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Addictions Receiving Facility Services
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Services used to help people who are struggling with drug or alcohol addiction
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As medically necessary and recommended by us
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Prior authorization is required
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Allergy Services
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Services to treat conditions such as sneezing or rashes that are not caused by an illness
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We cover blood or skin allergy testing and up to 156 doses per year of allergy shots
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Prior authorization is required
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Ambulance Transportation Services
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Ambulance services are for when you need emergency care while being transported to the hospital or special support when being transported between facilities
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Covered as medically necessary.
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Prior authorization is required for Non-Emergent Ground Medical Transport and all Air Medical Transport
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Ambulatory Detoxification Services
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Services provided to people who are withdrawing from drugs or alcohol
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As medically necessary and recommended by us
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Prior authorization is required
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Ambulatory Surgical Center Services
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Surgery and other procedures that are performed in a facility that is not the hospital (outpatient)
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Covered as medically necessary.
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Certain outpatient surgeries require prior authorization. Call 1-844-243-5187 for more information.
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Anesthesia Services
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Services to keep you from feeling pain during surgery or other medical procedures
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Covered as medically necessary.
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All inpatient and elective admissions require prior authorization.
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Assistive Care Services
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Services provided to adults (ages 18 and older) help with activities of daily living and taking medication
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We cover 365/366 days of services per year
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No prior authorization is required
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Behavioral Health Assessment Services
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Services used to detect or diagnose mental illnesses and behavioral health disorders
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We cover:
- One initial assessment per year
- One reassessment per year
- Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day)
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No prior authorization is required
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Behavioral Health Overlay Services
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Behavioral health services provided to children (ages 0 – 18) enrolled in a DCF program
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We cover 365/366 days of services per year, including therapy, support services and aftercare planning
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Prior authorization is required.
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Behavioral Health Services – Child Welfare
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A special mental health program to children enrolled in a DCF program
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As medically necessary and recommended by us
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Prior authorization is required
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Cardiovascular Services
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Services that treat the heart and circulatory (blood vessels) system
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We cover the following as prescribed by your doctor:
- Cardiac testing
- Cardiac surgical procedures
- Cardiac devices
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Certain Cardiovascular services may require prior authorization. Call 1-844-243-5187 for more information.
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Child Health Services Targeted Case Management
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Services provided to children (ages 0 - 3) to help them get health care and other services
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Your child must be enrolled in the DOH Early Steps program
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No prior authorization is required.
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Chiropractic Services
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Diagnosis and manipulative treatment of misalignments of the joints, especially the spinal column, which may cause other disorders by affecting the nerves, muscles, and organs
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We cover:
- One new patient visit
- 24 established patient visits per year
X-rays
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No prior authorization is required.
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Clinic Services
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Health care services provided in a county health department, federally qualified health center, or a rural health clinic
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No prior authorization is required
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Community-Based Wrap-Around Services
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Services provided by a mental health team to children who are at risk of going into a mental health treatment facility
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As medically necessary and recommended by us |
Prior authorization is required
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Crisis Stabilization Unit Services
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Emergency mental health services that are performed in a facility that is not a regular hospital
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As medically necessary and recommended by us |
No prior authorization is required
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Dialysis Services
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Medical care, tests, and other treatments for the kidneys. This service also includes dialysis supplies, and other supplies that help treat the kidneys
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We cover the following as prescribed by your treating doctor:
- Hemodialysis treatments
- Peritoneal dialysis treatments
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No prior authorization is required
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Drop-In Center Services
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Services provided in a center that helps homeless people get treatment or housing
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As medically necessary and recommended by us
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Prior authorization is required
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Durable Medical Equipment and Medical Supplies Services
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Medical equipment is used to manage and treat a condition, illness, or injury. Durable medical equipment is used over and over again, and includes things like wheelchairs, braces, crutches, and other items. Medical supplies are items meant for one-time use and then thrown away
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Some service and age limits apply. Call 1-844-243-5187 for more information.
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Certain DME services may require prior authorization. Call 1-844-243-5187 for more information.
