (including but not limited to cardiac an illness (including but not limited to cardiac an illness (including but not limited to cardiac
and respiratory conditions, diabetes and and respiratory conditions, diabetes and and respiratory conditions, diabetes and
hypertension), and then requires prior hypertension), and then requires prior hypertension), and then requires prior
authorization for medical necessity authorization for medical necessity authorization for medical necessity
Organ Transplants Prior authorization required Prior authorization required Prior authorization required
Physician Office Visits 100% Covered Covered 100% Covered
Preventive office visits - No co-pay
Non-preventive office visits - $10 co-pay
5
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Prescription Drug Covered through DSS (Gainwell Covered through DSS (Gainwell Covered through DSS (Gainwell
Coverage (retail Technologies) Technologies) Technologies)
pharmacy)
Providers may call: Providers may call: Providers may call:
CT Medical Assistance Pharmacy Prior CT Medical Assistance Pharmacy Prior CT Medical Assistance Pharmacy Prior
Authorization Center Authorization Center Authorization Center
1-866-409-8386 (phone) 1-866-409-8386 (phone) 1-866-409-8386 (phone)
1-866-759-4110 (fax) 1-866-759-4110 (fax) 1-866-759-4110 (fax)
1-866-604-3470 (TTY/TDD line) 1-866-604-3470 (TTY/TDD line) 1-866-604-3470 (TTY/TDD line)
Members may call: Members may call: Members may call:
1-866-409-8430 or 1-866-409-8430 or 1-866-409-8430 or
1-860-269-2031 1-860-269-2031 1-860-269-2031
www.ctdssmap.com www.ctdssmap.com www.ctdssmap.com
No co-pays Prescription Medication: No co-pays
Members must use their CONNECT card at Generic - $5 co-pay Members must use their CONNECT card at
the pharmacy to acquire prescriptions Brand - $10 co-pay the pharmacy to acquire prescriptions
Members must use their CONNECT card at
the pharmacy to acquire prescriptions
Preventative Care 100% covered including well child care or The following Preventive Services require no 100% covered including well child care or
EPSDT visits and Immunizations co-pay: EPSDT visits and Immunizations
• Immunizations and the office visit for the
immunization
• WIC evaluations
• Prenatal and postpartum care for women
under age 19
• Regular newborn screening exam in the
hospital or office
• Annual physical exams and lab tests
related to those exams
6
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Procedures requiring prior Tattooing Tattooing Tattooing
authorization regardless of Collagen injections Collagen injections Collagen injections
where the procedure is Insertion and removal of tissue expanders Insertion and removal of tissue expanders Insertion and removal of tissue expanders
performed Dermabrasion Dermabrasion Dermabrasion
Abrasion Abrasion Abrasion
Chemical Peel Chemical Peel Chemical Peel
Cervicoplasty Cervicoplasty Cervicoplasty
Blepharoplasty Blepharoplasty Blepharoplasty
Lipectomy/Liposuction Lipectomy/Liposuction Lipectomy/Liposuction
Destruction of cutaneous vascular lesions Destruction of cutaneous vascular lesions Destruction of cutaneous vascular lesions
Cryotherapy for acne Cryotherapy for acne Cryotherapy for acne
Electrolysis Electrolysis Electrolysis
Mastectomy for gynecomastia Mastectomy for gynecomastia Mastectomy for gynecomastia
Mastopexy Mastopexy Mastopexy
Breast reduction Breast reduction Breast reduction
Breast augmentation Breast augmentation Breast augmentation
Removal/insertion of breast implants Removal/insertion of breast implants Removal/insertion of breast implants
Breast reconstruction Breast reconstruction Breast reconstruction
TMJ related procedures TMJ related procedures TMJ related procedures
Oral splints Oral splint services Oral splint services
Interdental fixation devices Interdental fixation device services Interdental fixation device services
Interdental wiring non-fracture Interdental wiring non-fracture Interdental wiring non-fracture
Canthopexy Canthopexy Canthopexy
Otoplasty Otoplasty Otoplasty
Rhinoplasty Rhinoplasty Rhinoplasty
Septoplasty Septoplasty Septoplasty
Varicose vein injection treatment or stab Varicose vein injection treatment or stab Varicose vein injection treatment or stab
phlebotomy, ligation and division of veins phlebotomy phlebotomy
TMJ related procedures/treatments ligation and division of veins ligation and division of veins
Surgical treatment of Obesity TMJ related procedures/treatments TMJ related procedures/treatments
Insertion/removal of penile implants Surgical treatment of Obesity Surgical treatment of Obesity
Female genital repair Insertion/removal of penile implants Insertion/removal of penile implants
