Phonetic spelling of accenture Ac-cen-ture. These example sentences are selected automatically from various online news sources to reflect current usage of the word 'accentuate. Comments regarding accenture Post. Ensure that a microphone is installed and that microphone settings are configured correctly. Which is vs cognizant right way to say the number quinhentos in Portuguese? Need even more definitions? Its headquarters is located in Dublin, Ireland.
Open in Separate Window. Provider Directory. Access the Member page for member information about the Kansas Medical Assistance Program, KanCare, and the managed care organizations.
Registered members can login to the secure member portal. Access the Provider page for provider information including publications, interactive tools, and other helpful resources including the Provider Wizard for enrollment. Registered providers can also login to the secure provider portal. Drug Manufacturer. Access the Drug Manufacturer page for drug manufacturer information regarding processing related data in a timely manner.
For claims payment issues related to denial on the basis of medical necessity, we contract with physicians who are not network providers to resolve claims appeals that remain unresolved subsequent to first-level determinations. Amerigroup will abide by the determination of the physician resolving the dispute. You are expected to do the same. We will ensure the physician resolving the dispute will hold the same specialty or a related specialty as the appealing provider.
If you disagree with a previously processed claim or adjustment, you may submit to us a verbal or written request for reconsideration. Due to the nature of appeals, some cannot be accepted verbally and therefore must be submitted in writing.
The following table provides guidance for determining the appropriate submission method. Issue Type Verbal Allowed? You feel you were not paid according to your Verbal is allowed contract, such as at appropriate DRG or per diem rate, fee schedule, Service Case Agreement or appropriate bed type, etc. When inquiring on the status of a claim, if a claim is considered appealable due to no or partial payment, a dispute selection box will display.
Once this box is clicked, a Web form will display for you to complete and submit. If all required fields are completed, you will receive immediate acknowledgement of your submission.
When using the online tool, supporting documentation can be uploaded by use of the attachment feature on the Web dispute form and will attach to the form when submitted.
The payment appeal for reconsideration, whether verbal or written, must be received by Amerigroup within 90 calendar days of the Explanation of Payment EOP paid date or recoupment date. When submitting the appeal verbally or in writing you need to provide: A listing of disputed claims A detailed explanation of the reason for the appeal and Supporting statements for verbal appeals and supporting documentation for written; written appeals should also include a copy of the EOP and an Appeal Request form KS-PM.
The DMD scans the appeal into our document management system, which stamps the image with the received date and the scan date. Once the dispute is scanned, it is logged into the appeal database by the Intake team within the DMD.
Once the appeal is logged, it is routed in the database to the appropriate appeal unit. The appeal associates work appeals by demand, drawing items based on first-in, first-out criteria for routing appeals. The appeal associate will: Review the appeal and determine the next steps needed for the payment appeal Make a final determination if able based on the issue or route to the appropriate functional area s for review and determination Ensure a determination is made within 30 calendar days of the receipt of the payment appeal and Contact you via your preferred method of communication phone, fax, or letter and provide the payment information, if overturned, or if further appeal rights are upheld or partially upheld.
Your preferred method of communication is determined from the PSU agent requesting this information during your call or your selection on the Appeal Request form. If no preference is provided, a letter will be mailed to you If your claim s remains denied or partially paid or you continue to disagree, you may file a second-level appeal in writing. Second-level verbal appeals will not be accepted.
Second-level appeals received after this will be upheld for untimely filing and will not be considered for further payment. You must submit a written second-level dispute to the centralized address for disputes. A more senior appeal associate, or one that did not complete the first-level review, will conduct the second-level review. If additional information is submitted to support payment, the denial is overturned.
Otherwise, the appeal associate conducts the review as per the steps in the first-level process. Once the dispute is reviewed for the second level, the appeal associate will notify you of the decision via your preferred method of communication within 30 calendar days of receipt of the second-level payment appeal. We will apply established clinical criteria to the payment appeal. After review, we will either approve the payment dispute or forward it to the medical director for further review and resolution.
Exhaustion of Dispute Levels In the event of a dispute arising out of this agreement that is not: Within the scope of relationship management set forth in the agreement or Resolved by informal discussions among the parties, the parties shall attempt to negotiate the dispute KS-PM.
The description shall explain the nature of the dispute in detail and set forth a proposed resolution, including a specific time frame within which the parties must act. The party receiving the letter must respond in writing within 30 days with a detailed explanation of its position and a response to the proposed resolution.
Within 30 days of the initiating party receiving this response, principals of the parties who have authority to settle the dispute will meet to discuss the resolution of the dispute. The initiating party shall initiate the scheduling of this negotiation session. In the event the parties are unable to resolve the dispute following the negotiation, a party shall have the right to pursue all available remedies at law or equity, including injunctive relief.
You must submit your written request to the Office of Administrative Hearings so it is received within 33 days of the letter with our final resolution.
You may fax the request to or mail it to: Office of Administrative Hearings S. Kansas Ave. Amerigroup maintains a benefit package and procedural coverage for members at least as comprehensive as the Medicaid State plan. Anesthesia may be either general, wherein the patient is rendered unconscious, or local where a localized area is rendered insensate. Examples of Augmentative and alternative Communication are speech synthesizers and other mechanical and electronic devices.
These Devices give severely speech-impaired people ways to communicate their thoughts with others. Interpretive services, also known as a Telephone device for the Deaf, allows the hearing impaired to use a typewriter-like device to communicate and send messages over the phone to a relay service for translation by an interpreter. This service also includes translation services. Interpretive services, also known as a Telephone Device for the Deaf TDD , lets those who are deaf or hard of hearing: Use a typewriter-like device to communicate and send messages over the phone to a relay service for translation by an interpreter Access translation services Certain limits apply.
