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Benefit
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HMO Personal Care Plan
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Point-of-Service Personal Care Plan
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HMO Open Access
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Point-of-Service Open Access
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Allergy Testing
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• Limited to a maximum of $315 every two (2) calendar years for: 1.) allergenic
extracts (or RAST allergen specific testing); 2.) drug, biological or venom
sensitivity. Testing that exceeds this maximum is the member’s
responsibility.
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Ambulance |
• Coverage for medical emergencies without pre-authorization.
• Land or air ambulance/medical transportation that is not due to an emergency
requires pre-authorization.
• If transport is required from one facility to another on a weekend or
holiday, transport must be provided by a participating service. Providers are
also required to contact ConnectiCare’s Notification Line at 1-888-261-2273 to
advise ConnectiCare of the transport.
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Blood & Blood Products
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• Coverage for receipt of blood and for autologous blood transfusions for the
following procedures, when the procedures are covered benefits:
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- Bilateral knee replacement
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- Hysterectomy
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- Coronary Artery Bypass Graft (CABG)
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- Laminectomy/spinal fusion
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- Facial reconstruction
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- Prostatectomy
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- Heart valve replacement
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- Total hip replacement
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Custodial Care
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• Custodial care is not a covered benefit. It includes services and supplies furnished to a member who
has a medical condition that is chronic or non-acute and which, at our discretion, either:
• Are furnished primarily to assist the patient in maintaining activities of daily living, whether or not the
Member is disabled, including, but not limited to, bathing, dressing, walking, eating, toileting and maintaining personal hygiene or
• Can be provided safely by persons who are not medically skilled, with a reasonable amount of instruction, including,
but not limited to, supervision in taking medication, homemaking, supervision of the patient who is unsafe to be left
alone, and maintenance of bladder catheters, tracheotomies, colostomies/ileostomies and intravenous infusions (such as TPN)
and oral or nasal suctioning. This would also include chronic ventilator care.
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DME & Disposable Supplies
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• Coverage varies by plan.
• DME, orthotics & prosthetics must be obtained from a participating
commercial DME vendor unless otherwise authorized by ConnectiCare and
pre-authorization must be obtained through ConnectiCare.
• HCPCS coding is required on claims.
• See the CT Appendix for a listing of DME that requires pre-authorization.
• The rental and/or purchase of CPAP and BI-PAP machines must be done through
our preferred vendors.
Note: The list of covered DME and disposable supplies is reviewed
periodically and subject to change at the sole discretion of
ConnectiCare.
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Genetic Analysis & Testing
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All genetic testing requires pre-authorization, with the exception of the
following:
• Routine chromosomal analysis (e.g., peripheral blood, tissue culture,
chorionic villous sampling, amniocentesis) - CPT 83890 - 83914, billed with Modifier 8A or ICD-9 diagnosis codes V77.6 or V83.81
• DNA testing for cystic fibrosis - CPT 88271 - 88275; 88291, billed with Modifier 2A - 2Z or ICD-9 codes V10.6x or V10.7x
• FISH (fluorescent in situ hybridization) for the diagnosis of lymphoma or
leukemia - CPT 88230 - 88269; 88280 - 88289; 88291; 88299
Note: These procedures are covered procedures, but do not require
pre-authorization in network. When performed out of network, these procedures do
require pre-authorization.
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Home Health Care |
• Home health services are coordinated by ConnectiCare's Health Services:
• To verify benefits and eligibility - (phone) 1-800-828-3407
• To inquire about an existing authorization - (phone) 1-800-562-6833
• To request a continuation of an authorization for home health
care or IV therapy fax (860) 409-2437
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Infertility Services
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• All infertility services that are subject to the mandate must be
pre-authorized, including: a) injectible infertility drugs for the purpose of
ovulation induction, b) intrauterine insemination with or without the use of
oral or injected medications for ovulation induction, and c) all ART procedures.
(A 12-month waiting period may apply for members in individual
[ConnectiCare®Solo] plans.)
• Lifetime maximums apply to certain services.
• Members are no longer eligible for coverage after their 40th
birthday.
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Laboratory & Pathology
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• All routine laboratory services must be obtained from participating laboratories.