Vaginoplasty for inter-sex state Female genital repair Female genital repair
Procedures related to sterilization reversal Vaginoplasty for inter-sex state Vaginoplasty for inter-sex state
7
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Procedures requiring prior Chemodenervation Procedures related to sterilization reversal Procedures related to sterilization reversal
authorization regardless of Blepharoptosis repair Chemodenervation Chemodenervation
where the procedure is Brow ptosis repair Blepharoptosis repair Blepharoptosis repair
performed Correction lid retraction Brow ptosis repair Brow ptosis repair
(cont.) Procedures to correct myopia, refractive Correction lid retraction Correction lid retraction
errors and surgically induced astigmatism Procedures to correct myopia, refractive Procedures to correct myopia, refractive
Procedures related to corneal prosthetics errors and surgically induced astigmatism errors and surgically induced astigmatism
Genetic testing (see code list under genetic Procedures related to corneal prosthetics Procedures related to corneal prosthetics
testing Genetic testing (see code list under genetic Genetic testing (see code list under genetic
testing category) testing)
Reconstructive surgery Prior authorization required. Not a covered Prior authorization required. Not a covered Prior authorization required. Not a covered
benefit except for surgery related to a benefit except for surgery related to a benefit except for surgery related to a
malignant tumor or some other cases of malignant tumor or some other cases of malignant tumor or some other cases of
surgeries needed to restore normal function. surgeries needed to restore normal function. surgeries needed to restore normal function.
Screening, Brief Covered Codes: 99408 and 99409 Covered Codes: 99408 and 99409
Covered Codes: 99408 and 99409
Intervention and Referral
to Treatment (SBIRT) When rendering SBIRT Services, providers When rendering SBIRT Services, providers
When rendering SBIRT Services, providers
Covered for Primary Care must: must:
must:
Providers (PCPs) Only • Use a validated screening tool • Use a validated screening tool
• Use a validated screening tool
• Utilize evidenced based brief intervention • Utilize evidenced based brief intervention
• Utilize evidenced based brief intervention
guidelines guidelines
guidelines
• Make referrals to treatment as • Make referrals to treatment as
• Make referrals to treatment as
appropriate appropriate
appropriate
For a list of validated screening tools please For a list of validated screening tools please
For a list of validated screening tools please
access the following link: access the following link:
access the following link:
https://www.samhsa.gov/sbirt/resources https://www.samhsa.gov/sbirt/resources
https://www.samhsa.gov/sbirt/resources
Documentation Requirements: Documentation Requirements:
Documentation Requirements:
Provider must document: Provider must document:
Provider must document:
8
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Screening, Brief • The screening tool used • The screening tool used • The screening tool used
Intervention and Referral • The score obtained • The score obtained • The score obtained
to Treatment (SBIRT) • The time spent performing the service • The time spent performing the service • The time spent performing the service
Covered for Primary Care • Any action taken as a result of the • Any action taken as a result of the • Any action taken as a result of the
Providers (PCPs) Only screening (including referrals) screening (including referrals) screening (including referrals)
(cont.) • Name and credentials of practitioner who • Name and credentials of practitioner who • Name and credentials of practitioner who
provided the service provided the service provided the service
• A dated note • A dated note • A dated note
Billing: Billing: Billing:
SBIRT codes may be billed on the same date SBIRT codes may be billed on the same date SBIRT codes may be billed on the same date
of service as an Evaluation and Management of service as an Evaluation and Management of service as an Evaluation and Management
(E&M) code. Modifier 25 should be used to (E&M) code. Modifier 25 should be used to (E&M) code. Modifier 25 should be used to
indicate that the SBIRT services were distinct indicate that the SBIRT services were distinct indicate that the SBIRT services were distinct
and separate from the E & M service with and separate from the E & M service with and separate from the E & M service with
medical record documentation to support. medical record documentation to support. medical record to support.