Precertification required. Its practitioners, who study hearing and treat those with hearing losses, are audiologists. Employing various testing strategies e.
Covered services include: Hearing aid repairs Fitting of monaural hearing aids Fitting of binaural hearing aids, with documentation on the hearing evaluation form, for: - Children under 21 years of age Medicaid or CHIP - A legally blind adult with significant bilateral hearing loss - A previous binaural hearing aid user or.
If an audiologist diagnoses a hearing loss he or she will provide recommendations to a patient as to what options e. The device consists of a microphone, a battery power supply, an amplifier, and a receiver. KS-PM An occupational requirement for binaural listening A bone anchored hearing aid BAHA when certain medical conditions are met for members who: - Are age 5 or older - Cannot use standard hearing aids due to a medical condition - Have the manual dexterity or the help needed to snap the device onto the abutment - Can maintain proper hygiene where the fixture is kept Certain limits apply.
Use our online precertification look up tool or call our Provider Services team. Covered mental health services are listed below. Not all services are covered for all members. Call Provider Services at to check benefits. For information on notification and precertification requirements, please see Appendix B. Covered services include: Inpatient admission, evaluation and assessment Inpatient psychiatric treatment requires an inpatient psychiatric hospital preadmission screening hour observation Electro-convulsive treatment ECT Treatment in a mental health nursing facility for members under age 21 or over age Psychological and neuropsychological testing Assessments for members who may be seriously and persistently mentally ill SPMI or may have a serious emotional disturbance SED Targeted case management Screening and assessment for risk of inpatient care Treatment planning with members and members families Crisis response and intervention Outpatient therapy and medication management, including: - Evaluation and assessment - Individual, family and group therapy - Medication management and administration.
Traditional outpatient therapy services do not require precertification. Call our Provider Services team for help understanding precertification requirements for any service or use our online precertification look-up tool. Requires a PRTF preadmission screening. Substance use disorder services indicated below will be provided upon member selfreferral and do not require precertification but will be reviewed for medical necessity after a predetermined number of hours or days.
Providers must meet state provider type, location and training requirements. They will: Work with the member, his or her family, and the member s providers to develop and set up the proper care plan Think of the member s needs for social, educational, therapeutic and other nonmedical support services, as well as the strengths and needs of the family Teach the member about self-direction. A cardiac rehabilitation program includes counseling and information about the patient's condition; a supervised exercise program; lifestyle and risk factor modification programs such as smoking cessation, information on nutrition and controlling high blood pressure; and emotional and social support.
Chemotherapy is the use of drugs to kill bacteria, viruses, fungi and most commonly cancer cells. A chemotherapy regimen a treatment plan and schedule usually includes drugs to fight cancer plus drugs to help support completion of the cancer treatment at the full dose on schedule. Radiation therapy is the use of a certain type of energy called ionizing radiation to kill cancer cells and shrink tumors. KS-PM Covered services include: Services to assess, plan, arrange, and monitor the options to meet a person s health care needs Covered services include: Phase II Cardiac Rehab when performed in an outpatient or cardiac rehab unit setting and when the member: - Has completed a recent cardiology consult within three months of starting the cardiac rehab program - Has completed Phase I Cardiac Rehab and - Has had one or more of the following conditions: Acute heart attack within the last three months after an inpatient discharge Coronary bypass surgery within three months after an inpatient discharge Stable angina pectoris chest pain, usually caused by lack of oxygen to the heart muscle within three months after diagnosis Patient Demand Cardiac Monitoring, under certain conditions Certain limits apply.
Precertification is required. Covered services include: Life sustaining therapies as ordered by a qualified health provider, such as - Chemotherapy and - Radiation See the section Medical Services for Members in Waiver Groups for services covered for members in the Technology Assisted TA waiver group. A health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these directors on the function of the nervous system and general health.
There is an emphasis on manual treatments including spinal manipulation or adjustment. Circumcision is the surgical removal of the end of the prepuce of the penis for males of all ages. Circumcision is usually performed at the request of the parents or physician.
There are very few medical indications for this procedure. A carefully designed and executed investigation of the effects of a drug administered to human subjects. The goal is to define the clinical effectiveness and pharmacological effects toxicity, side effects, incompatibilities, or interactions of the substance.
A cochlear implant device is an electronic instrument, part of which is implanted surgically to stimulate auditory nerve fibers, and part of which is worn or carried by the individual to capture, analyze and code sound. The purpose of implanting the device is to provide awareness and identification of sounds and to facilitate communication for persons who are profoundly hearing impaired.
Only crossover services from Medicare are covered for dual-eligible members. Medicare limits apply. Chiropractic services are not covered for Medicaid members. Certain limits apply. Circumcisions are covered. No precertification required. Covered when medically necessary. Precertification may be required. Use our. It is generally performed to improve function, but may also be done to approximate a normal appearance.
This may include but not limited to: cleft palate repair, breast reconstruction, etc. This differs from cosmetic surgery which is performed to reshape normal structures of the body to improve the patient s appearance and self-esteem.
This may include but not limited to: Blepharoplasty, Botox, Breast Augmentation, etc. Dental Preventive, Restorative any diagnostic, preventive, or corrective dental procedures administered by or under the direct personal supervision of a dentist in the practice of the practitioner's profession. Dental Orthodontics a specialty of dentistry concerned with the study and treatment of malocclusions improper bites , which may be a result of tooth irregularity, disproportionate jaw relationships, or both.
