Section 4 Covered Services by wuxiangyu

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									PROVIDER MANUAL 2010




                          Section 4


                       Covered Services
PROVIDER MANUAL 2010




Covered Benefits & Services

As a Delaware Medicaid & Medical Assistance (DMMA) health plan, DPCI is responsible for all
covered medical conditions within the Basic Benefit Package for each DPCI member. The
package includes inpatient, outpatient and ambulatory medical and surgical services,
gynecological, obstetric and family planning services; limited behavioral health services and a
variety of other services (see below for a listing).

DPCI members are also entitled to a number of services that are not included in the Basic Benefit
Package. These services, referred to as “wrap-around” services, are covered under the State of
Delaware’s fee-for-service program.

All services provided must be medically necessary and some services may have limitations (e.g.,
behavioral health) or require prior authorization (e.g., orthotics). Specific information about
prior authorization is included in Section 14 – Prior Authorization.

All benefits have to be medically necessary. Some services may require prior authorization. This list is not all
inclusive.



                   Member Benefit                                                             Covered
Allergy Testing                                                                               Covered
Ambulance (Emergency)                                                                         Covered
Bed Liners (age 4 and up)                                                                     Covered
Behavioral Health/Alcohol and Substance                                                       Covered
Abuse – Outpatient                                                         18 and above - 20 visits per contract year
                                                                           Under Age 18 – 30 visits per contract year
Behavioral Health – Inpatient Hospitalization                                                 Covered
                                                                           18 and above – 30 days per contract year
                                                                           Under age 18 – Covered by Department of Services
                                                                           for Children, Youth and their Families, Division of
                                                                           Child Mental Health (use your Medical Assistance
                                                                           ID card)
Blood and Plasma Products                                                                     Covered
Bone Mass Measurement                                                                         Covered
(Bone Density)
Cancer Screenings                                                                             Covered
Cancer Testing and Treatment                                                                  Covered
Chemotherapy                                                                                  Covered
Childbirth Education                                                                          Covered
Colorectal Screening Exam                                                                     Covered
Contact Lenses or Eyeglasses                                                                  Covered
CT Scans                                                                                      Covered
Dental Services                                                            The Delaware Medical Assistance Program covers
(800) 372-2022                                                             certain dental care for children up to age 21
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                                          DPCI Provider Relations Department 1-800-287-9860

Section 4 Covered Benefits and Services
Revised February 2010
PROVIDER MANUAL 2010




                   Member Benefit                                                             Covered
                                                                           (Includes the Delaware Healthy Children Program).
                                                                           Exception: removal of bony impacted wisdom teeth
                                                                           covered by DPCI
                                                                           Note: Refer to “Services That Are Not Covered”
                                                                           below and “Dental Services” information in Section
                                                                           4 of Provider Manual.
Diabetic Care                                                                                   Covered
Diabetic Education                                                                              Covered
Diabetic Equipment (insulin pump and pump                                                       Covered
supplies)
Diabetic Supplies (glucose monitor and strips)                             Covered by the State of Delaware Medicaid
                                                                           Program
Dialysis                                                                                        Covered
Diapers (age 4 and up)                                                                          Covered
Drugs (given in your doctor’s office)                                                           Covered
Durable Medical Equipment (DME)                                                                 Covered
Early Periodic Screening, Diagnosis and                                                         Covered
Treatment (EPDST)
Emergency Room Care                                                                             Covered
Eye Tests, routine                                                                              Covered
Contact Block Vision (1-800-879-6901)
Eyeglasses and Contacts                                                                         Covered
Family Planning (No referral needed)                                                            Covered
Genetic Testing                                                                                 Covered
Glaucoma Screening                                                                              Covered
Gynecology Visits                                                                               Covered
Hearing Aids and Batteries (External)                                                           Covered
                                                                             *children up to age 21 when medically necessary
Hearing Exams                                                                                    Covered
HIV/AIDS Testing                                                                                 Covered
Home Health and Aide Services                                                                    Covered
Hospice Care                                                                                     Covered
Hospital Services (Inpatient and Outpatient)                                                     Covered
Immunizations                                                                                    Covered
Infusion Therapy                                                                                 Covered
Laboratory Services                                                                              Covered
Mammograms                                                                                       Covered
Medical Supplies                                                                                 Covered
MRI and MRA Scans                                                                                Covered
Obstetrical/Maternity Care                                                                       Covered
Orthopedic Shoes and Inserts                                                                     Covered
Outpatient Surgery, Same Day Surgery,                                                            Covered
Ambulatory Surgical Center
Pain Management Services                                                                        Covered
                                                  www.DelawarePhysiciansCare.com                                       - 25 -
                                          DPCI Provider Relations Department 1-800-287-9860