Reference: DSS PB 2015-79 “Screening, Reference: DSS PB 2015-79 “Screening, Reference: DSS PB 2015-79 “Screening,
Brief Intervention and Referral to Treatment Brief Intervention and Referral to Treatment Brief Intervention and Referral to Treatment
(SBIRT) in Primary Care”. (SBIRT) in Primary Care”. (SBIRT) in Primary Care”.
Smoking and Tobacco Covered 100% when done in physician office Covered 100% when done in physician office
Cessation Counseling
(Individual and Group Individual Counseling: Individual Counseling: Individual Counseling:
Counseling) Covered Codes: 99406, 99407 will require a Covered Codes: 99406, 99407 will require a Covered Codes: 99406, 99407 will require a
tobacco related diagnosis code. primary tobacco related diagnosis code. tobacco related diagnosis code.
Group Counseling: Group Counseling: Group Counseling:
• Covered code 99412 requires a primary • Covered code 99412 requires a primary • Covered code 99412 requires a primary
diagnosis code on the claim to be in the diagnosis code on the claim to be in the diagnosis code on the claim to be in the
following range: Nicotine Dependence following range: Nicotine Dependence following range: Nicotine Dependence
(ICD-10 F17.200 - F17.299) (ICD-10 F17.200 - F17.299) (ICD-10 F17.200 - F17.299)
• PA not required • PA not required • PA not required
9
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Smoking and Tobacco • Group size limited to 3-12 members • Group size limited to 3-12 members • Group size limited to 3-12 members
Cessation Counseling • Limited to 12 sessions per member per • Limited to 12 sessions per member per • Limited to 12 sessions per member per
(Individual and Group episode of care and 24 sessions per episode of care and 24 sessions per episode of care and sessions per
Counseling) member per 365 days. member per 365 days. member per 365 days.
(cont.)
Specialist 100% Coverage Covered 100% Coverage
$10 co-pay applies
No co-pay for allergy injections
Synagis® Prior Authorization Required Prior Authorization Required Medication Not Applicable for Membership
The Synagis Prior Authorization form is The Synagis Prior Authorization form is
located on the HUSKY Health website at: located on the HUSKY Health website at:
www.ct.gov/husky. Once on the home page www.ct.gov/husky. Once on the home page
click Information For Providers → Prior click Information For Providers → Prior
Authorization → Prior Authorization Forms Authorization → Prior Authorization Forms
and Manuals. and Manuals.
Providers may contact the HUSKY Health Providers may contact the HUSKY Health
Synagis Program by calling 1-800-440-5071 Synagis Program by calling 1-800-440-5071
and selecting the prompts for medical and selecting the prompts for medical
authorizations. authorizations.
Out of Network Services Non-covered Non-covered Non-covered
Providers must be an enrolled CMAP Providers must be an enrolled CMAP Providers must be an enrolled CMAP
provider to be reimbursed for services. provider to be reimbursed for services. provider to be reimbursed for services.
Non-emergent care requires prior Non-emergent care requires prior Non-emergent care requires prior
Out of State Care
authorization. authorization. authorization.
Out of Country Care Out of the country care (including emergency Out of the country care (including emergency Out of the country care (including emergency
(with the exception of Puerto care) is not a covered benefit (with the care) is not a covered benefit (with the care) is not a covered benefit (with the
Rico and USA territories of exception of Puerto Rico and other USA exception of Puerto Rico and other USA exception of Puerto Rico and other USA
10
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
American Samoa, Federated territories – where emergency care is territories – where emergency care is territories – where emergency care is
States of Micronesia, Guam, covered). covered). covered).