Covered services include those services: Ordered by a court of law or other enforcement agency This includes medically necessary services. Covered services include the surgery and related services and supplies to: Correct physical defects from birth, an illness or physical trauma or Perform mastectomy reconstruction for post-cancer treatment Reconstruction is limited to one process per breast per lifetime.
Covered services include: For members age 20 and younger: Exam and cleaning every six months X-rays when required for proper treatment and diagnosis Fillings, tooth restoration, extractions and other treatments for children who qualify Topical application of fluoride of three treatments per member per calendar year when billed by a professional provider and three treatments per 12 months for the same member when billed by a dental provider.
These services are limited to crisis exception scenarios according to the member s assessed level of service need as specified in the member s plan of care. These are accepted dental procedures that can include diagnostic, prophylactic, and restorative care, as well as anesthesia services provided in the dentist s office.
Crisis exception scenarios may also allow for the purchase, adjustment, and repair of dentures. Diabetic self-management training: a program intended to educate members in the successful self-management of diabetes.
The program includes instructions in self-monitoring of blood glucose: education about diet and exercise; an insulin treatment plan developed specifically for the patient who is insulin-dependent; and motivation for patients to use the skills for selfmanagement. Diabetic supplies: items necessary for the self-testing of glucose levels of the blood Note: Dental providers can access the Scion Dental provider manual on our provider website for a full list of covered services and codes.
Covered services include home health services that: Help eligible members manage their diabetes in a home setting instead of a nursing facility or other institution Are reasonable and medically needed Do not duplicate other resources offered Diabetic supplies refer to Medical Supplies section for details KS-PM. These may include but are not limited to syringes, lancets, needles, etc. Nuclear mmedicine: procedures and tests performed by a radioisotope laboratory utilizing radioactive materials as required for diagnosis and treatment of patients.
KS-PM Lab and radiology Covered services include: Obtaining and testing of blood samples, hematology, blood chemistry, microbiology and other diagnostic testing, using physical specimens such as tissue, urine or blood Nuclear medicine Procedures and tests performed by a radioisotope lab, using radioisotope materials as required for diagnosis and treatment of patients e. A medical necessity form must accompany the claim when billing for a cytogenetic study for a pregnant woman older than 21 years of age.
Laboratory services performed by the Kansas Department of Health and Environment are excluded from the Amerigroup contract with Kansas but may be covered by fee-for-service for Medicaid-eligible persons.
A routine obstetrical OB sonogram will not be covered if the sonogram is performed solely to determine the fetal sex or to provide parents a view and photograph of the fetus. See Additional Information. Laboratory procedures performed on inpatients are content of service of the DRG reimbursement to the hospital and should not be billed by either the independent laboratory or hospital.
Urinalysis UA is considered content of service of the reimbursement to the physician for antepartum care when the UA is obtained for a diagnosis of pregnancy.
Infertility services, including any tests, procedures, or drugs related to infertility services, are not covered. For all hospitals except critical access hospitals, outpatient procedures including, but not limited to, surgery, X- rays and EKGs provided within three days of a hospital admission for the same or similar diagnosis are considered content of services.
Complications from an outpatient sterilization resulting in an inpatient admission are the only exception to this policy. A freestanding clinic is a facility that operates solely for the provision of dialysis services. For locations other than freestanding, the services are rendered either in an inpatient or outpatient hospital setting. KS-PM Precertification may be required. Covered services for persons with End Stage Renal Disease ESRD or acute renal failure include: Life-sustaining therapies, including renal dialysis as ordered by a qualified network provider Treatment for conditions directly related to ESRD until the member is eligible for Medicare Training and supervision of personnel and clients for home dialysis, medical care and treatment, including home dialysis helpers Supplies and equipment for home dialysis Diagnostic lab work Treatment for anemia and Intravenous drugs Precertification is required.
DME does not include disposable medical supplies. Teaching and training services also referred to as educational services provide knowledge essential to the member's condition and participation in his or her own treatment.
Amerigroup uses the state formulary and preferred drug list. Mental health medications are not included on the Kansas preferred drug list. Therapeutic classes not listed are not part of the PDL and will continue to be covered as they always have for the Kansas Medical Assistance Pharmacy Program. Medically needed nutritional supplements for infants Legend prenatal vitamins for members who are pregnant; includes up to three months postpartum coverage for women who are breastfeeding Prescription weight loss drugs, smoking cessation products and benzodiazepines when medically needed Medically needed over-the-counter products with a prescription, including diabetic supplies, glucometers and blood glucose strips Precertification may be required if permitted by Kansas regulation.
Precertification is required for most DME. Waiver members will have access to an added list of DME based on the waiver. Covered services include: Health education for heart disease Medical nutrition therapy provided by a certified dietician for members age 20 and younger who are in an eligible program, when referred by an EPSDT provider.
Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior and create environments that support good health practices. While services provided in schools by Early Childhood Intervention providers and Local Education Agencies are not covered by Amerigroup but are reimbursed by the state, Amerigroup covers: School-based services provided by local health departments Covered services provided in schools by community mental health centers Covered services in situations where a child s course of treatment is interrupted due to school breaks, after school hours or during summer months KAN BE HEALTHY Early Periodic Screening, Diagnosis and Treatment EPSDT programs cover screening and diagnostic services to determine physical or mental defects in recipients under age 21, as well as health care and other measures to correct or improve any defects and chronic conditions discovered.
Well-baby and well-child care services include regular or preventive diagnostic and treatment services necessary to ensure the health of babies, children and adolescents as defined by the state.