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Early Intervention Services
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Services to children ages 0 - 3 who have developmental delays and other conditions
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We cover:
- One initial evaluation per lifetime, completed by a team
- Up to 3 screenings per year
- Up to 3 follow-up evaluations per year
- Up to 2 training or support sessions per week
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No prior authorization is required
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Emergency Transportation Services
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Transportation provided by ambulances or air ambulances (helicopter or airplane) to get you to a hospital because of an emergency
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Covered as medically necessary.
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All air ambulance services require prior authorization (emergent requests may be submitted post-service).
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Evaluation and Management Services
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Services for doctor’s visits to stay healthy and prevent or treat illness
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We cover:
- One adult health screening (check-up) per year
- Child health check-ups are provided based on age and developmental needs
- One visit per month for people living in nursing facilities
Up to two office visits per month for adults to treat illnesses or conditions
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No Prior authorization is required
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Family Therapy Services
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Services for families to have therapy sessions with a mental health professional
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We cover:
- Up to 26 hours per year
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No prior authorization is required
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Family Training and Counseling for Child Development
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Services to support a family during their child’s mental health treatment
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As medically necessary and recommended by us
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Prior authorization is required
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Gastrointestinal Services
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Services to treat conditions, illnesses, or diseases of the stomach or digestion system
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We cover:
- Covered as medically necessary
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Certain Gastrointestinal services may require prior authorization. Call 1-844-243-5187 for more information.
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Genitourinary Services
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Services to treat conditions, illnesses, or diseases of the genitals or urinary system
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Covered as medically necessary
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No prior authorization is required
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Group Therapy Services
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Services for a group of people to have therapy sessions with a mental health professional
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We cover:
- Up to 39 hours per year
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No prior authorization is required
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Hearing Services
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Hearing tests, treatments and supplies that help diagnose or treat problems with your hearing. This includes hearing aids and repairs
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We cover hearing tests and the following as prescribed by your doctor:
- Cochlear implants
- One new hearing aid per ear, once every three years
- Repairs
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Certain Hearing services require authorization. Call 1-844-243-5187 for more information.
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Home Health Services
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Nursing services and medical assistance provided in your home to help you manage or recover from a medical condition, illness or injury
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We cover:
- Up to 4 visits per day for pregnant recipients and recipients ages 0-20
- Up to 3 visits per day for all other recipients
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Prior authorization is required
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Hospice Services
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Medical care, treatment, and emotional support services for people with terminal illnesses or who are at the end of their lives to help keep them comfortable and pain free. Support services are also available for family members or caregivers
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- Covered as medically necessary
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Prior authorization is required
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Individual Therapy Services
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Services for people to have one-to-one therapy sessions with a mental health professional
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We cover up to 26 hours per year
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No prior authorization is required
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Infant Mental Health Pre and Post Testing Services
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Testing services by a mental health professional with special training in infants and young children
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As medically necessary and recommended by us
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Prior authorization is required
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Inpatient Hospital Services
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Medical care that you get while you are in the hospital. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you
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We cover the following inpatient hospital services based on age and situation:
- Up to 365/366 days for recipients ages 0-20
- Up to 45 days for all other recipients (extra days are covered for emergencies)
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Inpatient admissions require prior authorization
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Integumentary Services
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Services to diagnose or treat skin conditions, illnesses or diseases
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- Covered as medically necessary
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Certain Integumentary services may require prior authorization. Call 1-844-243-5187 for more information.
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Laboratory Services
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Services that test blood, urine, saliva or other items from the body for conditions, illnesses or diseases
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- Covered as medically necessary
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Certain Laboratory services may require prior authorization. Call 1-844-243-5187 for more information.