Section 4 Covered Benefits and Services
Revised February 2010
 PROVIDER MANUAL 2010




                    Member Benefit                                                                  Covered
PET Scans                                                                                            Covered
Pharmacy/ Prescription Drugs                                                Covered by Delaware Medical Assistance
Physicals                                                                                            Covered
Podiatry Care                                                                                        Covered
Pregnancy-related Services                                                                           Covered
Primary Care Services                                                                                Covered
Private Duty Nursing                                                                                 Covered
Prostate Cancer Screenings                                                                           Covered
Prosthetics and Orthotics                                                                            Covered
Radiation Therapy                                                                                    Covered
Rehabilitation (Medical-Inpatient Hospital)                                                          Covered
Skilled Nursing Facility Care                                                                  Covered up to 30 days
Sleep Apnea Studies                                                                                  Covered
Smoking Cessation                                                           Covered by Delaware Medical Assistance
Specialist Physician Services                                                                        Covered
Therapy – Outpatient                                                                                 Covered
Occupational/Physical/Speech
Transportation - (Non Emergency)                                                                     Covered
Urgent Care, After Hours, and Walk-In Centers                                                        Covered
and Retail Clinics
Well Woman Services                                                                                  Covered
X-Rays                                                                                               Covered

Services That Are Not Covered

 There are a number of services that are either not covered by DPCI or by the Delaware Medical
 Assistance Program such as: Providers will not be reimbursed for any of the following excluded
 services:
                      Abortion, unless rape, incest or to save the life of the mother
                      Autopsies
                      Chiropractic services
                      Christian Science nurses and/or sanitariums
                      Cosmetic services, items, procedures or treatments
                      Dental Services for member 21 years or older
                      Drugs dispensed by the practitioner, with the exception of oral abortive agents
                      that meet federal criteria when administered by the provider
                      Experimental procedures designated by Medicare (other than those transplants
                      covered by transplant criteria)
                      Hearing aids for member 21 years or older
                      Hippotherapy
                      Infertility treatments
                      In home exercise equipment
                      Inpatient care in Institutions for Mental Diseases (IMDs) for members age 21-64
                                                   www.DelawarePhysiciansCare.com                                      - 26 -
                                           DPCI Provider Relations Department 1-800-287-9860

 Section 4 Covered Benefits and Services
 Revised February 2010
     PROVIDER MANUAL 2010


                          Inpatient hospital tests not ordered by the attending doctor, except in an
                          emergency
                          Non-emergency services from an out of network provider that are not approved
                          Paternity testing
                          Pharmaceuticals that are not covered are: drug efficacy study implementation
                          (DESI) drugs, drugs for cosmetic purposes, obesity, sexual dysfunction,
                          investigational drugs, or compound prescriptions
                          Prescriptions not generated by a participating provider, except in an emergency
                          when the member is out of the region
                          Residential weight loss clinic
                          Respite care (except when provided through a Home and Community Based
                          Services (HCBS) waiver program)
                          Routine podiatry, unless medically necessary and appropriate. Routine foot care
                          is covered only for members with diabetes or circulatory/vascular disorders.
                          Services that are not medically necessary
                          Sex change services and/or hormone therapy
                          Single antigen vaccines when a combined antigen was medically appropriate
                          Sterilization of a mentally incompetent or institutionalized individual. These
                          services are only covered under very limited circumstances (e.g., individual is
                          mentally competent, individual is at least 21 years old and has given consent). The
                          signed 30 day consent form is required.
                          Vaccines for travel outside of the United States
                          Work related and travel physicals