Covered services include: Complete medical screens, including: - Complete health and development history with assessment for both physical and mental health development - Complete, unclothed physical exam - Proper immunizations shots according to Advisory Committee on Immunization Practices ACIP ; immunizations must be reviewed at each screen and brought up-to-date as necessary and according to age and health history - Lab tests, including lead blood level assessment - Health education - Vision screening - Hearing screening - Dental screenings Other needed health care or diagnostic screens or exams Certain limits apply.
Emergency services are inpatient and outpatient services that are furnished by a provider qualified to furnish emergency services and that are needed to evaluate or stabilize an emergency medical condition; may include Behavioral Health Emergency Room Services. Enteral nutrition, also called tube feeding, is a way to provide food through a tube placed in the nose, the stomach or the small intestine. Precertification must be obtained from Amerigroup in these cases.
Covered services include emergency services given by a network or out-of-network provider under these conditions: The member has an emergency medical condition; this includes cases in which the absence of getting medical care right away would not have had the outcome defined as an emergency medical condition or Amerigroup tells the member to get emergency services The attending emergency physician or the provider treating the member will decide when he or she is stable for transfer or discharge.
Precertification is not required. Covered services include: DME, home health, home infusion and medical supply services provided in the home Medically needed tube-fed products and supplies for eligible adults Medically needed oral and tube-fed enteral nutrition for eligible children age 20 and younger Repairs and replacement parts for tubedelivered enteral nutrition equipment when - Owned by the patient - The equipment is less than five years old and no longer under warranty Certain limits apply.
These members may have access to added benefits: Technology Assisted waiver participants Hospice and nursing facility residents Family planning services are covered for members of childbearing age who choose to delay or prevent pregnancy. Services include: Medical history and physical exam.
Members may choose a network or non-network provider. There has been a physical examination, pretest counseling, and other diagnostic studies.
The determination of the diagnosis in the absence of such testing remains uncertain and would impact the care and management of the individual on whom the testing is performed. Professional services: services rendered by primary care providers, specialists, nurse practitioners, physician assistants, and other nonancillary providers. KS-PM Certain limits apply. Covered services must be provided by an Amerigroup network provider; referrals may be needed for certain services Covered services include: Specialty physician services such as Screening Brief Intervention and Referral to Treatment SBIRT Prenatal health promotion and methods to reduce risks as medically needed Screening, diagnosis and treatment of sexually transmitted diseases as medically needed HIV testing and counseling as medically needed.
Home health skilled nursing services are differentiated from private duty nursing services in that skilled nursing services are supplied on an intermittent basis, generally through a home health agency.
Services provided to the member in the home by an LPN. Covered services include: DME, home health, home infusion and medical supply services provided in the home Home health skilled services provided for acute, intermittent, short-term and intensive courses of treatment, including: - Full skilled nursing services - Brief skilled nursing visit if one of the following is performed: An injection Blood draw or Placement of medicine in containers Home infusion therapy Limited high-risk obstetrical services for a medical diagnosis that complicates pregnancy and may result in poor outcomes for the mother, unborn child or newborn Physical, occupational, or speech and audiology services given in the home for members age 20 and younger when the member is not able to get these services in the local community Certain limits apply.
Precertification is. Hospice care must be reasonable and necessary to manage the member s illness and conditions. TPN may be given to people who are not able to absorb nutrients through the intestinal tract or to those undergoing highdose chemotherapy or radiation and bone marrow transplants Hospice care or palliative care is any form of medical care or treatment that concentrates on reducing the severity of the symptoms of a disease or slows its progress rather than providing a cure.
It aims at improving quality of life by reducing or eliminating pain and other physical symptoms, enabling the patient to ease or resolve psychological and spiritual problems, and supporting the partner and family. Hospice care is multidisciplinary and includes home visits, professional medical help available on call, teaching and emotional support of the family, and physical care of the client.
Some hospice programs provide care in a center as well as in the home. Hyperbaric oxygen HBO therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. Covered services include: Nursing services Medical social services Counseling services for patients and their families, including dietary, spiritual and bereavement Continuous home care when given to keep a person at home during a medical crisis; a minimum of eight hours of care during a hour day, starting and ending at midnight, must be given All drugs related to the patient s terminal illness Members getting hospice care may be eligible for Home- and Community-Based Services; see the section Medical Services for Members in Waiver Groups for details.
Precertification is required for all services rendered by a Hospice provider, including inpatient services rendered at nursing facilities. This therapy is used to treat: Carbon monoxide poisoning Air embolism Smoke inhalation Acute cyanide poisoning Decompression sickness and Certain cases of blood loss or anemia.
An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight.
The physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. Physicians should use a hour period as a benchmark, i.
Inpatient hospital services include bed and board, nursing services, diagnostic or therapeutic services, and medical or surgical services. Immunizations for members age 18 and younger are covered through the Vaccines for Children VFC Amerigroup covers the administration fees associated with these immunizations.
The SL modifier should not be used unless the State declares a vaccine shortage. Inpatient hospital services include: Bed and board Nursing services Diagnostic or therapeutic services and Medical or surgical services Certain limits apply. Precertification is required for all services rendered by an inpatient hospital other than emergency services. Only services provided by private intermediate care facilities for the mentally retarded are eligible for coverage.
Members must have an approved level of care by the state to access this service. One routine visit per month is covered in. These may include but are not limited to dressing materials, suction tubing, syringes, incontinence supplies, ostomy supplies and burn pressure garments.