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Medical Foster Care Services
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Services that help children with health problems who live in foster care homes
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Must be in the custody of the Department of Children and Families
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No prior authorization is required
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Medication Assisted Treatment Services
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Services used to help people who are struggling with drug addiction
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- Covered as medically necessary
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No prior authorization is required
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Medication Management Services
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Services to help people understand and make the best choices for taking medication
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- Covered as medically necessary
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No prior authorization is required
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Mental Health Partial Hospitalization Program Services
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Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from mental illness
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As medically necessary and recommended by us
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Prior authorization is required
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Mental Health Targeted Case Management
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Services to help get medical and behavioral health care for people with mental illnesses
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Covered as medically necessary
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Prior authorization is required
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Mobile Crisis Assessment and Intervention Services
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A team of health care professionals who provide emergency mental health services, usually in people’s homes
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As medically necessary and recommended by us
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No prior authorization is required
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MultiSystemic Therapy Services
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An intensive service focused on the family for children at risk of residential mental health treatment
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As medically necessary and recommended by us
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Prior authorization is required
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Neurology Services
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Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord or nervous system
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- Covered as medically necessary
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Certain neurology services may require prior authorization. Call 1-844-243-5187 for more information.
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Non-Emergency Transportation Services
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Transportation to and from all your medical appointments. This could be on the bus, a van that can transport disabled people, a taxi, or other kinds of vehicles
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We cover the following services for recipients who have no transportation:
- Out-of-state travel
- Transfers between hospitals or facilities
- Escorts when medically necessary
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No prior authorization is required.
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Nursing Facility Services
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Medical care or nursing care that you get while living full-time in a nursing facility. This can be a short-term rehabilitation stay or long-term
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- We cover 365/366 days of services in nursing facilities as medically necessary
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Prior authorization is required.
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Occupational Therapy Services
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Occupational therapy includes treatments that help you do things in your daily life, like writing, feeding yourself, and using items around the house
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We cover for children ages 0-20 and for adults under the $1,500 outpatient services cap:
- One initial evaluation per year
- Up to 210 minutes of treatment per week
- One initial wheelchair evaluation per five years
We cover for people of all ages:
- Follow-up wheelchair evaluations, one at delivery and one 6-months later
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The initial evaluation does not require prior authorization. Subsequent visits do require prior authorization.
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Oral Surgery Services
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Services that provide teeth extractions (removals) and to treat other conditions, illnesses or diseases of the mouth and oral cavity
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- Covered as medically necessary
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Certain Oral Surgery services may require prior authorization. Call 1-844-243-5187 for more information.
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Orthopedic Services
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Services to diagnose or treat conditions, illnesses or diseases of the bones or joints
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- Covered as medically necessary
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Certain Orthopedic services may require prior authorization. Call 1-844-243-5187 for more information.
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Outpatient Hospital Services
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Medical care that you get while you are in the hospital but are not staying overnight. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you
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- Emergency services are covered as medically necessary
- Non-emergency services cannot cost more than $1,500 per year for recipients ages 21 and over
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Certain Outpatient Hospital services may require prior authorization. Call 1-844-243-5187 for more information.
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Pain Management Services
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Treatments for long-lasting pain that does not get better after other services have been provided
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- Covered as medically necessary. Some service limits may apply
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Certain pain management services require prior authorization. Call 1-844-243-5187 for more information.
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Partial Hospitalization Services
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Services for people leaving a hospital for mental health treatment
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As medically necessary and recommended by us
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Prior authorization is required
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Physical Therapy Services
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Physical therapy includes exercises, stretching and other treatments to help your body get stronger and feel better after an injury, illness or because of a medical condition
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We cover for children ages 0-20 and for adults under the $1,500 outpatient services cap:
- One initial evaluation per year
- Up to 210 minutes of treatment per week
- One initial wheelchair evaluation per year
We cover for people of all ages:
- Follow-up wheelchair evaluations, one at delivery and one 6-months later
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The initial evaluation does not require prior authorization. Subsequent visits do require prior authorization.
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Podiatry Services
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Medical care and other treatments for the feet
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We cover:
- Up to 24 office visits per year
- Foot and nail care
- X-rays and other imaging for the foot, ankle and lower leg
- Surgery on the foot, ankle or lower leg
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No prior authorization is required
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Prescribed Drug Services
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This service is for drugs that are prescribed to you by a doctor or other health care provider
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We cover:
- Up to a 34-day supply of drugs, per prescription
- Refills, as prescribed
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Certain Prescribed Drug services require prior authorization. Call 1-844-243-5187 for more information.
