Pages Navigation Menu

Medical Coverage Policies

MULTIPLE SURGICAL POLICY PROCEDURE POLICY

Description of Service

When a service involves multiple surgical procedures by the same professional provider, in the same setting, and on the same date of service, surgery reduction guidelines will apply.

Reimbursement Policy

Multiple surgical procedures (modifier 51): Procedures performed during the same operative session by the same provider are reimbursed at 100% of the regular, reasonable, and customary amount for the primary or first surgical procedure and 50% of the regular, reasonable, and customary amount for each secondary procedure.

Bilateral procedures (modifier 50): Procedures performed on both sides of the body during the same operative session are reimbursed at 100% of the regular, reasonable, and customary amount of the first surgical procedure and 50% of the regular, reasonable, and customary amount of the secondary procedure.

Exclusions: The above policy will not apply to procedures which are modifier 51 exempt based on AMA CPT Guidelines. The policy does not apply to procedures determined to be not medically necessary.

INPATIENT HOSPITAL POLICY

Payment Policy

The following guidelines apply to inpatient hospital stays incurred at an in-network or out-of-network facility. The eligibility of benefits is based on the specific plan provisions and/or exclusions.

Description of Hospital

A facility which is:
• is legally operated for the inpatient care and treatment of an illness or injury
• is primarily engaged in providing medical and diagnostics services
• has continuous 24 hour nursing services; and
• has a staff of one or more physicians on-site at all times

It does not mean:
• a rest, nursing, or convalescent home
• a facility or institution primarily for the treatment of alcoholics or drug addicts
• a facility primarily affording custodial care
• a free-standing ambulatory surgical facility that arranges for overnight stays within the facility

Description of Inpatient

An inpatient stay means a confinement in a hospital which results in the hospital making a room and board charge. It also means an overnight stay in an observation unit of a hospital.

Pre-certification Program

To qualify for full benefits, all inpatient hospital stays must be pre-certified according to your plan’s pre-certification program. It is the responsibility of the insured to ensure that a call is made to the pre-certification hotline as follows:

Non-Emergency Hospitalizations – the pre-certification hotline must be called at least 72 hours before an insured is scheduled for a non-emergency or elective service.

Medical Emergency – the pre-certification hotline must be called within 2 business days (or as soon as reasonably possible if the insured’s condition prevents them from calling within that time frame) following an emergency admission.

Pre-certification Phone Number: 800-245-3005

Billing and Reimbursement

The following information is required when filing a bill for an inpatient hospital stay:
• UB-92/UB-04 (if the claim is not electronically filed through the appropriate PPO network)
• Complete itemization and full description of all charges (miscellaneous charges will not accepted)
• Invoicing (to include manufacturer, brand, and model) for any implant charges (revenue code 0278)
• Operative report for operating room charges of $5000 or greater
• Supply charges

Routine supplies (i.e., admission kits, gloves, IV tubing, etc.) are generally available to all patients and should be included in the standard room and board cost.

Non-routine supplies billed separately from standard room and board will be considered reimbursable when documentation is provided supporting the medical necessity of the supply and that the supply was reasonable for the diagnosis or treatment of the illness and there is documentation to support the delivery to and the use of the supply to the patient for whom it was ordered.

General Information

Pekin Life Insurance Company reimburses medically necessary services. The plan will provide reimbursement for hospital room and board at the standard semi-private room rate. A patient may request a private room; however, the insured will be responsible for paying the rate differential. Intensive Care Unit (ICU) charges are covered in full when ordered by the primary physician and the level of care is medically necessary.

Benefit Information

General benefit information may be verified by faxing a request to 1-309- 346-8265. The information will be returned by fax within twenty four (24) working hours.

Insureds Responsibility

An insured may be liable for any of the following:
• Deductible
• Co-insurance
• Copayment
• Usual & Customary disallowed amounts
• Non-covered services

ANESTHESIA PAYMENT POLICY

The following payment policies apply to medically necessary anesthesia services rendered by in-network or out-of-network providers. The eligibility of benefits for anesthesia services is based on the specific plan provisions or exclusions. Anesthesia services are normally covered when rendered in conjunction with covered surgical procedures.

Description of Service

Anesthesia is the administration of a drug or anesthetic agent by an Anesthesiologist, Certified Registered Nurse Anesthetist, or an Anesthesia Assistant for medical or surgical purposes to obtain muscular relaxation or to induce partial or total loss of sensation to a surgical site or to obtain total loss of consciousness.

Billing and Reimbursement

Anesthesia services can be billed using the following AMA Current Procedural Terminology.