A facility which meets specific regulatory certification requirements which primarily provide inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital Kansas Medicaid does not make a distinction between skilled nursing facilities and nursing facilities. Additionally, other services that are covered benefits, like hospice, home health, DME, etc.
Members in some waiver groups will be eligible for added services. Covered services include: Services provided at licensed nursing facilities when the individual has been determined to meet the clinical and financial eligibility criteria for nursing facility level of care or when Amerigroup determines the nursing facility level of care criteria has been satisfied for a member requiring a short-term placement for skilled or physical rehabilitation or other services.
Short-term placements may occur for any adult member. Only one nursing facility will be paid for the same member and the same date of service. Nursing facilities will not be reimbursed for providing dental services. Services in nursing facilities for mental health are not covered under the state's contract with Amerigroup for individuals aged 22 through 64, but may be covered under fee-for-service for Medicaid-eligible persons.
A maximum of 18 home leave days for NFs are allowed per calendar year. Observation is an outpatient service, including behavioral and medical. When an inpatient hospital admission follows a psychiatric observation stay, the observation days are content of service of the inpatient reimbursement. Services for the sole purpose of pain management are not covered. Podiatry is the diagnosis, treatment, and prevention of conditions of the human feet.
Preventative health examinations and services serve to deter the occurrence of an adverse condition or disease. This may include but is not limited to a routine physical, an examination of the bodily functions and condition of an individual; generally, patient symptomatology or complaints do not precipitate the visit.
Orthotics: a support, brace or splint used to support, align, prevent, or correct the function of movable parts of the body. Shoe inserts are orthotics that are intended to correct an abnormal, or irregular walking pattern, by altering slightly the angles at which the foot strikes a walking or running surface.
Other orthotics include neck braces, lumbosacral supports, knee braces and KS-PM Covered services include: Those that can be properly given on an outpatient or ambulatory basis such as: - Preventive care - Lab and radiology services - Therapies - Ambulatory surgery Observation services, if needed to decide whether a member should be admitted to the hospital Certain limits apply. Precertification required for most services other than lab services. Covered services include but are not limited to: Implantable Infusion Pumps Implantable Drug Delivery Systems when medically needed for cancer pain and spasms related to cancer Precertification is required.
Medicaid members under age 21 and CHIP members under age 19 are eligible to receive: Podiatry services Medically needed consult services and Medically needed elective surgery precertification required Covered services include: Routine physicals Physical exams when the exam is one or more of the following: - A screening exam covered by the EPSDT program for adults age 18 up to age 21 - An annual exam for members with disabilities - A screening Pap smear, mammogram or prostate exam Covered services include: Replacement, corrective or supportive devices prescribed by a physician or other licensed practitioner to: - Artificially replace a missing portion of the body - Prevent or correct physical deformity or malfunction or - Support a weak or deformed portion of the body.
Prosthetics: Prosthetic devices are artificial devices or appliances that replace all or part of a permanently inoperative or missing body part. Physical Therapy PT : the treatment of disease by physical and mechanical means as massage, regulated exercise, water, light, heat, and electricity ; also called physiotherapy. It is a branch of treatment that uses physical means to relieve pain, regain range of movement, restore muscle strength and return patients to normal activities of daily living.
RT also includes pulmonary rehabilitation designed for people who have chronic lung disease; the primary goal is to achieve and maintain the maximum level of independence and functioning. Although most pulmonary rehabilitation programs focus on the needs of people who have COPD, people with other types of lung disease may benefit as well.
Covered services include: Physical therapy Occupational therapy Speech therapy Respiratory therapy These services must: Be prescribed by the member s PCP or attending physician for an acute condition Make it possible for the member to improve as a result of rehab Precertification is required. Members in some waiver groups may be eligible for added services. These covered services are given to members without referrals from their Primary Care Provider PCP or precertification from Amerigroup.
These services can be accessed from a provider other than a member s PCP. Also includes items such as nicotine patches, gum or other nonsmoking aids. Covered products include: Nicotine patches Prescription medication to manage withdrawal and other effects. Nicotine gum, oral nicotine and nasal inhalers Nicotine inhalers and Chantix are covered for maximum of 24 weeks; all other smoking cessation products are covered for a maximum of 12 weeks of therapy per year Amerigroup covers sterilizations and hysterectomies in accordance with federal CMS requirements.
Sterilization is covered only if: A person is at least 21 years old at the time consent is given A person is not mentally incompetent A person has voluntarily given written informed consent and At least 30 days, but not more than days, have passed between the date of informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery - An individual may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery if at least 72 hours have passed since he or she gave informed consent for the sterilization.
Sterilization by hysterectomy is covered only if:. Emergency response means responding immediately at the BLS or ALS level of service to a call or the equivalent in areas without a call system.
An immediate response is one in which the ambulance entity begins as quickly as possible to take the steps necessary to respond to the call. Includes mileage, supplies, services and medication administration as required. Also includes rotary wing ambulance helicopter , fixed wing air ambulance aircraft , and specialty care transport which is ground ambulance supplying services beyond the level of EMTparamedic such as nursing, respiratory care, emergency medicine or cardiovascular care; to include behavioral health ambulance.
Nonemergency: a ride, or reimbursement for a ride, provided so that a member with no other transportation resources can receive services from a medical provider.
Nonemergency transportation does not include transportation provided on an emergency basis, such as trips to the emergency room in life threatening situations; may include but is not limited to taxi, bus or van transport.
