Point-of-Service Open Access

• Covered with no benefit maximum.

• 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.

• Coverage for receipt of blood and for autologous blood transfusions for the following procedures, when the procedures are covered benefits:

• 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.

• Covered with no deductible.

• 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 NY Appendix for listing of DME that requires pre-authorization.

Note: The list of covered DME and disposable supplies is reviewed periodically and subject to change at the sole discretion of ConnectiCare.

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.

• 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 - 1-800-562-6833

• To request a continuation of authorization for home health care or IV therapy (see Forms, to obtain a copy of the applicable form) - fax (860) 409-2437

• Covered according to New York State mandate.

• All routine laboratory services must be obtained from participating laboratories.

• All requests to initiate or extend a mental health 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.

• Services or supplies that are new or recently emerged, as well as 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.

• Pre-authorization is required.

• 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 or the first working day 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

• 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.

• Some plans may have a copayment requirement for radiology services.

• Physicians may make referrals to participating specialists without entering them into the telephonic referral system.

• Covered following a three (3) day hospital stay

• 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.