• Anesthesia Services (CPT Codes 00100 – 01999)
• Moderate (Conscious) Sedation (CPT Codes 99143 – 99150)
• Anesthesia add on codes are reported in addition to their primary anesthesia code.

Services rendered by out-of-network providers will be reimbursed using the following relative value calculation.

• Base Units + (Time Units X Conversion Factor) = Regular, Reasonable & Customary Allowance.

Supervision of a CRNA by an anesthesiologist will only be considered for reimbursement if the modifiers of QK or QY are appropriately appended to the billed anesthesia procedure. Services billed by the CRNA must include the appropriate modifier of QX or QZ. When services are billed by both the anesthesiologist and the CRNA, for the same anesthetic service, reimbursement will be split (50%-50%) between the supervising anesthesiologist and the CRNA.

General Information

Pekin Life Insurance Company reimburses medically necessary services provided in the most cost-effective setting for the services needed. All policy language for coverage applies.

Benefit Information

General benefit information may be verified by faxing a request to 1-309-346-8265. The information will be returned by fax within twenty-four (24) working hours.

Insured’s Responsibility

An insured may be liable for any of the following:

• Deductible
• Co-insurance
• Copayment
• Usual & Customary disallowed amounts
• Non-covered services

AIR AMBULANCE TRANSPORT POLICY

Payment Policy

The following guidelines apply to air ambulance services. These guidelines should be used only as a reference as actual eligible benefits are based on the specific plan provisions and/or exclusions.

Description

Air ambulance transportation is a service provided by either helicopter or a fixed wing aircraft, specifically designed, equipped, and staffed for transporting the sick or injured. It does not include chartered or commercial air flights.

Criteria

Air ambulance transport may be considered medically necessary when the following criteria are met:
• The medical condition was such that urgent and rapid transport was necessary to stabilize or preserve the patient’s life.
• Transport could not have been provided safely by ground ambulance due to great distances, traffic obstacles, or prolonged transport times which would endanger the patient’s health or the point of pick-up was inaccessible by ground transport.
• Transport was to the nearest acute care hospital equipped to provide the level of care required to treat the patient’s illness.

Note

Air ambulance services are not covered for transport to a facility which is not an acute care hospital (i.e., nursing facility, physician’s office, patient’s home).

Payment Guidelines

If it is determined that transport could have been appropriately provided by ground ambulance, benefit for the air ambulance service will be based on what the cost would have been for ground transport, if less costly, subject to policy limits for air and ground ambulance transportation.

Benefit Information

General benefit information may be verified by faxing a request to 1-309-346-8265. The information will be returned by fax within twenty-four (24) working hours.

Insured’s Responsibility

An insured may be liable for deductible, co-insurance, copayment amounts, usual and customary disallowed amounts, and/or non-covered services.

VARICOSE VEIN TREATMENT

Payment Policy

This document describes the guidelines used to assist with coverage decisions regarding treatment of varicose veins. These guidelines should be used only as a reference as actual eligible benefits are based on the specific plan provisions and/or exclusions.

Description

Varicose vein treatment is eligible for benefit when it is medically necessary treatment of an illness as defined by the plan.

Not all varicose veins require medical treatment. Treatment recommended to correct significantly symptomatic varicosities or symptomatic complications of varicosities is normally considered a covered expense. Before proceeding with elective/non-urgent treatment, a preauthorization of coverage is recommended.

The plan does not provide coverage for treatment of varicose veins when the primary goal is to alter or improve appearance.

Guidelines

Common forms of varicose vein treatment include the following:
• Ligation and Excision
• Sclerotherapy
• Stab Phlebectomy
• Radiofrequency Ablation
• Endovenous Laser Ablation

The treating physician should submit documentation supporting the medical necessity of the recommended treatment. The following documentation is necessary for a complete review:
• Proposed treatment plan (to include AMA CPT codes)
• Current patient evaluation
• Prior consultations or treatment of the condition (or related symptoms)
• Documentation of all conservative management, including failure of a 3-6 month trial of compression therapy (compression/support hose)
• Doppler evaluation or duplex ultrasound of the varicosities

Note

Following an internal review of the proposed treatment plan and submitted supporting documentation, if questions regarding medical necessity still exist, an outside medical review will be conducted.

Benefit Information

General benefit information may be verified by faxing a request to 1-309-346-8265. The information will be returned by fax within twenty-four (24) working hours.

Insured’s Responsibility

An insured may be liable for deductible, co-insurance, copayment amounts, usual and customary disallowed amounts, and/or non-covered services.

 

Call Toll-Free 1-800-322-0160