Nonemergency nonambulance transportation to and from covered medical services is covered; based on need, these forms of transportation may include: Taxi Sedan Wheelchair van Public transportation Gas reimbursement Ambulance transportation to and from covered medical services are covered when the transportation is: Within the scope of an eligible member s medical care program Medically needed based on the member s condition at the time of the ambulance trip and as recorded in the member s record Right for the member s actual medical need Coverage is limited to medically needed ambulance transportation when a member cannot be safely or legally transported any other way.
If a member can safely travel by car, van, taxi or other means, the ambulance trip is not medically needed, and the ambulance service is not covered. Ground or water ambulance services Services are covered when the eligible member: Has an emergency medical need for transportation Needs medical care during the trip Must be taken by stretcher or gurney or Needs to be transferred from one hospital to another and the transferring or discharging hospital does not offer the right facilities for the medical services the member needs Ambulance coverage includes: Specialty care transport, which is hospitalto-hospital transport by ground ambulance of a critically injured or ill member at a level of service beyond the scope of a paramedic Air ambulance rotary or fixed-wing aircraft services.
Glaucoma screening: Glaucoma represents a family of eye diseases commonly associated with optic nerve KS-PM In certain cases, air ambulance is covered when it is decided it is less costly than ground ambulance. Air ambulance transportation for hospital transfers is covered only if transportation by ground ambulance would endanger the member s life or health. These services are covered for members diagnosed with certain medical conditions. Routine examinations: Vision services include visual examination; fitting, dispensing and adjustment of eyeglasses; follow-up examinations; and contact lenses.
Glaucoma screening: Glaucoma represents a family of eye diseases commonly associated with optic nerve damage and visual field changes Precertification is required.
Covered services include: Eye exams and refraction and fitting services: - Once every 12 months for members age 21 and older - Once every 12 months for members age 20 and younger or more frequently if medically necessary Glasses are covered: - Once every 12 months for members age 21 and older - Once every 12 months for members age 20 and younger or as medically necessary up to three pairs per year Repair and adjustment of glasses are KS-PM.
Contact lenses and replacements are covered with prior authorization for the following medical necessity must be present : - Monocular aphakia - Bullous keratopathy - Keratoconus - Corneal transplant - Anisometropia of more than three diopters of difference that is causing vision distortion and cannot be corrected with glasses Contact lens adaptation includes six months of care.
Contact lens replacement includes neutralization per lens. Contact lenses are noncovered for cosmetic purposes or for athletic participation. Contact sunglasses, colored or tinted of any kind, are noncovered. Contact lens fitting is allowed once per lifetime when contacts are first prescribed. Subsequent fittings will be considered if a new type of contact lens is being prescribed and fitted. Members may not pay extra to upgrade your glasses or frames. Services must: Be obtained from an Amerigroup network provider Include follow-up treatment for any problems found Precertification is required.
Covered services include: Annual mammogram screening for women age 40 and older; precertification is required for women age 39 and younger Annual Pap test Abortion is covered only: If the pregnancy is the result of an act of rape or incest, or In the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a lifeendangering physical condition caused by or arising from the pregnancy itself, that would as certified by a physician, place the KS-PM.
Spontaneous abortion miscarriage is covered. The state decides who is eligible for these programs. This service is designed to provide children with Autism Spectrum Disorders ASD early intensive intervention treatment and to allow primary caregivers to receive needed support through services.
Children receiving waiver services must be diagnosed using an approved autism-specific screening tool and meet the functional criteria using the Vineland II Survey Interview Form. Covered services include: Clinical and therapeutic consult services Intensive Individual Support IIS Respite services for a family member who serves as the primary caregiver to the member and is not paid to provide these services Parent support and training Family adjustment counseling Interpersonal communication therapy Certain limits apply: Clinical and therapeutic consult services: max.
Parent support and training services: max. All Autism Waiver services require precertification. All services require prior authorization. Money Follows the Person Grant services for those in the TBI Waiver: Transition service Transition coordination service Community bridge building Community transition counseling and Assistive services Precertification is required for all services.
FE Waiver Services: These services include: Adult day care Assistive technology crisis exception only Attendant care Comprehensive support crisis exception only for members who: - Live alone or. Certain limits apply: Adult day care: No more than two units of one to five hours of adult day care services will be covered over a hour period.
All services require precertification. All SED waiver services require precertification. The variety of services described are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those beneficiaries with the desire to live outside of an institution.
CDDO staff determines an individual s eligibility for the waiver. Assistive Services Assistive Services Assistive services are supports or items that meet a person s assessed needs by improving or promoting the person s: Health Independence Productivity Integration into the community These services must: Increase the member s ability to live independently Increase or enhance the member s productivity or Improve the member s health and welfare Examples include but are not limited to wheelchair modifications, ramps, lifts, assistive technology, and accessibility-related modifications to bathroom and kitchens.
Certain limits apply: Purchase or rental of used assistive technology is limited to those items not covered by Amerigroup as a standard Medicaid or KAN Be Healthy benefit. R by a physician, and identified on the member s plan of care. Wheelchair modifications must be specific to the individual member s needs and not utilized as general agency equipment.
Van lifts purchased must meet any engineering and safety standards recognized by the Secretary of the U. Department of Transportation. Van lifts can only be installed in family vehicles or vehicles owned or leased by the member. A van lift must not be installed in an agency vehicle unless an informed exception is made by Amerigroup.
Communication devices will only be purchased when recommended by a speech pathologist. Communication devices can only be accessed after a member is no longer eligible to receive services through the local education system. Communication devices are purchased for use by the member only not for use as agency equipment.
Home modifications must not increase the finished square footage of an existing structure. Home modifications must not be accessed for new construction. Home modifications must be used on property the member leases or owns or in the family home if still living there, but not on agency owned and operated property unless an informed exception is made by Amerigroup.