• In-office procedures are restricted to a specific list of tests that relate
to the specialty of the provider. (See Other Benefit Information, found at the end of
this section.)
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Mental Health/ Alcohol/Substance Abuse
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• All requests to initiate or extend a mental health or substance abuse
authorization should be directed to our Behavioral Health Program at
1-800-349-5365. Requests may be made by either the physician or the
member.
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New Technology
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• Services or supplies that are new or recently emerged uses of existing
services and supplies, are not covered benefits, unless and until we determine
to cover them.
• Any treatment for which there is insufficient evidence of therapeutic value
for the use for which it is being prescribed is also not
covered.
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Oral Surgery |
• Pre-authorization is required.
• Coverage is provided for Temporomandibular Joint (TMJ) surgery or
orthognathic procedures with pre-authorization, when medical necessity is
established. Supporting evidence, which may be required includes: 1.) abnormal
MRI; and 2.) abnormal arthrogram
• Postoperative physical therapy for TMJ surgery is limited to ninety (90) days
from the date of surgery when pre-authorized as part of surgical procedure.
• Most plans exclude purely dental services, including oral surgery, but
benefits vary by employer.
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Pre-authorization |
• For a specific listing of services and procedures that require
pre-authorization refer to the Appendices within this Manual.
• The admitting physician is responsible for pre-authorizing elective
admissions five (5) working days in advance. Notify ConnectiCare within
twenty-four (24) hours after an emergency admission at 1-888-261-2273.
• Without pre-authorization, these services and procedures may not be covered
or may be covered at a reduced rate.
• Clinical Review Prior Authorization Request Form
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Radiology
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• For pre-authorization of the following radiological services, call
1-877-607-2363 or request online at http://www.radmd.com/.
• Bone Mineral Density exams ordered more frequently than every twenty-three (23) months
• CT scans (all diagnostic exams)
• MRI/MRA (all examinations)
• Nuclear cardiology
• PET scans
• Stress echocardiograms
• Virtual colonoscopy for diagnostic purposes only, as determined by medical necessity criteria (CPT code 0067T)
• If authorization is not obtained, payment for the service may be denied.
• In-office procedures are
restricted to a specific list of tests that relate to the specialty of the
physician. (See Other Benefit Information, found at the end of this section.)
• Some plans may have a copayment requirement for radiology services.
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Referrals |
• Physicians are required to make referrals to participating specialty
physicians, including chiropractic physicians.
• No specialist-to-specialist referrals permitted, except OB/Gyns may make
referrals..
• Referrals must be logged in ConnectiCare’s telephonic referral system or electronically via
Provider Connection.
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• Physicians may make referrals to participating specialists without entering
them into the telephonic referral system.
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Skilled Nursing Facility
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• Coverage for skilled nursing facility (SNF) admissions with
pre-authorization.
• If you admit a member to a SNF on a weekend or holiday, ConnectiCare will
automatically authorize payment for SNF services from the day of admission
through the next business day. You must call ConnectiCare’s Notification Line at
(860) 674-5870 or 1-888-261-2273 to advise ConnectiCare of the admission. This
line is available twenty-four (24) hours a day, seven days a week. If you do not
inform ConnectiCare according to these guidelines, the SNF may not receive
payment for any additional days of the member's stay. Admission to a SNF for
rehabilitation, in the absence of a hospitalization or acute episode of illness,
requires pre-authorization and is subject to medical necessity
review.
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Vision (Routine) Care
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• For plans where coverage applies, one routine eye exam per year covered at
100% after copayment (no referral required). To determine copayment requirement,
call ConnectiCare's Eligibility & Referral Line at 1-800-562-6834. See Automated and Online Features, for additional
information.
• Discounts on frames, lenses, and contact lenses: 25% discount for items
costing $250 or less; 30% discount for items over $250. Note: Some plans may
vary.
Note: Refractions (CPT 92015) are considered part of the office
visit and are not separately reimbursed.
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* ConnectiCare reserves the right to use third-party vendors to
administer some benefits, including utilization management services.
Note: Some plans may have different benefits/limits; refer
members to Member Services for verification at 1-800-251-7722.