                                                Value Added Programs and Services

             Program                                                What It Is                           Who Can Get This
                                                                                                             Benefit
Case Management                                  A case manager may be assigned to help            Members with special care needs.
                                                 members plan for and receive health care
                                                 services.

                                                 The case manager keeps track of what
                                                 services are needed and what services
                                                 have been provided.
Disease Management                               Special services to help members learn            Members with:
                                                 about living with the following diseases:           Asthma
                                                      Asthma                                         CHF
                                                     Congestive Heart Failure (CHF)                  COPD
                                                     Chronic Obstructive Pulmonary                   Diabetes
                                                     Disease (COPD)
                                                     Diabetes

                                                 A disease manager can help the members
                                                 manage their disease.
PACTsm Program                                   We help members keep doctor visits,               Pregnant members.
                                                 before and after their baby is born.

                                                       www.DelawarePhysiciansCare.com                                   - 27 -
                                               DPCI Provider Relations Department 1-800-287-9860

     Section 4 Covered Benefits and Services
     Revised February 2010
      PROVIDER MANUAL 2010


                                                  Members can receive text messages on
                                                  their cell phone reminding them of
                                                  appointments and health tips.
Promise Programsm                                 Keep doctor appointments and qualify for          Pregnant members.
                                                  things they need for their baby.

                                                  Members can earn a portable crib, play
                                                  yard, car seat or stroller. The more
                                                  appointments they keep, the higher level
                                                  item they will qualify to receive.
Teen D.R.E.A.M.sm (Dare to Raise                  A health education and life skills program        Teens
Expectations About Myself)                        offered to our teen members to increase
                                                  their self esteem.
We Can! ™ Make Healthy Choices                    After-school activity programs to keep            DPCI Children
Obesity Prevention Campaign                       kids active.




      Basic Benefit Packages

      There are Basic Benefit Packages for individuals who are:

             Categorically eligible (e.g., Temporary Aid to Needy Families (TANF) or Social
             Security Insurance (SSI) related) Title XIX
             Expanded population beneficiary (e.g., adults below 100% of Federal Poverty
             Level, known as FPL) Title XIX
             Eligible for the Delaware Healthy Children Program (Title XXI – State Children’s Health
             Insurance Program)
      Regardless of the member’s eligibility status, participating providers should bill DPCI for all
      Basic Benefit package services.

      Categorically Eligible and Expanded Population (Title XIX) Members Basic Benefit
      Package

      The services listed below are included in the Basic Benefit package for categorically eligible and
      expanded population members:

                Physician services
                Inpatient and outpatient hospital, including pharmaceuticals and blood products
                Laboratory services
                Home health services
                Emergency transportation
                Durable medical equipment and supplies
                Disposable medical supplies
                Podiatry – routine for diabetics and vascular disease
                Orthotics/Prosthetics
                Glasses or contact lenses up to $125 value once every 12 months
                                                        www.DelawarePhysiciansCare.com                                  - 28 -
                                                DPCI Provider Relations Department 1-800-287-9860

      Section 4 Covered Benefits and Services
      Revised February 2010
PROVIDER MANUAL 2010