Assistive services require at least two bids from companies qualified by or affiliated with the CDDO. The bids must be submitted and reviewed prior to the approval of the prior authorization. All assistive services must have prior authorization. The member or responsible party must arrange for the purchase. Work must not be initiated until approval has been obtained through prior authorization. Note: Responsible party is defined as the member s guardian or someone appointed by the member or guardian who is not a paid provider of services for the member.
Supported employment activities cannot be provided until the member has applied to the local Rehabilitation Services office. Coverage of employment-related activities under the waiver will be suspended until the case is closed by Rehabilitation Services.
If the member is determined ineligible for vocational training through Rehabilitation Services, then this service can be provided as a waiver service. Documentation of the determination. Day services providers may provide up to a maximum of eight hours or 32 units of service for a consumer on any given day, and cannot exceed 25 hours or units per week.
Maximum of units per plan of care. Beneficiaries must be out of their home a minimum of five hours per day or a total of 25 hours per week unless one of the following applies: A person operates a homebased business A person is unable to be out of their home due to medical necessity or significant physical limitations related to frailty which a physician has provided current, written verification for the necessity to remain in the house Note: Current is within the past days and must be reviewed at least every days thereafter.
KS-PM Medical Alert This monitoring system provides support to members who have a medical need that could be critical at any time. Examples of medical needs that may require this service are: Quadriplegia Head injury Diabetes that is hard to control Severe heart conditions, Severe convulsive disorders Severe chronic obstructive pulmonary disease.
This service must be billed at a monthly rate. Examples of qualified providers of this service include, but are not limited to, agencies, hospitals, and emergency transportation service companies.
Residential Supports cannot be provided in the member s family home. However, this service may be provided to a member in his or her own home or apartment as long as the community service provider is licensed by KDADS to provide this service. Residential Supports for children cannot be provided in a home where more than two members funded with State or Medicaid money reside. Children who receive Residential Supports with a nonrelated family must be at least 5 but no older than 21 years of age eligibility ends on the 22 nd birthday.
Residential Supports is paid on a daily rate where one unit equals one day. Residential Supports for adults can serve no more than eight individuals in one home. Supported Employment must be provided away from the member s place of residence.
Supported employment services must not. Coverage under the waiver will be suspended until the case is closed by Rehabilitation Services. If the member is determined ineligible for vocational training then this service can be provided as a waiver service. Documentation of this determination must be maintained in the member s file.
Case managers are responsible for ensuring that vocational rehabilitation services are NOT being duplicated for waiver members Supported Home Care: These services are provided by an agency to help an individual who lives someone meeting the definition of family or is in one of these settings: A child, age 5 to 21, who is in the custody of KDADs but is not living with immediate family A child, age 15 or older, who lives with a person who is not immediate family and has not been appointed legal guardian or custodian Individual one-to-one services provide direct help with: Daily living and personal adjustment Attendant care Taking medicines usually taken on one s own Accessing medical care Supervision Reporting changes in an individual s condition and needs Extending therapy services Walking and exercising Household services needed for health care at home or performed along with KS-PM.
Educational services must be equal to or greater than the seven hours per day in which school is regularly in session. These hours do not have to be consecutive hours. The minimum number of hours required for kindergarten students is seven hours per day for those eligible for full-day kindergarten services and three-and-ahalf hours per day for those eligible for half-day kindergarten Members receiving Supportive Home Care cannot also receive Residential Supports SHC services are limited to a maximum of an average eight hours per day in any given month.
The services are only for the activities described previously unless sufficient rationale is provided for hours in excess of an average of eight hours per day. The absolute maximum allowable Supportive Home Care is an average of twelve hours per day in any given month.
A member can receive SHC services from more than one worker, but no more than one worker can be paid for services at any given time of day. SHC services should not be used for lawn care, snow removal, shopping, ordinary housekeeping, or meal preparation during the times when the person with whom the member lives would normally prepare a meal.
SHC retainer services can be billed up to a maximum of 14 days per calendar year, at a level consistent with the approved plan of care. These services are provided. They are provided to assist members who selfdirect their care with retaining their current care provider s. Wellness Monitoring Wellness monitoring requires a registered nurse RN to review a member s level of wellness. The RN decides if the member is: Using medical health services properly, as recommended by the physician Keeping a stable health status at home without frequent skilled nursing help Wellness monitoring includes checking or monitoring: Orientation to surroundings Skin characteristics Edema Personal hygiene Blood pressure Respiration Pulse Adjustments to medicine KS-PM Certain limits apply: The member lives in a noninstitutional setting.
The member is able to maintain independence with Wellness Monitoring visits no more than every 60 days. Direct medical intervention is obtained through the appropriate medical provider and is NOT funded by this program.
Wellness Monitoring must be provided by a licensed RN in private employment or employed by a home health agency, local health department, CDDO, or affiliate. The RN who provides Wellness Monitoring may also provide nursing care and supervise medical attendants. Wellness Monitoring is not covered when provided within the same day period as skilled nursing services provided by a home health agency.
Only one visit by an RN, per 60 days, is covered. The Wellness Monitoring RN must. With the member s consent, this may also be forwarded to the primary care physician as appropropriate. Written documentation is required for services provided and billed to Amerigroup. KS-PM Consideration will be made when documentation submitted with the claim indicates the medical need.
This limitation will be monitored postpay. Certain limits apply: The maximum allowable units per member are units per calendar year. Prior authorization must be requested prior to services being reimbursed for additional TCM units The case manager would assist the member in obtaining appropriate housing, getting utilities established and other activities necessary for the beneficiary to move from an institutional setting to a community- based setting.