Midway Islands, Northern
Marina Islands, US Virgin
Islands)
Translation Services 1.800.440.5071 1.800.440.5071 1.800.440.5071
Benefit Exclusions Exclusions: this is a general listing and Exclusions: this is a general listing and
includes but is not limited to the following: Exclusions: this is a general listing and includes but is not limited to the following:
• Infertility treatment (i.e. reversal includes but is not limited to the following: • Infertility treatment
• Infertility treatment (i.e. reversal
• sterilization; artificial insemination; • (i.e. reversal sterilization; artificial
sterilization; artificial insemination; in vitro
in vitro fertilization; fertility drugs) insemination; in vitro fertilization; fertility
fertilization; fertility drugs)
• Drugs used to treat sexual or erectile drugs)
• Weight reduction programs
dysfunction • Drugs used to treat sexual or erectile
• Surgical treatment or hospitalization for dysfunction
• Weight reduction programs
the treatment of morbid obesity except
• All services of a plastic or cosmetic • Weight reduction programs
where prior authorized medically
• nature e.g. hair transplants, electrolysis necessary care, treatment, procedures, • All services of a plastic or cosmetic
services or supplies that are primarily for nature e.g. hair transplants, electrolysis
• Ambulatory BP monitoring
dietary control including, but not limited • Ambulatory BP monitoring
• Care out of the country
to, any exercise weight reduction • Care out of the country
• Services for which prior authorization is programs, whether formal or informal
required and is not obtained • Services for which prior authorization is
• All services of a plastic or cosmetic required and is not obtained
• Services that are considered to be of an nature e.g. hair transplants, electrolysis.
unproven, experimental or research • Services that are considered to be of an
Ambulatory BP monitoring
nature or cosmetic, social, habilitative, unproven, experimental or research
• Services for which prior authorization is nature or cosmetic, social, habilitative,
vocational, recreational or educational
required and is not obtained vocational, recreational or educational
• Services that are not medically necessary
• Services that are considered to be of an • Services that are not medically necessary
• Services required by third parties, such unproven, experimental or research
as school or employers, court ordered • Services required by third parties, such
nature or cosmetic, social, habilitative,
testing, diagnostics, etc. as school or employers, court ordered
vocational, recreational or educational
testing, diagnostics, etc.
• Services not within scope of practitioners • Services that are not medically necessary
scope of practice pursuant to state law
11
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312HUSKY Health Benefits and Prior Authorization Requirements Grid*
Physician
Effective: January 1, 2012
Member Services: 800-859-9889
Authorizations: 800-440-5071 Option #2
Authorization Fax: 203-265-3994
Benefit Exclusions • Nuclear powered pacemakers • Services required by third parties, such • Services not within scope of practitioners
(cont.) • Implantation of nuclear powered as school or employers, court ordered scope of practice pursuant to state law
pacemakers testing, diagnostics, etc. • Nuclear powered pacemakers
• Inpatient charges related to autopsy • Services not within scope of practitioners • Implantation of nuclear powered
scope of practice pursuant to state law pacemakers
• Services beyond what is necessary to
treat the medical problems, • Acupuncture, biofeedback, hypnosis • Inpatient charges related to autopsy
• Services that have nothing to do with the • Nuclear powered pacemakers • Services beyond what is necessary to
illness or problem of the visit. • Implantation of nuclear powered treat the medical problems, Services that
• Services or items for which the provider pacemakers have nothing to do with the illness or
does not usually charge • Inpatient charges related to autopsy problem of the visit.
• Drugs that are not approved by the FDA. • Routine foot care • Services or items for which the provider
does not usually charge Drugs that are
• Services not usually performed by the • Sterilization
not approved by the FDA.
provider • Services beyond what is necessary for
• Services not usually performed by the
• Sterilizations for patients who are under treatment
provider
age twenty-one (21), mentally • Services not related to illness or
incompetent, or institutionalized • Sterilizations for patients who are under
problems at the time of treatment
age twenty-one (21), mentally
• Hysterectomies performed solely for the
incompetent, or institutionalized
purpose of rendering an individual
permanently incapable of reproducing • Hysterectomies performed solely for the
purpose of rendering an individual
permanently incapable of reproducing
12
*Not a Legal Document. Contents provide a general description of HUSKY Health benefits. Coverage subject to change per the CT Department of Social Services (DSS).
Last Update: 03/28/2023 / MMTPE0001-0312You can also read