          Annual optometry/optician services
          Rehabilitation facility services
          Ambulatory surgical center
          Dialysis center services
          Family planning services
          Nurse/midwife
          Abortion services only if necessary to save the life of the mother or if the
          pregnancy is the result of an act of rape or incest – subject to federal funding rules
          Case management services
          Care coordination services
          Physical and occupational therapies, and services for members with speech, hearing and
          language disorders
          Hospice care
          Any other medically necessary medical, diagnostic, screening, preventive, restorative,
          remedial, therapeutic or rehabilitative services
          Certified registered nurse practitioner
          General medical clinic services except for environmental investigation for source
          of lead and Preschool Developmental Diagnostic Nursery which is covered as a
          wrap-around service by the State fee for service program
          EPSDT screening clinic, except Part C Multidisciplinary Assessment which is
          covered as a wrap-around service by the State fee for service program
          Methadone clinic treatment
          Extended pregnancy services
          EPSDT group and individual services
          EPSDT nutrition services and occupational, speech and physical therapies
          Behavioral health services
          Federally Qualified Health Center services (FQHC)
          Skilled nursing services in a nursing facility – up to 30 days per diagnosis
          Private duty nursing services based on medical necessity

Additional Wrap-Around Services for Title XIX Eligible Members

Title XIX eligible members (categorical and expansion population) are eligible to receive
the following additional wrap-around service:

          Non-emergency medically necessary transportation
          Routine dental and orthodontic services for handicapping malocclusions for children
          Assessments and medically necessary early intervention services identified during the
          assessment process, approved by the child’s PCP and included on a Child’s Individuals
          Family Service Plan (IFSP) as Part C of the Individual with Disabilities Education Act
          Prescribed Pediatric Extended Care services for members under age 21 authorized by
          Medicaid staff
          Environmental investigation for source of lead by the Department of Public Health for
          members under age 21
          Preschool Developmental Diagnostic Nursery

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                                          DPCI Provider Relations Department 1-800-287-9860

Section 4 Covered Benefits and Services
Revised February 2010
PROVIDER MANUAL 2010


          EPSDT/CSCRP (Children’s Services Cost Recovery Project) services provided by
          enrolled school districts
          Chronic renal disease transportation services authorized by Medicaid staff
          Day health and rehabilitation

Delaware Healthy Children Program (Title XXI) Members Basic Benefit Package

The services listed below are included in the Basic Benefit Package for Delaware Healthy
Children Program Members:

          Inpatient and outpatient hospital services
          Physician services
          Surgical services
          Clinic (including health center services) and other ambulatory health care services
          Laboratory and radiology
          Prenatal care and pre-pregnancy family planning services and supplies
          Outpatient behavioral health services (see Section 4 regarding service limitations)
          Durable medical equipment and other medically-related or remedial devices such as
          prostheses, implants, hearing aids and adaptive devices
          Glasses or contact lenses up to $125 value once every 12 months
          Annual optometry/optician services
          Disposable medical supplies
          Home and community-based health care services - limited to medically necessary home
          health services provided as part of the Basic Benefit package. Excludes personal care,
          chore services, day care, respite care or home modifications. Home health aide services
          are covered as medically necessary according to the State’s published definition.
          Private duty nursing services – up to 28 hours per week
          Abortion services only if necessary to save the life of the mother or if the pregnancy is
          the result of an act of rape or incest – subject to federal funding rules
          Case management services
          Care coordination services
          Physical and occupational therapies, and services for members with speech, hearing and
          language disorders
          Hospice care
          Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or
          rehabilitative services
          Emergency transportation only

Additional Wrap-Around Services for Title XXI Eligible Children

Title XXI eligible children under the Delaware Healthy Children Program are eligible to receive
the following additional wrap-around services:

          Over the counter medications limited to products that may be less toxic, have fewer side
          effects, and be less costly than an equivalent legend product.

                                                  www.DelawarePhysiciansCare.com                - 30 -
                                          DPCI Provider Relations Department 1-800-287-9860

Section 4 Covered Benefits and Services
Revised February 2010
PROVIDER MANUAL 2010




Additional Services (AKA “Wrap Around” Services) Provided by the State of
Delaware

In addition to the Basic Benefit Package, DPCI members are entitled to a number of other
services that are covered under the State of Delaware’s fee-for-service program and are referred
to as “wrap-around” services. Participating providers should bill the State of Delaware directly
for these wrap-around services. Coverage of wrap-around services varies depending on the
eligibility category of the member.