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Private Duty Nursing Services
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Nursing services provided in the home to people ages 0 to 20 who need constant care
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We cover up to 24 hours per day
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Prior authorization is required.
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Psychiatric Specialty Hospital Services
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Emergency mental health services that are performed in a facility that is not a regular hospital
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As medically necessary and recommended by us
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No prior authorization is required.
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Psychological Testing Services
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Tests used to detect or diagnose problems with memory, IQ or other areas
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We cover 10 hours of psychological testing per year
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Prior authorization is required.
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Psychosocial Rehabilitation Services
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Services to assist people re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores
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We cover up to 480 hours per year
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Prior authorization is required.
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Radiology and Nuclear Medicine Services
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Services that include imaging such as x-rays, MRIs or CAT scans. They also include portable x-rays
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- Covered as medically necessary
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Certain imaging services may require prior authorization. Call 1-844-243-5187 for more information.
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Regional Perinatal Intensive Care Center Services
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Services provided to pregnant women and newborns in hospitals that have special care centers to handle serious conditions
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Covered as medically necessary
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Regional Perinatal Intensive Care Center Services may require prior authorization. Call 1-844-243-5187 for more information.
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Reproductive Services
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Services for women who are pregnant or want to become pregnant. They also include family planning services that provide birth control drugs and supplies to help you plan the size of your family
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We cover family planning services. You can get these services and supplies from any Medicaid provider; they do not have to be a part of our Plan. You do not need prior approval for these services. These services are free. These services are voluntary and confidential, even if you are under 18 years old.
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No prior authorization is required
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Respiratory Services
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Services that treat conditions, illnesses or diseases of the lungs or respiratory system
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We cover:
- Respiratory testing
- Respiratory surgical procedures
- Respiratory device management
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Certain Respiratory services may require prior authorization. Call 1-844-243-5187 for more information
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Respiratory Therapy Services
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Services for recipients ages 0-20 to help you breathe better while being treated for a respiratory condition, illness or disease
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We cover:
- One initial evaluation per year
- One therapy re-evaluation per 6 months
- Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day)
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No prior authorization required |
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Self-Help/Peer Services
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Services to help people who are in recovery from an addiction or mental illness/p>
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As medically necessary and recommended by us
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Prior authorization is required
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Specialized Therapeutic Services
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Services provided to children ages 0-20 with mental illnesses or substance use disorders
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We cover the following:
- Assessments
- Foster care services
- Group home services
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No prior authorization is required
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Speech-Language Pathology Services
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Services that include tests and treatments help you talk or swallow better
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We cover the following services for children ages 0-20:
- Communication devices and services
- Up to 210 minutes of treatment per week
- One initial evaluation per year
We cover the following services for adults:
- One communication evaluation per 5 years
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The initial evaluation does not require prior authorization. Subsequent visits do require prior authorization.
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Statewide Inpatient Psychiatric Program Services
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Services for children with severe mental illnesses that need treatment in the hospital
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Covered as medically necessary for children ages 0-20
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Prior authorization is required.
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Substance Abuse Intensive Outpatient Program Services
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Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from substance use disorders
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As medically necessary and recommended by us
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Prior authorization is required.
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Substance Abuse Short-term Residential Treatment Services
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Treatment for people who are recovering from substance use disorders
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As medically necessary and recommended by us
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Prior authorization is required.
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Therapeutic Behavioral On-Site Services
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Services provided by a team to prevent children ages 0-20 with mental illnesses or behavioral health issues from being placed in a hospital or other facility
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We cover:
- Up to 9 hours per month
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Prior authorization is required
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Transplant Services
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Services that include all surgery and pre- and post-surgical care
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Covered as medically necessary
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Prior authorization is required.
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Visual Aid Services
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Visual Aids are items such as glasses, contact lenses and prosthetic (fake) eyes
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We cover the following services when prescribed by your doctor:
- Two pairs of eyeglasses for children ages 0-20
- Contact lenses
- Prosthetic eyes
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No prior authorization is required
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Visual Care Services
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Services that test and treat conditions, illnesses and diseases of the eyes
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- Covered as medically necessary
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Certain Visual Care services may require prior authorization. Call 1-844-243-5187 for more information.
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