TCM may be limited, at the choice for the person directing and controlling the services, to reviewing the services on a regular basis to ensure the member s. Overnight Respite Care Overnight respite is temporary care provided to a beneficiary to: Relieve the beneficiary s family member who serves an unpaid primary caregiver KS-PM Allow family members to have periods of relief for vacations, holidays and scheduled time off This service is available to waiver members who have a family member who serves as the primary caregiver who is not paid to provide any waiver service for the member.
Overnight Respite may only be provided to members living with a person immediately related to the member. Immediate family members are parents including adoptive parents , grandparents, spouses, aunts, uncles, sisters, brothers, first cousins and any stepfamily relationships.
Overnight Respite cannot be provided by a member s spouse or by a parent of a member who is a minor child under 18 years of age. A member can receive Overnight Respite services from more than one worker, but no more than one worker can be paid for services at any given time of day. An Overnight Respite provider cannot be paid to provide services to more than one member at any given time of day.
Overnight Respite is limited to 60 days, per member, per calendar year. Overnight Respite is billed on a daily rate, and the services provided must meet the member s support needs for a minimum of eight and maximum of 12 hours.
A self-direct option may be chosen for. If the member is not capable of providing selfdirection, the member s guardian or someone acting on his or her behalf may choose.
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Covered mental health services are listed below. Not all services are covered for all members. Call Provider Services at to check benefits. For information on notification and. Other services require prior notification as well as authorization and medical necessity review after specified limits are reached. Traditional outpatient therapy services do not require precertification.
Call our Provider Services team for help understanding precertification requirements for any service or use our online precertification look-up tool.
Requires a PRTF preadmission screening. For information on precertification requirements, please see Appendix B. Substance use disorder services indicated below will be provided upon member self- referral and do not require precertification but will be reviewed for medical necessity after a predetermined number of hours or days. Providers must meet state provider type, location and training requirements. Blood administration involves the introduction of blood or blood plasma into a vein or artery.
Service coordination is designed to give support and respond to the needs of persons who have long-lasting limits caused by:. This assessment includes:. Case managers and service coordinators will use information from the assessment to set up a member-centered plan of care.
They will:. A cardiac rehabilitation program includes counseling and information about the patient's condition; a supervised exercise program; lifestyle and risk factor. There is an emphasis on manual treatments including spinal manipulation or adjustment.
Only crossover services from Medicare are covered for dual-eligible members. Medicare limits apply. Chiropractic services are not covered for Medicaid members. Circumcision is usually performed at the request of the parents or physician. There are very few medical indications for this procedure. The goal is to define the clinical effectiveness and pharmacological effects toxicity, side effects, incompatibilities, or interactions of the substance.
The purpose of implanting the device is to provide awareness and identification of sounds and to facilitate communication for persons who are profoundly hearing impaired. Reconstructive surgery is performed on abnormal structures of the body, caused by birth defects, developmental abnormalities, trauma or injury, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. This may include but not limited to: cleft palate repair, breast reconstruction, etc.
This may include but not limited to: Blepharoplasty, Botox, Breast Augmentation, etc. Members in the Frail Elderly waiver may be eligible for oral health services that are not otherwise covered for Medicaid adults. These services are limited to crisis exception.
Crisis exception scenarios may also allow for the purchase, adjustment, and repair of dentures. Note: Dental providers can access the Scion Dental provider manual on our provider website for a full list of covered services and codes.
The program includes instructions in self-monitoring of blood glucose: education about diet and exercise; an insulin treatment plan developed specifically for the patient who is insulin-dependent; and motivation for patients to use the skills for self- management. These may include but are not limited to syringes, lancets, needles, etc. Reason for exclusion or termination.. At a time when there is no automatic right to change, you or the claims representative may request a change of health care provider if either believes that the health care provider is.
A participating Primary Care Provider PCP may not seek or request to terminate their relationship with a Member, or transfer a Member to another Provider of care based upon the. Reason for exclusion or termination.. At a time when there is no automatic right to change, you or the claims representative may request a change of health care provider if either believes that the health care provider is.
A participating Primary Care Provider PCP may not seek or request to terminate their relationship with a Member, or transfer a Member to another Provider of care based upon the. As a member of Community Care, you have the right to choose a primary care provider PCP in the provider network and receive the services listed in your care plan when you need them. MCO contracts with providers Care System or a collaborative primary care providers affiliated with behavioral health providers with delegated management of care to the provider Care.
In submtnlng this claim lor payment from federal funds, I certify that: 1 the Information on this fonn Is true, accurate and complete; 2 Ihave familiarized myself with all applicable. Kansas n providers. The health intervention has the purpose of treating a medical condition. The following definitions shall apply to these terms only as they are used above. Partially controlled observational studies and uncontrolled clinical series may be considered to be suggestive, but shall not by themselves be considered to demonstrate a causal relationship unless the magnitude of the effect observed exceeds anything that could be explained either by the natural history of the medical condition or potential experimental biases.
Each new intervention for which clinical trials have not been conducted because of epidemiological reasons, including rare or new diseases or orphan populations, shall be evaluated on the basis of professional standards of care or expert opinion as described below in paragraph I. Coverage of existing interventions shall not be denied solely on the basis that there is an absence of conclusive scientific evidence.
In document Provider Manual. Related documents. Provider Manual. Maryland HealthChoice Program n providers. Family Care Partnership Member Handbook. Member Handbook. Integrated Care System Partnerships.
Best Practices Symposium January 28, Amerigroup Community Care providers.