Wrap-Around Services for All DPCI Members

All DPCI members are eligible to receive the following wrap-around services:

          Skilled nursing services after a 30-day minimum per calendar year.
          Pharmacy benefits (only when dispensed by a pharmacy provider to a member or the
          member’s representative for use in other than a hospital setting.)
          Medically necessary behavioral health services in excess of the DPCI limits.
          Day treatment by continuous treatment teams for mental illness or substance abuse.

Transplant Services

DPCI covers the following organ/tissue transplant procedures for members who meet applicable
eligibility and medical necessity criteria:
          Heart
          Lung
          Liver
          Bone marrow
          Pancreas
          Kidney

The review and approval process for covered transplants is coordinated by DPCI’s Medical
Management Department Transplant Coordinator. Physicians should direct all authorization
requests for covered transplant procedures to the DPCI Prior Authorization department at 1-866-
543-2167, Option #2, Option #3.

Family Planning Services

Family planning services are provided as part of the Basic Benefit package. Members may
access these services directly through any Medicaid participating provider without prior
authorization. Participating providers will bill DPCI and be paid on a fee-for-service basis.
Family planning services for purposes of out-of-network reimbursement are defined as those
services provided to individuals of childbearing age to temporarily or permanently prevent or
delay pregnancy and may include the following services:
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                                          DPCI Provider Relations Department 1-800-287-9860

Section 4 Covered Benefits and Services
Revised February 2010
PROVIDER MANUAL 2010


          Health education and counseling about contraceptive methods
          Limited history and physical exam
          Laboratory tests if medically indicated as part of the contraceptive choice process
          Diagnosis and treatment of sexually transmitted diseases, if medically indicated
          Screening, testing and counseling of individuals at risk for HIV and referral for treatment
          Follow-up care for problems associated with contraceptive methods
          Contraceptive pills/devices/supplies
          Tubal ligation
          Vasectomies
          Pregnancy testing and counseling
          Pap smear, if performed according to the US Preventive Services Task Force Guidelines,
          which specifies cervical cancer screening every one to three years based on the presence
          of risk factors.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

EPSDT services are federally-mandated services intended to provide preventive health care to
children and young adults (under the age of 21 years) at periodic intervals as determined by
Centers for Medicare and Medicaid Services (CMS). At a minimum the following screening
services must be offered:

          Comprehensive medical and developmental history; including anticipatory
          guidelines/health education, nutrition assessment, developmental assessment and
          fine/gross motor skills
          An unclothed physical exam
          Appropriate vision, hearing and laboratory testing
          Dental screening beginning at age three
          Blood lead testing
          Behavioral health screening
          Nutritional assessment

In addition to any diagnostic and treatment services included in the Basic Benefit package,
EPSDT eligible members must be provided the following services, if the need for such services
is indicated by the screening services:

          Diagnosis and treatment for defects in vision and hearing
          Dental care as early as needed, including relief of pain and infections, routine
          maintenance and restoration of teeth (for Title XIX members only)
          Appropriate immunizations if determined at the time of screening that the immunization
          is needed.
          Prenatal care services
          Any other follow-up diagnostic and treatment services deemed medically necessary to
          ameliorate or correct a problem identified during the screening process. These services
          are to be provided as long as they are Medicaid covered services


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                                          DPCI Provider Relations Department 1-800-287-9860

Section 4 Covered Benefits and Services
Revised February 2010
PROVIDER MANUAL 2010


See Section 8 and Section 18 for more information about the EPSDT program.

Vaccines for Children (VFC) Program

The federal-sponsored Vaccines for Children (VFC) program supplies free vaccines to
participating providers to certain groups of children under age 19 (i.e., Medicaid, uninsured,
American Indian and Alaskan Native children).
        All participating providers are expected to enroll in the VFC program in order to receive
        the free vaccines.
        DPCI will reimburse participating providers a VFC administration fee as determined by
        the State of Delaware.
        DPCI will not reimburse for the cost of vaccines as they are supplied free-of-charge
        through the VFC Program.
        DPCI will not reimburse the cost of vaccines for children covered under the Delaware
        Healthy Children Program, as the State of Delaware funds the VFC program for these
        children. Providers may use the VFC Program vaccines for Delaware Healthy Children
        members and must record on the Immunization Reporting (IR) form vaccines used for
        children covered under the Healthy Children Program.
        The provider must bill DPCI for the biological and administration codes in order to
        receive reimbursement.
        Participating providers must follow the Advisory Committee on Immunization Practices
        (ACIP) schedule for immunizations, located on the DPCI website.
        Immunization Reporting (IR) documents will be given to providers who administer and
        provide immunizations, for recording and reporting all immunizations. These forms are
        provided by the State to physicians and others to keep and use for the next immunization.

The VFC Program is not available for children covered under the Delaware Healthy Children
Program (Title XXI). However, the State of Delaware provides supplemental funding to the VFC
program for vaccines provided to these children. Participating providers will be reimbursed by
DPCI for the administration fee for immunizations provided to these children.

Part C of the Individual with Disabilities Education Act (IDEA)

IDEA mandates both the Individualized Family Support Plan (IFSP) for children with disabilities
age zero to three and the Individualized Education Plan (IEP) for children with disabilities age
three to 20. DPCI strongly encourages all participating providers to coordinate plan benefits
with the member’s school district and other appropriate providers to prevent duplication of
coverage, assure medical necessity guidelines are met and provide for service delivery in a cost-
effective manner.

The school districts will be responsible for providing school-based therapy services (e.g.,
occupational, physical and speech therapy) for children who are eligible to receive services under
the Individuals with Disability Education Act. DPCI and its participating providers are
responsible for providing services in the IEP/IFSP that are medically necessary outside of the
school setting. The IFSP or IEP is considered to be the authorizing document for these services.

                                                  www.DelawarePhysiciansCare.com              - 33 -
                                          DPCI Provider Relations Department 1-800-287-9860

Section 4 Covered Benefits and Services
Revised February 2010
PROVIDER MANUAL 2010


PCPs are encouraged to refer children to and participate in the Child Development Watch. Multi-
disciplinary teams that include the PCP and DPCI coordinate assessments and services with the
Delaware Department of Health and Social Services Child Development Watch Program. There
is currently a multidisciplinary assessment conducted by Child Development Watch that is paid
directly by the Department of Health and Social Services.

Dental Services

DPCI is responsible for all costs associated with removal of bony impacted wisdom teeth
procedures for DPCI members.

DMMA will reimburse anesthesia and facility costs for all other dental services to children
performed in an outpatient setting on a fee-for-service basis. DMMA policy prohibits fee-for-
service reimbursement of Ambulatory Surgical Centers (ASCs) for dental services. Therefore,
ASCs can not be paid for these services.

Requests to perform dental procedures in an outpatient setting should be submitted to the Dental
Prior Authorization Unit at:
                                     Fax: (302) 255-4481
                                  Attention: Dental PA Unit
                                           Or Mail:
                                        Dental PA Unit
                                  Division of Social Services
                                         P.O. Box 906
                                    New Castle, DE 19720

Note: Dental procedures for clients over 21 years of age are NOT covered in any setting. Dental
services include any services related to the dental treatment such as drugs, anesthetics, and use of
operating/recovery room, etc. While there is no adult dental benefit members can be referred to
Delaware Department of Health and Social Services (DHSS) Division of Medical and Medicaid
Services (DMMS) at 1-800-372-2022, option 5 to explore community resources.

Behavioral Health Services

Please refer to Section 5 for behavioral health services and benefits.




                                                  www.DelawarePhysiciansCare.com               - 34 -
                                          DPCI Provider Relations Department 1-800-287-9860

Section 4 Covered Benefits and Services
Revised February 2010

								
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